When is a pulmonary artery (PA) catheter indicated for surgery?

When Pulmonary Artery Catheters Are Needed for Surgery

Routine use of pulmonary artery (PA) catheters in surgery is not recommended, even in high-risk patients, as it does not reduce mortality or morbidity. 1

Do NOT Use PA Catheters Routinely

• PA catheterization should not be used routinely in any surgical patient, regardless of risk level. 1 The largest randomized trial of 1,994 high-risk surgical patients (ASA class III-IV) showed no mortality or morbidity benefit, and actually found increased pulmonary embolism rates in the PA catheter group. 1

• Standard perioperative risk patients and those with stable hemodynamics should never receive PA catheters. 2 This represents the vast majority of surgical cases.

Consider PA Catheters Only in Highly Selective Cases

PA catheterization may be considered when ALL three conditions are met simultaneously: 1

1. Severe Uncorrectable Hemodynamic Conditions

PA catheter use may be reasonable when patients have underlying cardiovascular conditions that significantly affect hemodynamics AND cannot be corrected before surgery: 1

• Decompensated heart failure with persistent severe symptoms despite initial therapy 1, 2
• Severe valvular disease (mitral regurgitation, tricuspid regurgitation, aortic stenosis) when non-invasive assessment is inadequate 1, 2
• Combined shock states requiring differentiation of cardiogenic, distributive, or mixed etiologies 1, 2
• Severe pulmonary hypertension when accurate pulmonary vascular resistance measurement is needed for therapeutic decisions 1, 2

2. High-Risk Surgical Procedure

• The surgery must involve major operations with significant anticipated intraoperative or postoperative fluid shifts. 1, 2 Minor or intermediate-risk procedures do not warrant PA catheter use regardless of patient condition.

3. Appropriate Practice Setting

• The facility must have expertise in PA catheter interpretation and protocols for acting on the hemodynamic data obtained. 1, 2 Simply having the data without proper interpretation and therapeutic response negates any potential benefit.

Clinical Decision Algorithm

Step 1: Can the patient's hemodynamic abnormalities be corrected before surgery?

• If YES → Do not use PA catheter 1
• If NO → Proceed to Step 2

Step 2: Can non-invasive methods (echocardiography, central venous pressure monitoring) adequately assess and guide management?

• If YES → Do not use PA catheter 2
• If NO → Proceed to Step 3

Step 3: Is this a major surgical procedure with significant fluid shifts?

• If NO → Do not use PA catheter 1
• If YES → Proceed to Step 4

Step 4: Does your institution have expertise in PA catheter management?

• If NO → Do not use PA catheter 1
• If YES → PA catheter may be considered (Class IIb recommendation) 1

Important Caveats

• Historical data suggesting benefit in patients with prior myocardial infarction is confounded by concurrent changes in management, including increased beta-blocker use. 1 This does not justify routine PA catheter use today.

• PA catheters are monitoring devices only - outcomes depend entirely on correct interpretation and appropriate therapeutic protocols implemented in response to the data. 1 Without these elements, the catheter provides no benefit.

• Complications include: cardiac arrhythmias, venous thrombosis, pulmonary embolism, catheter-related infections, pulmonary artery rupture, and worsening tricuspid regurgitation. 3 These risks must be weighed against potential benefits.

• Less invasive alternatives should be prioritized: Central venous pressure monitoring and echocardiography can guide management in most cases without the risks of PA catheterization. 2, 3