Division of Acute Care Surgery (Trauma, Emergency Surgery and Surgical Critical Care), Los Angeles County and University of Southern California Medical Center, Los Angeles, CA, USA.
World J Surg. 2011 Aug;35(8):1809-17. doi: 10.1007/s00268-011-1149-9.
The use of pulmonary artery catheter (PAC) is controversial. The purpose of this study was to document the changing pattern of PAC use and to determine its effect on outcome.
The use of PAC was analyzed in patients ≥16 years old admitted to the surgical intensive care unit (SICU) over a 9-year period starting in 2000. Patients with SICU length of stay exceeding 30 days were excluded. For the evaluation of PAC's effect on outcome, PAC and no-PAC patients were matched utilizing propensity scores.
During the 9-year study period, a total of 5,192 trauma patients were admitted to the SICU. Of these, 426 (8.2%) were <16 years old, and 174 (3.4%) had a SICU length of stay that exceeded 30 days. For the remaining 4,592 patients, the mean ± SD age was 39.5 ± 18.8 years, and the mean ISS was 19.9 ± 12.4. PAC was utilized in 19.5% (n = 896) of all the patients admitted to the SICU. The trend for PAC use decreased significantly over the years (P value for trend <0.001), from 38.6% in the year 2000 to 4.2% in the year 2008. This decrease was noted in all age and injury severity groups of patients. The overall mortality, however, remained at the same levels (P value for trend = 0.111). Patients managed with a PAC were significantly older, more severely injured, more frequently injured by a blunt mechanism, and were admitted more often in a hypotensive or comatose status. In the early part of the study, the PAC was utilized on the first day and for 4.1 days on average. In the later part of the study, however, the PAC was used on the second day and for a shorter period of time (3 days on average, P < 0.001). In the matched study population, patients in the PAC group had almost twofold higher odds for death, when compared to the no-PAC group [34.2% vs. 22.5%, Odds Ratio (95% CI): 1.78 (1.42, 2.26), P < 0.001]. Patients younger than 50 years of age who had an ISS ≥16 had worse outcome when managed with a PAC, whereas patients aged 30-69 years with an ISS <16 had a higher survival. The overall complication rate was fivefold higher in patients receiving a PAC [46.3% vs. 14.2%, Odds Ratio (95% CI): 5.22 (4.04, 6.74), P < 0.001].
The use of PAC has decreased almost 10-fold over the last decade at our institution. The PAC is being used later during the ICU course and for a shorter period of time. In a matched population, the use of PAC is associated with a significantly higher mortality and complication rate, but the reason for this association remains uncertain. The use of PAC is invasive and is associated with known complications and financial costs. While the use of PAC maybe useful in a select population, routine and widespread use of the PAC should be avoided.
肺动脉导管（PAC）的使用存在争议。本研究旨在记录 PAC 使用模式的变化，并确定其对结果的影响。
分析了 2000 年开始的 9 年期间入住外科重症监护病房（SICU）的年龄≥16 岁的患者中 PAC 的使用情况。排除 SICU 住院时间超过 30 天的患者。为了评估 PAC 对结果的影响，利用倾向评分对 PAC 患者和非 PAC 患者进行匹配。
在 9 年的研究期间，共有 5192 名创伤患者入住 SICU。其中，426 名（8.2%）年龄<16 岁，174 名（3.4%）SICU 住院时间超过 30 天。对于其余 4592 名患者，平均年龄±标准差为 39.5±18.8 岁，平均 ISS 为 19.9±12.4。PAC 在入住 SICU 的所有患者中使用了 19.5%（n=896）。PAC 使用的趋势在过去的几年中显著下降（趋势 P 值<0.001），从 2000 年的 38.6%降至 2008 年的 4.2%。这种下降在所有年龄和损伤严重程度的患者群体中都有体现。然而，总体死亡率保持在相同水平（趋势 P 值=0.111）。接受 PAC 治疗的患者年龄较大，损伤更严重，更常因钝性机制受伤，且低血压或昏迷状态下入院的频率更高。在研究的早期阶段，PAC 在入院的第一天使用，平均使用 4.1 天。然而，在研究的后期，PAC 在第二天使用，且使用时间较短（平均 3 天，P<0.001）。在匹配的研究人群中，与非 PAC 组相比，PAC 组的患者死亡的几率几乎高出两倍[34.2%对 22.5%，比值比（95%置信区间）：1.78（1.42，2.26），P<0.001]。ISS≥16 且年龄<50 岁的患者接受 PAC 治疗后预后较差，而 ISS<16 且年龄为 30-69 岁的患者存活率更高。接受 PAC 治疗的患者的总体并发症发生率高 5 倍[46.3%对 14.2%，比值比（95%置信区间）：5.22（4.04，6.74），P<0.001]。
在过去十年中，我们机构 PAC 的使用减少了近 10 倍。PAC 现在在 ICU 治疗过程中较晚使用，且使用时间较短。在匹配的人群中，PAC 的使用与死亡率和并发症发生率显著增加有关，但这种关联的原因尚不清楚。PAC 是一种有创的治疗方法，会导致已知的并发症和经济成本。虽然 PAC 在某些特定人群中可能有用，但应避免常规和广泛使用 PAC。
