The Impact of a Pulmonary-Artery-Catheter-Based Protocol on Fluid and Catecholamine Administration in Early Sepsis
The Impact of a Pulmonary-Artery-Catheter-Based Protocol on Fluid and Catecholamine Administration in Early Sepsis
Carina Bethlehem,1 Frouwke M. Groenwold,1 Hanneke Buter,1 W. Peter Kingma,1 Michael A. Kuiper,1 Fellery de Lange,1,2 Paul Elbers,1 Henk Groen,3 Eric N. van Roon,4 and E. Christiaan Boerma1
1Department of Intensive Care, Medical Centre Leeuwarden, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
2Department of Cardiothoracic Anaesthesiology, Medical Centre Leeuwarden, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
3Department of Epidemiology, University Medical Centre Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
4Department of Clinical Pharmacy and Clinical Pharmacology, Medical Centre Leeuwarden, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
Received 21 July 2011; Revised 6 October 2011; Accepted 2 December 2011
Academic Editor: Maxime Cannesson
Copyright © 2012 Carina Bethlehem et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objective. The pulmonary artery catheter (PAC) remains topic of debate. Despite abundant data, it is of note that many trials did not incorporate a treatment protocol. Methods. We retrospectively evaluated fluid balances and catecholamine doses in septic patients after the introduction of a PAC-based treatment protocol in comparison to historic controls. Results. patients were included. The first day the PAC group had a significantly higher positive fluid balance in comparison to controls ( versus litre, ). After 7 days the cumulative fluid balance in the PAC group was significantly lower than in controls ( versus litre, ). Maximum dose of norepinephrine was significantly higher in the PAC group. Compared to controls this was associated with a significant reduction in ventilator and ICU days. Conclusions. Introduction of a PAC-based treatment protocol in sepsis changed the administration of fluid and vasopressors significantly.
1. Introduction
The pulmonary artery catheter (PAC) by Swan and Ganz, in the setting of critically ill patients, was originally introduced to “apply physiologic principles to the understanding of the circulatory abnormalities characterizing an illness in an individual patient, and to provide a rational basis for selection of therapy with objective, quantitative assessment of patient response” [1, 2]. In the following decades, this mechanistic perspective on the clinical relevance of PAC and other monitoring devices was gradually abandoned and replaced by “evidence-based medicine,” with emphasis on its potential value to reduce morbidity and mortality. Ever since, multiple randomised controlled trials in different subsets of ICU patients have been performed, to evaluate the use of PAC to improve outcome [3–7]. Lack of consistency in the results of these trials have led many to believe that the use of PAC should be done with great restraint [8]. Others, however, have stressed the potential methodological drawbacks of these trials, that may obscure underlying beneficial effects of the use of PAC; correct measurement, correct interpretation, and correct application of PAC-derived data are all essential to the final result [9, 10]. Today, many aspects of such methodological flaws have been acknowledged. Errors in measurements [11, 12], delay in insertion of PAC in acutely ill patients [13], misinterpretation of static filling pressures as a marker of preload [14], absence of therapeutic strategies [6, 7], as well as faulty supranormal endpoints [15] have all been reported. Furthermore, over the years the use of PAC has shifted from intermittently measuring static filling pressures towards a continuous indicator of (dis)balance between oxygen supply (cardiac output) and consumption (mixed venous oxygen saturation, SvO2). Furthermore it has now become a tool for the assessment of functional hemodynamic parameters, such as fluid responsiveness. To our knowledge, data on the effect of a PAC-based protocol, that integrates most of these aspects seem to be lacking.
In the present study we aimed to evaluate the influence of a PAC-based protocol on fluid administration and catecholamine use of well-trained intensivists in the specific setting of critically ill patients with early-phase severe sepsis/septic shock. We chose this particular group of patients, under the assumption that (a change in) hemodynamic management might have considerable potential impact on patient morbidity. Primary endpoints were the fluid balance after 24 hours and 7 days and maximum dose of dopamine and norepinephrine within the first 24 hours. Secondary outcome variables were days on the ventilator and length of stay (LOS) ICU.
2. Material and Methods2.1. Patients
The study was performed in a closed-format 22-bed mixed ICU in a tertiary teaching hospital. A (...truncated)