The Association Between Indwelling Arterial Catheters and Mortality in Hemodynamically Stable Patients With Respiratory Failure

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Abstract

Indwelling arterial catheters (IACs) are used extensively in the ICU for hemodynamic monitoring and for blood gas analysis. IAC use also poses potentially serious risks, including bloodstream infections and vascular complications. The purpose of this study was to assess whether IAC use was associated with mortality in patients who are mechanically ventilated and do not require vasopressor support.

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Genetic Matching for Estimating Causal Effects: A General Multivariate Matching Method for Achieving Balance in Observational Studies

Alexis Diamond, Jasjeet S. Sekhon (2013)

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Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials.

C O’Connor, Robert Califf, Pankaj Shah … (2005)

Randomized clinical trials (RCTs) evaluating the pulmonary artery catheter (PAC) have been limited by small sample size. Some nonrandomized studies suggest that PAC use is associated with increased morbidity and mortality. To estimate the impact of the PAC device in critically ill patients. MEDLINE (1985-2005), the Cochrane Controlled Trials Registry (1988-2005), the National Institutes of Health ClinicalTrials.gov database, and the US Food and Drug Administration Web site for RCTs in which patients were randomly assigned to PAC or no PAC were searched. Results from the ESCAPE trial of patients with severe heart failure were also included. Search terms included pulmonary artery catheter, right heart catheter, catheter, and Swan-Ganz. Eligible studies included patients who were undergoing surgery, in the intensive care unit (ICU), admitted with advanced heart failure, or diagnosed with acute respiratory distress syndrome and/or sepsis; and studies that reported death and the number of days hospitalized or the number of days in the ICU as outcome measures. Information on eligibility criteria, baseline characteristics, interventions, outcomes, and methodological quality was extracted by 2 reviewers. Disagreements were resolved by consensus. In 13 RCTs, 5051 patients were randomized. Hemodynamic goals and treatment strategies varied among trials. A random-effects model was used to estimate the odds ratios (ORs) for death, number of days hospitalized, and use of inotropes and intravenous vasodilators. The combined OR for mortality was 1.04 (95% confidence interval [CI], 0.90-1.20; P = .59). The difference in the mean number of days hospitalized for PAC minus the mean for no PAC was 0.11 (95% CI, -0.51 to 0.74; P = .73). Use of the PAC was associated with a higher use of inotropes (OR, 1.58; 95% CI, 1.19-2.12; P = .002) and intravenous vasodilators (OR, 2.35; 95% CI, 1.75-3.15; P<.001). In critically ill patients, use of the PAC neither increased overall mortality or days in hospital nor conferred benefit. Despite almost 20 years of RCTs, a clear strategy leading to improved survival with the PAC has not been devised. The neutrality of the PAC for clinical outcomes may result from the absence of effective evidence-based treatments to use in combination with PAC information across the spectrum of critically ill patients.

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Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations.

Tony Dremsizov, , Alan White … (2006)

To describe the organization and distribution of intensive care unit (ICU) patients and services in the United States and to determine ICU physician staffing before the publication and dissemination of the Leapfrog Group ICU physician staffing recommendations. Stratified, weighted survey of ICU directors in the United States, performed as part of the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS) study. Using lenient definitions, we defined an ICU as "high intensity" if > or =80% of patients were cared for by a critical care physician (intensivist) and defined an ICU as compliant with Leapfrog if it was both high-intensity and providing some form of in-house physician coverage during all hours. Three hundred ninety-three ICU directors. None. We obtained a 33.5% response rate (393/1,173). We estimated there were 5,980 ICUs in the United States, caring for approximately 55,000 patients per day, with at least one ICU in all acute care hospitals. The predominant reasons for admission were respiratory insufficiency, postoperative care, and heart failure. Most ICUs were combined medical-surgical ICUs (n = 3,865; 65%), were located in nonteaching, community hospitals (n = 4,245; 71%), and were in hospitals of <300 beds (n = 3,710; 62%). One in four ICUs were high-intensity (n = 1,578; 26%), half had no intensivist coverage (n = 3,183; 53%), and the remainder had at least some intensivist presence (n = 1,219; 20%). High-intensity units were more common in larger hospitals (p = .001) and in teaching hospitals (p < .001) and more likely to be surgical (p < .001) or trauma ICUs (p < .001). Few ICUs had any in-house physician coverage outside weekday daylight hours (20% during weekend days, 12% during weeknights, and 10% during weekend nights). Only 4% (n = 255) of all adult ICUs in the United States appeared to meet the full Leapfrog standards (a high-intensity ICU staffing pattern plus dedicated attending coverage during daytime plus dedicated coverage by any physician during nighttime). ICU services are widely distributed but heterogeneously organized in the United States. Although high-intensity ICUs have been associated previously with improved outcomes, they were infrequent in our study, especially in smaller hospitals, and virtually no ICU met the Leapfrog standards before their dissemination. These findings highlight the considerable challenge to any efforts designed to promote either 24-hr physician coverage or high-intensity model organization.