Recommendations
The votes by the Task Force (see tables 6 and 7 of the original guideline document) demonstrated that the appropriateness of routine pulmonary artery (PA) catheterization depends on the combination of risks associated with the (a) patient, (b) surgery, and (c) practice setting (the latter referring to the risks from PA catheterization introduced by practice conditions and staff circumstances). The votes are depicted graphically in figure 3 of the original guideline document. With some exceptions, routine catheterization is generally inappropriate for low- or moderate-risk patients. The three variables are defined in greater detail below.
Patient
Patients at increased risk for hemodynamic disturbances are those with clinical evidence of significant cardiovascular disease, pulmonary dysfunction, hypoxia, renal insufficiency, or other conditions associated with hemodynamic instability (e.g., advanced age, endocrine disorders, sepsis, trauma, burns). Patients at low risk include those with American Society of Anesthesiologists (ASA) physical status of 1 or 2 or those with hemodynamic disturbances unlikely to cause organ dysfunction. Those at moderate risk are in category ASA 3 or have hemodynamic disturbances that occasionally cause organ dysfunction. Those at high risk are in category ASA 4 or 5 and have hemodynamic disturbances with a great chance of causing organ dysfunction or death. The assessment of risk should be based on a thorough analysis of the medical history and physical examination findings, rather than on exclusive consideration of specific laboratory results or other quantitative criteria.
Procedure
Surgical procedures associated with an increased risk of complications from hemodynamic changes, including damage to the heart, vascular tree, kidneys, liver, lungs, or brain, may increase the chance of benefiting from PA catheterization. This report does not provide a list of indicated procedures and disease states for catheterization because the Task Force believes that catheterization decisions should be based on the hemodynamic risk characteristics of the individual case rather than on the type of procedure. The Task Force defines low-risk procedures as those carrying a small probability of fluid changes or hemodynamic disturbances and having low perioperative morbidity or mortality. Moderate-risk procedures have a moderate chance of fluid changes, hemodynamic disturbances, or infection that could cause morbidity or mortality. High-risk procedures have a predictably large chance of fluid changes or hemodynamic disturbances or other factors with high risk of morbidity and mortality.
Patients undergoing procedures that usually lack hemodynamic complications may need PA catheterization if circumstances pose a special risk. The clinician should therefore assess hemodynamic risks based on the case at hand and not on generic criteria.
Practice Setting
The setting for the procedure may increase the risk of complications from hemodynamic changes. Factors that should be considered in assessing perioperative risk include catheter use skills and technical support. Factors affecting postoperative risk include the level of training and experience of nursing staff in the recovery room and intensive care unit (ICU), technical support for ancillary services, and the availability of specialists and equipment to manage potential complications detected by the PA catheter.
