Cardiovascular monitoring in sepsis: why pulmonary artery catheters should not be used

The pulmonary artery catheter (PAC) has been used extensively to guide treatment of severe sepsis. However, it has some risk of complications, and limitations in knowledge of its proper use may lead to inaccurate data. In 1996, an observational cohort study found that use of a PAC in the first 24 hours of intensive care was associated with increased 30-day mortality, length of stay and cost. This prompted prospective randomised studies. Six such studies have been published, four of which included significant numbers of patients with sepsis. All have found that, although there was no increase in deaths with PAC use, neither was there benefit in mortality in the intensive care unit, hospital or up to 90 days, nor any difference in ICU or hospital length of stay, and no reduction in organ failures or need for organ support. The PAC-Man study, a pragmatic study of 1014 patients, found no benefit compared to usual treatment, which in 80% of cases was allowed to include alternative measures of cardiac output. The recent Fluid And Catheter Treatment Trial (FACTT) of 1000 patients had similar findings when the control group used central venous pressure and clinical assessment of adequacy of cardiac output. Functional rather than static measures of pressure better predict fluid responsiveness. Furthermore, whether measuring cardiac output using any method can improve outcome is unknown. In the treatment of patients with severe sepsis as a whole, the PAC offers no benefit and some risk. Subgroups with specific benefit or harm may exist.