This 'hypertext' guide to the use of pulmonary arterial catheters is intended for use by both medical staff and critical care nursing staff.

It has been produced in the belief that a significant proportion of the physicians ^{1, 2} and nurses ^{3, 4} who work in critical care areas may not have an appropriate working knowledge of the use of these catheters.

It is also a response to the suggestions that:

"Improved training in the insertion, interpretation, and implementation of the pulmonary artery catheter and the data it generates is required." ⁵

"Clinician knowledge about use of the PAC and its complications should be improved." ⁶ and

"A need exists for collaborative education of physicians and nurses in performing, obtaining, and interpreting information from the use of pulmonary artery catheters." ¹¹

The problem of inappropriate or incorrect use of the PAC has been addressed by numerous professional groups including the American Society of Anesthesiologists, who have published a set of practice guidelines ⁷ and the American Heart Association, who have defined the requisite cognitive skills for haemodynamic monitoring ⁸.

The guide addresses most of the issues which are raised in this definition of requisite cognitive skills ⁸ and incorporates a simulator which can be used for proficiency examination and simulation testing as recommended by the American Society of Anesthesiologists task force ⁷ .

Readers are also referred to the important consensus statement published in the journal 'Critical Care Medicine' ⁵ and the review by Gomez and Palazzo ⁹ - both of which evaluate the role of the pulmonary artery catheter in considerable detail. More recently, Ivanov et al ¹⁰ have conducted a meta-analysis of 1610 critically-ill patients who were participating in RCTs designed to examine the efficacy of pulmonary arterial catheterisation. These (and other studies) are discussed in the section entitled 'Risk:Benefit analysis'.

Using the hypertext:
The 'hypertext' uses traditional techniques. - References (and abstracts if available) can be viewed by clicking on the appropriate red reference number. Similarly, figures and tables can be viewed by clicking on the red hypertext link. The meaning of any abbreviations used in the text are defined in the 'abbreviations' page.

In order to play the videos, click on the appropriate link wherever a video is cited. You will need the Microsoft Windows Media Player version 7 to play the clip.

'Jumps' to another section are made by clicking on the appropriate section in the index, or in the body of the text itself. Use the 'Back' button of your browser to retrace your path through the text.

To print the contents of a page, 'right click' your mouse-button and select the 'print' option.

Using the simulator:
The guide is intended to be used in combination with the simulator which reproduces the behaviour of a pulmonary artery catheter as it is passed through the right side of the circulation on its way to the pulmonary artery. The simulator can be found at http://www.manbit.com and is installed automatically if you have purchased the CD version of the project. This simulator is controlled by a 'state engine' which reproduces many of the problems which may be observed during the insertion of a PAC. These include:

Overwedging.

Atrial arrhythmias.

Ventricular arrhythmias.

Ventricular fibrillation.

Complete heart block.

Passage down the Inferior Vena Cava.

Ventricular coiling.

Pulmonary artery rupture.

The simulator includes scenarios for patients with acute myocardial infarction, pulmonary hypertension and mitral incompetence. It can also be interfaced to a manikin (available from Syrinx Technology) that allows the user to catheterise the internal jugular vein with a pulmonary artery catheter introducer and to pass a pulmonary artery catheter to its final wedged position in the pulmonary artery.

The simulator also incorporates a haemodynamic and metabolic calculator, a vasoactive infusion rate calculator and a working model of the haemoglobin dissociation curve. The use of the simulator is described in the section titled 'Simulation Exercises'.

The guide has been developed by Dr. Andrew Pybus, with the assistance of Drs. Maggie Bailey and Michael Cooper - all of whom are practising cardiac anaesthetists in Sydney, Australia.

Sponsorship:
The production of this version was sponsored by Becton Dickinson Critical Care Systems PL.

Contacting the authors:
Dr Andrew Pybus
Dr Michael Cooper
Dr Maggie Bailey

Internet Standards Compliance:
The document seeks to comply with the recommendations of the British Healthcare Internet Association on 'Quality Standards for Medical Publishing on the World Wide Web'.

1. Iberti TJ, Fischer EP, Liebowitz AB et al. A multicenter study of a physician's knowledge of the pulmonary artery catheter. JAMA 264:2928-2933, 1990

2. Gnaegi A, Feihl F, Perret C. Intensive care physicians' insufficient knowledge of right heart catheterisation at the bedside: time to act? Crit Care Med 1997; 25:213-220

3. Burns D; Burns D; Shively M; Critical care nurses' knowledge of pulmonary artery catheters. Am J Crit Care, 5(1):49-54 1996 Jan

4. Iberti TJ; Daily EK; Leibowitz AB; Schecter CB; Fischer EP; Silverstein JH. Assessment of critical care nurses' knowledge of the pulmonary artery catheter. Crit Care Med, 22:1674-8, 1994 Oct

5. Vincent JL, Dhainaut JF, Perret C, Suter P. Is the pulmonary artery catheter misused? A European view. Crit Care Med, 26:1283-7, 1998 Jul

6. Pulmonary Artery Catheter Consensus conference: consensus statement. Crit Care Med 1997 Jun;25(6):910-25

7. Roizen MF, Berger DL, Gabel RA et al Practice Guidelines for pulmonary artery catheterization. A report by the American Society of Anesthesiologists task force on pulmonary artery catheterization. Anesthesiology 78:380-394, 1993

8. American Heart Association Task Force on Clinical Privileges in Cardiology. Clinical competence in hemodynamic monitoring. J Am Coll Cardiol 15:1463, 1990

9. Gomez CMH and Palazzo MGA Pulmonary artery catheterization in anaesthesia and intensive care. Br. J. Anaesth. 1998; 81: 945-956

10. Ivanov R, Allen J, Calvin JE The incidence of major morbidity in critically ill patients managed with pulmonary artery catheters: a meta-analysis. Crit Care Med 2000 Mar;28(3):615

11. Bernard GR, Sopko G, Cerra F et al Pulmonary artery catheterization and clinical outcomes: National Heart, Lung, and Blood Institute and Food and Drug Administration Workshop Report. Consensus Statement. JAMA 2000 May 17;283(19):2568-72

Last edited on: 24/12/2000