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Pulmonary artery catheterisation offers no benefit

London Toby Reynolds

Pulmonary artery catheterisation offers no demonstrable benefit for intensive care patients in the United Kingdom, a new research report says. Furthermore, economic analysis indicates that lives could be saved or prolonged at a modest cost by stopping its routine use, it concludes.

Such catheterisation has been a standard treatment in intensive care for almost 30 years, particularly in the United States. The authors, of the Intensive Care National Audit and Research Centre, London, note that the device was widely adopted without evidence of its benefit, on the assumption that detailed knowledge of haemodynamic variables would help management (Health Technology Assessment 2006;10(29):1-150).

This assumption has, however, been controversial. Several studies found little or no benefit in managing critical illness with pulmonary artery catheterisation, and recent editorials have said that its routine use cannot be deemed necessary in several settings (New England Journal of Medicine 2006;354:2273).

“PAC [pulmonary artery catheterisation] was adopted into mainstream intensive care practice without any evaluation of its clinical or cost effectiveness; and indeed recent research evidence suggested that the device may do more harm than good,” said one of the report’s authors, Kathy Rowan.

The report aimed to evaluate the cost and clinical effectiveness of managing patients with or without pulmonary artery catheterisation in a general intensive care setting. It brought together a systematic review and a randomised controlled trial with an economic analysis.

The trial (Lancet 2005;366:472-7) followed more than 1000 patients and allowed use of alternative monitoring equipment if catheterisation was not used. It found that use of pulmonary artery catheterisation in the UK neither improved survival nor reduced the time patients spent in hospital.

The report’s economic analysis indicated that withdrawing the device from routine use in the NHS would bring health benefits, at a cost per quality adjusted life year of £2985 (€4410; $5590), a level the authors say compares favourably with many routinely provided treatments, such as managing coronary heart disease with statins.

Use in the UK of pulmonary artery catheterisation has declined as alternative haemodynamic monitoring methods have become available. But not all specialists in critical care thought that the report’s findings should lead to a further decline.

Andrew Rhodes, an intensive care consultant at St George’s Hospital, London, said, “There are two conclusions that can be drawn from these data. Either the use of the PAC in severely sick patients is of no benefit to the patient or the device is helpful but this has not yet been proven in a rigorous scientific fashion.”

Jukka Takala, professor of intensive care medicine at Bern University Hospital, said the important question was how the device was being used. “You could present the same arguments for any device used in monitoring critically ill patients. It is a questionable approach to criticise technologies when you should actually ask the question of whether we know what we are doing with them.”

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