dxy

Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients*.
Friese, Randall S. MD; Shafi, Shahid MD; Gentilello, Larry M. MD
Publish Ahead of Print, POST ACCEPTANCE, 4 April 2006

OBJECTIVE: To evaluate the association between pulmonary artery catheter (PAC) use and mortality in a large cohort of injured patients. We hypothesized that PAC use is associated with improved survival in critically injured trauma patients.
DESIGN: Retrospective database analysis.
SETTING: A total of 268 level 1 trauma centers from across the United States.
PATIENTS: A total of 53,312 patients admitted to the intensive care units of the trauma centers participating in the National Trauma Data Bank maintained by the American College of Surgeons.
MEASUREMENTS AND MAIN RESULTS: The National Trauma Data Bank was queried to identify patients aged 16-90 yrs with complete data on base deficit, and Injury Severity Score (n = 53,312). Patients were initially divided into two groups: those managed with a PAC (n = 1,933) and those managed without a PAC (n = 51,379). Chi-square and Student's t-test analysis were utilized to explore group differences in mortality. In a second analysis, groups were stratified by base deficit, Injury Severity Score, and age to further explore the influence of injury severity on PAC use and mortality. In addition, a logistic regression model was developed to asses the relationship between PAC use and mortality after adjusting for differences in age, mechanism, injury severity, injury pattern, and co-morbidities. Overall, patients managed with a PAC were older (45.8 +/- 21.3 yrs), had higher Injury Severity Score (28.4 +/- 13.5), worse base deficit (-5.2 +/- 6.5), and increased mortality (PAC, 29.7%; no PAC, 9.8%; p < .001). However, after stratification for injury severity, PAC use was associated with a survival benefit in four subgroups of patients. Each of these groups had advanced age or increased injury severity. Specifically, patients aged 61-90 yrs, with arrival base deficit worse than -11 and Injury Severity Score of 25-75, had a decrease in the risk of death with PAC use (odds ratio, 0.33; 95% confidence interval, 0.17-0.62). Three additional groups had a similar decrease in the risk of death with PAC use: odds ratio, 0.60 (95% confidence interval, 0.43-0.83), 0.82 (95% confidence interval, 0.44-1.52), and 0.63 (95% confidence interval, 0.40-0.98). Logistic regression analysis demonstrated a decreased mortality when a PAC was used in the management of patients with the following severe injury characteristics: Injury Severity Score of 25-75, base deficit of less than -11, or age of 61-90 yrs (odds ratio, 0.593; 95% confidence interval, 0.437-0.805).
CONCLUSIONS: Trauma patients managed with a PAC are more severely injured and have a higher mortality. However, severely injured patients (Injury Severity Score, 25-75) who arrive in severe shock, and older patients, have an associated survival benefit when managed with a PAC. This is the first study to demonstrate a benefit of PAC use in trauma patients.(Crit Care Med 2006; 34:●●●–●●●)
KEY WORDS: pulmonary artery catheter; complication; injury; trauma; mortality; National Trauma Data Bank
严重创伤病人使用PAC可降低死亡率
摘要翻译：
目的：评估大量创伤病人使用PAC与死亡率的相关性。我们假设，在危重创伤病人中使用PAC可提高存活率。
设计：回顾性数据分析。
地点：美国268个1级创伤中心。
患者：进入创伤中心ICU的53，312名患者，通过美国大学的外科医生收集资料入国家创伤数据库。
检测与主要结果：根据碱不足及创伤评分在国家创伤数据库检索年龄为16-90岁的患者（n=53，312）。患者被分为两组：使用PAC组（n=1，933）与非使用PAC组（n=51，379）。通过卡方检验和Student’s t-test分析组间死亡率的差异。通过碱缺乏、创伤严重性评分和年龄进一步分组分析创伤严重性对PAC使用和死亡率的影响。此外，通过调整年龄、机械装置、创伤严重性、损伤方式和co-morbidities的差异后，建立logistic回归模型以评估使用PAC与死亡率之间的关系。结果：PAC组年龄较大(45.8±21.3 yrs)，损伤严重性评分更高(28.4 _ 13.5)，碱缺乏更明显(-5.2±6.5)，死亡率更高(PAC, 29.7%; no PAC, 9.8%; p < .001)。然而，在根据损伤严重性分组后，四个亚组之间，使用PAC与存活率改善相关。这些组均为老年或创伤严重性高。特别是年龄在61-90者，碱缺乏甚至到-11，而损伤严重性评分为25-75，使用PAC后死亡率降低(odds ratio, 0.33; 95%可信区间, 0.17– 0.62)。另外三组使用PAC死亡率降低程度相当：odds ratio, 0.60 (95%confidence interval, 0.43– 0.83), 0.82 (95% confidence interval,0.44 –1.52), and 0.63 (95% confidence interval, 0.40–0.98)。logistic回归分析表明：在具有下列严重损伤特点的病人中使用PAC死亡率降低：损伤严重性评分25-75，碱缺乏低于-11，或年龄在61-90(odds ratio, 0.593;95% confidence interval, 0.437– 0.805)。
结论：使用PAC的创伤病人损伤更严重，死亡率更高。但是，存在严重休克的重度创伤病人（损伤严重性评分25-75）和老年患者使用PAC可改善死亡率。这是首次研究证明在创伤病人中使用PAC是有益的。
关键词：PAC；并发症；损伤；创伤；死亡率；国家创伤数据库

有关PAC较新的文献还有：
Cardiac output by PulseCOTM is not interchangeable with thermodilution in patients undergoing OPCAB: [L'evaluation du debit cardiaque par PulseCOTM n'est pas interchangeable avec celle de la thermodilution chez des patients devant subir un PACCB]
Yama***a et al.
Can. J. Anaesth 2005;52:530-534.

Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: The Task Force on Acute Heart Failure of the European Society of Cardiology
Endorsed by the European Society of Intensive Care et al.
Eur Heart Journal 2005;26:384-416.

PulseCO: a less-invasive method to monitor cardiac output from arterial pressure after cardiac surgery
Hamilton et al.
Ann. Thorac. Surg. 2002;74:S1408-1412.

Safe, highly selective use of pulmonary artery catheters in coronary artery bypass grafting: an objective patient selection method
Schwann et al.
Ann. Thorac. Surg. 2002;73:1394-1401.

现临床常用Swan-Ganz导管监测PAP，肺动脉阻塞压（PAOP），CO，SvO2，SVR等参数，而PAOP为其最重要参数之一，主要间接反映左心功能。
由于心室舒张末期容积测量难度大，常以心室充盈压即左室舒张末压（LVEDP）、PAOP、右房压（RAP）或中心静脉压（CVP）予以间接判断。左心室舒张末期，血液停止向心室充盈的瞬间，LVEDP=左房压（LAP）= PAOP，即左室舒张末容积（LVEDV，真实的左室前负荷）与以PAOP间接所反映的LVEDP之间存在相关性或一致性。动脉阻塞压（PAOP）、右房压（RAP）或中心静脉压（CVP）予以间接判断但左室顺应性、左心室功能、气道压、二尖瓣功能、左房顺应性或肺血管阻力的改变均可扰乱PAOP与左室前负荷间可能存在的相关性或一致性。因而此时PAOP 、LVEDP难以代表或反映LVEDV的变化，换言之，PAOP的临床监测意义则受限，甚至误导治疗。

编辑：西门吹血