We rarely use a PA catheter. In most cases, we find that a combination of clinical and lab parameters ( Bun/Creatinine etc ), plus CVP gives a reasonably accurate measure of volume status. There are occasional cases in patients with pulmonary hypertension, diffuse infiltrates, in which there is a conundrum regarding cardiogenic or non cadiogenic pulmonary edema a PAC will be placed, but this is not common.

Several studies in the 1980s seemed to show a benefit of the increase in physiological information. Many reports showing benefit of the PA catheter are from anaesthetic, and Intensive Care settings.but One explanation could be that nurses and physicians were insufficiently knowledgeable to adequately interpret the PA catheter measurements. Also, the benefits might be reduced by the complications from the use of the PAC.

We rarely use PA cath in our ICU patients. For hemodynamic measurement other invasive (like Picco or FlowTrac) and noninvasive(Passive Leg Raise,NICOM,ECHO) methods have shown an equal or even better impact.Especially CI measurement or answering the question of fluid-responsiveness does not need PA cath introducing, because correct placement without X-ray or interpreting the data can be frustrating sometimes. Value of CVP and PCWP pressure showed no good correlation to fluid-responsiveness and is especially in ICU-patients hard to define. What about PEEP-ventilation, abdominal pressure, patient position..... ? They all have influence an the pressure values.

The only indication for placing a PA cath in our cardiac ICU are patients with right heart failure due to pulmonary hypertension of any cause(exepct acute pulmonary embolism) to measure PA pressure during vasodilating drug testing.

No other device gives the same information in ICU as a PA catheter. However a PAC is not good at determining preload responsiveness. I will use a PA catheter if I am uncertain of the type of shock I am dealing with. This often turns out be right heart failure and pulmonary hypertension. In cardiogenic shock it is useful for inotrope management. However, in less complex patients a TTE/TEE, U/S assessment of IVC, straight leg raise and an arterial wave form (if mechanically ventilated) will answer the ever important question 'is my patient pre-load responsive?'

I do cardiac anaesthesia mostly and more than the indications for a PA catheter, I insert the PA catheter for learning, teaching purposes. If not PAC will become obsolete. PAC indeed help in sicker patients in particular weaing patients from CPB and in patients with pulmonary hypertension coming cardiac surgery or to treat patients in the post CPB period.

Currently, it is much easier to use less invasive methods to assess cardiac output and hemodynamics, but I think for the evaluation of the effectiveness of some therapies, in cardiogenic shock, right heart failure you can still use a PA catheter. It should assess the risk benefit of invasive maneuver and the fact of the real interpretation of the data that can certainly lead to errors.

The PA catheter is still a useful tool in experienced hands. Unfortunately, younger doctors are not acquainted either with the insertion technique, or the interpretation of the data. The reason is that we don't use as many catheters as in the past, because of availability of other methods to evaluate cardiac output and need for fluids, but also because of financial reasons. Therefore, I believe that the PA catheter is going to die as soon as the older doctors quit .

Must admit that Metaxia Papanikolaou is right, the younger doctors do not know or insertion technique nor the interpretation of data and because this is rarely taught and it is also true that there are several ways to assess the cardiac output and the need of fluids, less expensive and less invasive. I believe, however, that this method should not be completely abandoned.

In the last 80 and 9O -ties, we used largely Pulmonary artery catheter in very critically ill patients, but if we consider that, very often, the data were " not completely and correctely used" and that in the real ICU live, PAC was used only three or four times a day to calculate SvO2 and Cardiac output.

Thus, the PAC apoptosis was evident with the new possibilities of continuous measurement of all hemodynamic varaiables, and the availabity of echocardiography which can provide pertinent informations.

To day, in our MICU department, PAC is rarely used, less then 10 times a year for very very specific and complicated patients but our main indications are residents training.

We Are rarely using PA catheter only In certain cases and cardiac surgery

Certain cases like heart failure patient and pulmonary hyperatension patient coming for major surgery

We use them in liver transplant anaesthesia. If echocardiography during assessment suggests pulmonary hypertension we may confirm with a PAC before referring to a specialist treatment centre. Patients who respond to treatment may return for subsequent transplant.

We also insert a PAC for nearly all transplants - for continuous cardiac output and RVEF as well as PA pressure. Usually removed at the end of procedure or early postop in ICU.

25 years ago I used PA catheters (Continous CO, RV ejection fraction, SvO2, etc) for all cardiac surgeries, lung transplant, liver trasplant and all patients in the surgical ICU with shock. Now we use PA catheters for two indications: learning & teaching and patients with pulmonar hypertension and RV failure. Instead of PA catheters we use PiCCO for continous monitoring and echocardiography (trasnthoracic and transesophageal) for intermitent assessment of the circulation

I have only seen PA catheters used in the post-open heart (CABG) or valve-replacement surgical patients, but the PA catheter is usally discontinued after 4 to 6 hours post-op. Due to the studies relating the risk-benefit ratio, PA catheters are not used as often as before in the 80's and 90's. Using a PA catheter in the past was common-place for septic shock and the therapy as well as documentation of any trending progress could be obtained from the PA catheter, however if the septic patient developes ARDS, has any respiratory compromise, or the sepsis is from a pneumonia, the PA catheter's sensitivity decreases while the risk remains unchanged. Calculation and determination in fluid balance has been successfully obtained from PiCCO but more recently from the analysis of pulse-oximetry waveform variance (baseline variance or pulse pressure variance).

An effective technique to decrease the risk of PA cathters for patients with a competent pulmonary valve would be to use the PAD as a direct substitute for the wedge-pressure. This will eliminate the possibility of balloon over-inflation (PA rupture) or the inability to deflate the balloon causing PA necrosis.

Our technology today should be able to ascertain most if not all of the information the PA cathters render without all of the risks. I agree with Dr. Consani that the use of PA cathters should be abandoned.