肺动脉导管在心脏手术治疗中缺乏有效性( Anesthesia and analgesia）

华西小卒

肺动脉导管在心脏手术治疗中缺乏有效性
作者： Nanette M. Schwann et al
期刊名称： Anesthesia and analgesia
发表时间： 2011-09-14

中文内容：
肺动脉导管（PAC）于上世纪70年代引入了临床，因其可以提供前、后负荷、心肌收缩力、组织氧合等重要血流动力学信息而成为危重病及高危手术患者的标准监护措施，在危重病学、心脏病学及围术期得到了广泛应用。然而近10年来，Swan-Ganz导管的应用因其临床报道结果的不同而受到质疑，有的病情改善，有的并无明显效果，有的甚至恶化。
在“Lack of Effectiveness of the Pulmonary Artery Catheter in Cardiac Surgery”这篇文章中，Nanette M. Schwann等人分析了不同的医疗中心肺动脉导管的使用对冠状动脉旁路移植手术的预后影响。这项观察性研究纳入70个医疗中心5,065名接受CABG手术的患者，主要终点为全因死亡率、心梗、充血性心衰、中风等脑病、肾、肺功能受损，次要终点为治疗指数、术后气管插管、重症监护室时间等。结果发现，使用PAC患者跟不使用PAC患者比较，全因死亡率上升，血管风险增加，脑、肾、肺等发病率均增加；正性肌力药物使用增加，气管拔管时间延长，重症监护时间延长。这项观察性研究表明，冠状动脉搭桥手术中使用了PAC，增加患者死亡率和严重的终末器官并发症的风险。
纽约州锡拉丘兹SUNY Upstate医学院麻醉学系主任Nancy A.Nussmeier点评这项研究：具有临床意义，可能改变目前的临床实践，但仍有争议：这项正式的前瞻性观察研究显示在病人接受冠状动脉旁路移植手术时利用肺动脉导管（PAC）来监测血液动力学会增加严重终末器官并发症以及死亡的危险。这篇论文对实施冠状动脉旁路移植术时常规使用PAC的临床实践提出了质疑。

英文原标题：
Lack of Effectiveness of the Pulmonary Artery Catheter in Cardiac Surgery

BACKGROUND: The pulmonary artery catheter (PAC) continues to be used for monitoring of hemodynamics in patients undergoing coronary artery bypass graft (CABG) surgery despite concerns raised in other settings regarding both effectiveness and safety. Given the relative paucity of data regarding its use in CABG patients, and given entrenched practice patterns, we assessed the impact of PAC use on fatal and nonfatal CABG outcomes as practiced at a diverse set of medical centers.
METHODS: Using a formal prospective observational study design, 5065 CABG patients from 70 centers were enrolled between November 1996 and June 2000 using a systemic sampling protocol. Propensity score matched-pair analysis was used to adjust for differences in likelihood of PAC insertion. The predefined composite endpoint was the occurrence of any of the following: death (any cause), cardiac dysfunction (myocardial infarction or congestive heart failure), cerebral dysfunction (stroke or encephalopathy), renal dysfunction (dysfunction or failure), or pulmonary dysfunction (acute respiratory distress syndrome). Secondary variables included treatment indices (inotrope use, fluid administration), duration of postoperative intubation, and intensive care unit length of stay. After categorization based on PAC and transesophageal echocardiography use (both, neither, PAC only, transesophageal echocardiography only), we performed the primary analysis contrasting PAC only and neither (total, 3321 patients), from which propensity paring yielded 1273 matched pairs.
RESULTS: The primary endpoint occurred in 271 PAC patients versus 196 without PAC (21.3% vs.15.4%; adjusted odds ratio [AOR], 1.68; 95% confidence interval [CI], 1.24 to 2.26; P < 0.001). The PAC group had an increased risk of all-cause mortality, 3.5% vs 1.7% (AOR, 2.08; 95% CI, 1.11 to 3.88; P = 0.02) and an increased risk of cardiac (AOR, 1.58; 95% CI, 1.14 to 2.20; P = 0.007), cerebral (AOR, 2.02; 95% CI, 1.08 to 3.77; P = 0.03) and renal (AOR, 2.47; 95% CI, 1.68 to 3.62; P < 0.001) morbid outcomes. PAC patients received inotropic drugs more frequently (57.8% vs 50.0%; P < 0.001), had a larger positive IV fluid balance after surgery (3220 mL vs 3022 mL; P = 0.003), and experienced longer time to tracheal extubation (15.40 hours [11.28/20.80] versus 13.18 hours [9.58/19.33], median plus Q1/Q3 interquartile range; P < 0.0001). Use of PAC was also associated with prolonged intensive care unit stay (14.5% vs 10.1%; AOR, 1.55; 95% CI, 1.06 to 2.27; P = 0.02).
CONCLUSIONS: Use of a PAC during CABG surgery was associated with increased mortality and a higher risk of severe end-organ complications in this propensity-matched observational study. A randomized controlled trial with defined hemodynamic goals would be ideal to either confirm or refute our findings.
索引：
Anesth Analg. 2011 Nov;113(5):994-1002.