American Society of Anesthesiologists
View all recommendations from this societyReleased October 12, 2013
Don’t use pulmonary artery catheters (PACs) routinely for cardiac surgery in patients with a low risk of hemodynamic complications (especially with the concomitant use of alternative diagnostic tools (e.g., TEE).
The increased risk of hemodynamic complications as indicated above is defined as a patient with clinical evidence of significant cardiovascular disease; pulmonary dysfunction, hypoxia, renal insufficiency or other conditions associated with hemodynamic instability (e.g., advanced age, endocrine disorders, sepsis, trauma, burns).
The use of a PAC during cardiac surgery has been associated with increased mortality and a higher risk of severe end-organ complications. There is clear consensus in the literature that the use of a PAC cannot be recommended as a matter of routine, but for a definite role in a very select group of patients undergoing cardiac surgery. According to a survey by practicing anesthesiologists, the use of PAC could be recommended for specific indications in cardiac surgery including coronary artery bypass grafting (CABG) with poor left ventricular (LV) function, LV aneurysmectomy, recent myocardial infarction, pulmonary hypertension, diastolic dysfunction, acute ventricular septal rupture and insertion of left ventricular assist device. The appropriate indications remain debatable. However, although the PAC has no role in routine perioperative care, the existence of a specific subpopulation for which the use of this device may be beneficial cannot be excluded.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
The list started as an academic project of Onyi C. Onuoha, M.D., M.P.H A review of the literature and practice guidelines as approved by the American Society of Anesthesiologists (ASA) was performed to identify an evidence-based list of activities to question within the field of anesthesiology. A multi-step survey of anesthesiologists in both the academic and private sector and ASA Committees of Jurisdiction was performed to generate a “Top 5 List” list of preoperative and intraoperative activities. The final list was endorsed by the ASA and accepted for the Choosing Wisely® campaign. We believe that developing strategies whereby all stakeholders in the perioperative team are involved in the implementation is a means in which anesthesiologists could be engaged in the efforts to reduce over-utilization of low value, non-indicated medical services evident in the U.S. health system today.
ASA’s disclosure and conflict of interest policy can be found at www.asahq.org.
Sources
American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization. Anesthesiology. 2003 Oct; 99:988–1014.
Schwann NM, Hillel Z, Hoeft A, Barash P, Mohnle P, Miao Y, Mangano DT. Lack of effectiveness of the pulmonary artery catheter in cardiac surgery. Anesth Analg. 2011;113(5):994–1002.
Rajaram SS, Desai NK, Kalra A, Gajera M, Cavanaught SK, Brampton W, Young D, Harvey S, Bowan K. Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev. 2013;2:CD003408.
Kanchi M. Do we need a pulmonary artery catheter in cardiac anesthesia? – An Indian perspective. Ann Card Anaesth. 2011;14(1):25–9.
Harvey S, Stevens K, Harrison D, Young D, Brampton W, McCabe C, Singer M, Rowan K. An evaluation of the clinical and cost-effectiveness of pulmonary artery catheters in patient management in intensive care: a systematic review and a randomized controlled trial. Health Technol Assess. 2006;10(29);1–133.
Ramsey SD, Saint S, Sullivan SD, Day L, Kelley K, Bowdie A. Clinical and economic effects of pulmonary artery catheterization in nonemergent coronary artery bypass surgery. J Cardiothoracic Vasc Anesth. 2000;14(2):113–8.
Chatterjee K. Historical Perspectives in Cardiology. The Swan-Ganz catheters: past, present, and future – a viewpoint. Circulation. 2009;119:147–52.
Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M; Canadian Critical Care Clinical Trials Group. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5–14.
Miller AL, Beckman JA. (2013). Which patient should have a preoperative cardiac evaluation (stress test)? In L. Fleisher, Evidence-based practice of anesthesiology (3rd ed., pp. 61–70). Philadelphia (PA): Elsevier Saunders.
