SPECIAL ARTICLE Ant%hrsiol(w 2W. W:%- to14 D 20113 Arnckm k c k t y nf Ancsth&t>loljsrs. Inc. Ijppinc~m William% & Wlkinc. Inc.

Practice Guidelines for Pulmonary AHery Catheterization

An Updated Report by tbe American Society of Anesthesiologists Task Force on Pulmonary Artery Catheten'zatiolz

PRACTICE guidelines are systematically deveIoped rec- omendations that assist the practitioner and patient in making decisions about health care. These recommen- dations may be adopted, modified, or rejected according ta cIinica1 needs and constrains. Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidehnes are subject to revision as warranted by the evolution of medical knowledge, tech- nology, and practice. The guidelines provide basic recom- mendations that am supported by analysis of the current literature and by a synthesis of expert opinion, openfotum commentary, and clinical feasibility data. The recommen- dations, although derived in part from evidence obtained in other countries, are intended for ptactitioners in the United States; elements of the recommendatiom~ and the princi- ples on which they are based may also apply to practice settings in other countries.

The balloon-flotation pulmonary artery (PA) catheter was introduced in 1370.' PA catheter monitoring has expanded rapidly and broadly in clinical practice since the late 1970s. As of 1996, an estimated 2 million cath- eters were sold annually oddw wide,^ with an estima~ed 2 billion dollars spent in the United States alone."."

The appropriate indications for PA catheter monitor- ing have been debated for many years. The potential benefits of using the device are well known. Its use in

t This article is accompanied by an Editaria1 View. Please m: Arens J: On behalf of the American Society of Anesthesinlo- gists committee on practice parameters. ANEsWE\:claI.uciY 2003: $9775-6.

Developed by the American Snctety of Anesthesiologistr Tark Force on Guide- linlrs for Pulmonary Artery Catheterization: M~chaeI F. Rolzen, M.D. (Chair). Ikpanmenr of Anecthesiolr>w. SUNY Upstatc. S y a c i ~ x . Ncw York, and Drpan- men€ of Anesthesia and Cnrrcal Care, University of Chicago. Chrca~o, IlI~nolf. David 1, RcrI:cr, M.D (Pnvate kactlct.). Pledn~tmt. ~ l l f ~ r n ~ a : R o d d k (iahel. M.11.. Depannlent of Anestllcsiolrm. IJniwnity of Rr>chc%tcr. Rochcst~-r. Ncw Yurk: John Ccrson. M.11. (Pdvatc Practice). Syracuse. New York, Jonathan R. Mark. M.D.. Dcpartml-nt of hnesthesiolopy. Duke Umversity Medical Center. Durham, N o h C3rolina; Rohrn I. Parks. Jr., A1.D. ffrivatc Pmcti~r). Dallw TLX~Y; David A hulus. M.I3., Depanmcnt of Anrsthrs~r>lngy, Un~vcrsiv of Florida, GmnesvilIc, I:lurida: Juhn S. Srntth, M.D (Private Prxctice), h s Vepq. N e m d a ; and Sreven H. Worjlf. M.U.. M.P.H. M e t h u d o l o ~ Consultant). Depan- ment of Rrnily Practice, Virginia c.mmonwealrh Ilnivrsity. Fairfax. Virf:tnra. Submincrl for puhlicatiun Ntlvrmber 211. 2002. hrmprcx! for puhl~car~on Nnvem- ber 20. ZMIZ.

Address rrprep requests to the American Sociery of A n ~ s t h c ~ i o t o ~ m 520 North Norrhwest Highway. Rrk Ridge, lll~nois hon(IK2573. Individual Practicc Guideline may hc obraind at nu cost thruu~h thc Joumat Web sinr. www.nnesthes~olngy or^

measuring imponant hernodynamic indices (e.g., FA oc- cfusion pre~,cute, cardiac output, mixed venous oxygen saturation) allows more accurate determination of the hernodynamic status of critically ill patients than is po+ sible by clinical assessment alone. The additional infor- mation can be important in caring for patients with confusing clinicaI pictures, in whom errors in fluid man- agement and drug therapy can hare important conse- quences. In surgical patients, PA catheter data often help evaluate hernodynamic changes that may lead to serious perioperative complications. Preoperative PA catheter data are purported to be helpfuI in determining whether it is safe for high-risk patients to proceed with surgery.

PA catheterization can also have important adverse effects. Catheter insertion can resuIt in atterial injury, pneumothorax, and arrhythmias. The catheter can he associated with potentiaIly fatal PA hemorrhage, throrn- boernbolism, sepsis, and endocardial damage.

The American Society of AnesthesioIogists established the Task Force on Pulmonary Artery Catheterization in 1991 to examine the evidence for benefits and risks from PA catheter use in settings encountered by anesthesiol- ogists, By the rime the Society's guidelines were adopted in 1992 and published in 1993 ,~ several p u p s had issued statements on the appropriate indications for PA catheterization and on competency requirements for he- modynamic moni:toring. Rlese groups included the American College of Physicians/American College of Car- diolegy/herican Heart Association Task Force on CIin- ical Privileges in ~ardiology,b a panel estabiished by the Ontario Ministry of ~ealth, ' and an expert panel of the European Society of Intensive Care ~edicine.' In subsequent years, a variety of studies, most notably

an Investigation by Connors et wl.," raised douhts about the effectiveness and safety of pulmonary artery cathe- terization (PAC). This literature, and the controversy it stimulated, gave rise to additional policy statements from the American College of Chest Physicians (Northbrook, Illinois), American Thoracic Society (New York, New York), and the American ColIege of Cardiology (Re- thesda, ~a r~ land) ' ' and from such convocations as a consensus conference convened by the Society of Criti- cal Care Medicine (DesPlaines, ~llinois)" (subsequently endorsed by multiple organizations) and a 1998 work- shop convened by the Food and Drug Administration @ockvilIe, Maryland) and the National Institutes of HeaIth methesda, Maryland)." F ~ e w of these efforts fo-