News:Cardiologists’ Use of Pulmonary Artery Catheter Information in CCU Treatment Decisions
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October 10, 2007 By Grendel Burrell [1]
Chicago, Il: Despite debate and conflicting evidence over the efficacy of the pulmonary artery catheter (PAC), intensivists frequently employ this intervention in the ICU setting. The reasons for the varied outcomes in clinical trials and experience are not clear though reports have detailed complications due to insertion and maintenance of the insertion site and catheter (1, 2). Jain et al, in the September-October issue of the Journal of Intensive Care Medicine (3) describe the results of their effort to establish if cardiologists given PAC data from critically ill cardiology patients make uniform management choices.
Gnaegi et al suggested that the insufficient knowledge of bedside right-heart catheterization by intensive care physicians might require action after they undertook a study to evaluate French, Swiss, and Belgian intensive care physicians' knowledge about the PAC. 535 critical care physicians working in 86 ICUs participated. All physicians in any one ICU simultaneously, anonymously, and without prior notice, completed a multiple-choice questionnaire about aspects of bedside PAC. 68% of respondents in training self-reported that their knowledge of PAC was less than adequate; 36% of those who had completed their postgraduate training also believed their knowledge to be inadequate. The mean score of all respondents was 72.2 +/- 14.4%, significantly lower (p<.0001) in case of unfinished training (67.3 +/- 14.7%, lower quartile 56.7%, median 70.0%, upper quartile 76.7%), as compared with completed training (76.1 +/- 13.0%, lower quartile 70.0%, median 80.0%, upper quartile 86.7%). In multivariate analysis, the location of the ICU in a university hospital, the belief of respondent that his/her knowledge of the pulmonary artery catheter was adequate, and the responsibility for supervising catheter insertion were the only independent predictors of good performance on the questionnaire (p < .001 for all three variables). The survey was unable to identify any subcategory of physicians with a uniformly good knowledge of the PAC. The authors found “the proportion of incorrect answers to some basic items was disturbingly high. For instance, approximately 50% of the respondents, whether trained or in training, did not correctly identify pulmonary artery occlusion pressure from a clear chart recording.” (4)
Zarich and colleagues detailed the failure of a brief educational program to improve interpretation of PA occlusion pressure tracings. They sought to determine whether a brief educational program can reduce variability of interpretation of pulmonary artery occlusion pressure (PAOP) tracings, and designed a retrospective, observational study. The participants were 23 intensive care nurses and 18 physicians who interpreted PAOP tracings before and 1 week after receiving a single, brief educational session and/or written materials designed to reduce interobserver variability of PAOP interpretation. The authors found no significant differences in the variability of PAOP interpretations before and after in-service in either group and concluded that this specific educational program was ineffective in reducing variability of interpretation of PAOP tracings. They suggested that more comprehensive educational tools and programs might be required to improve performance of critical care personnel in PAOP interpretation. (5)
In a previous study, Jain et al found information to suggest that medical intensivists choose heterogeneous interventions when provided identical PAC information and that the intervention selected was influenced by concomitant echocardiographic information (6). In the current study, the authors sought to determine if the heterogeneity found amongst medical intensivists is a general phenomenon by learning whether cardiologists use PAC data to select homogenous interventions.
The authors of the current study executed a survey of board certified cardiologists in the state of Illinois and a survey of Chicago area board certified medical intensivists in which the participants were asked to respond to three clinical vignettes. The scenarios were developed by a board certified cardiologists and validated by a board certified intensivist. A portion of the vignettes included echocardiographic (echo) information in order to establish if additional noninvasive assessment of cardiac function affected physician decisions when using PAC data.
For each vignette, the participants were required to first answer whether or not a PAC was indicated. Next the respondents were asked to choose a single intervention from six choices, five common ICU treatments (normal saline infusion, dobutamine, dopamine, nitroprusside, or furosemide, or none of the above. There were 163 evaluable surveys.
60% of the group of survey participants had been in practice for >10 years. 60% of the participants managed patients in the CCU at least 17 week yearly, and 60% placed > 10 PACs each year. 24.4% of respondents placed >40 PACs/year.
For vignette #1, 65% of cardiologists and 50% of intensivists indicated that a PAC was required for the situation. For vignette #2, 82% of cardiologists and 30% of intensivists specified that a PAC was needed. For vignette #3, there was agreement between cardiologists and intensivists with only 10% of each group indicating the need for PAC.
For vignette #1, 71% of respondents selected the same choice for treatment, and in vignette #3, 90% selected the same intervention. For vignette # 2, 51% of cardiologists selected dobutamine, and 20% of cardiologists chose dopamine. In the same vignette, 75% of intensivists chose dobutamine. The most frequently selected intervention and the distribution of the selected interventions for each vignette was not statistically different between cardiologists and intensivists.
The authors note that the study may be limited by the information provided in the vignettes and the generalizability of the data. While done in the state of Illinois, the distribution of participants by characteristics of practice or years of experience may be different in other states. If the vast majority of the participants trained, for example, in Illinois, the training programs may influence decision-making.
The results of the study by Jain et al demonstrate that cardiologists value PAC information in some, but not all, complex CCU situations. Also, it appears that cardiologists tend to make relatively homogenous treatment decisions using PAC data. In this study, the echo information did not impact the perceived utility of PAC information or treatment pathways. The authors state, “one can infer that cardiologists seem to view echocardiographic information as superfluous when presented with PAC information.”
References:
<Biblio>
- ref1 pmid=8782638
</Biblio>
<Biblio>
- ref3 pmid=17895483
</Biblio>
<Biblio>
- ref4 pmid=9034253
</Biblio>
<Biblio>
- ref5 pmid=10945386
</Biblio>
<Biblio>
- ref6 pmid=14669763
</Biblio>
