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Ann Thorac Surg 2002;73:1401-1402
© 2002 The Society of Thoracic Surgeons
a SICU, Department of Anesthesia, Hospital of the University of Pennsylvania, 3400 Spruce Street, 5 Founders, Philadelphia, PA 19104, USA
e-mail: hansonb{at}mail.med.upenn.edu
As recently as fifteen years ago, it was axiomatic that the acquisition of more data about patients would confer improved outcomes. Nowhere was this belief more evident than in high profile environments like cardiac surgery. In the intervening decade, spiraling medical costs and our efforts to control them have modified the axiom to read "more is better provided you can afford it."
We now believe that less is better in some instances. Less ventilation is clearly in vogue, as are shorter hospital stays following routine cardiac surgery. However, we still like more date in the immediate perioperative period. Intraoperative transesophageal echocardiography (TEE) is increasingly integrated into the practice of cardiac surgery. Many cardiac surgeons and anesthesiologists use a "belt and suspenders" approach, combining TEE and pulmonary arterial catheterization. In addition, multifunctional pulmonary arterial catheters (PAC) providing continuous cardiac output, mixed venous oxygen saturation, and right ventricular end-diastolic volume are gaining market share.
There is another important caveat about data acquisition, which is "more is (sometimes) less." An example of a method of data acquisition that can be associated with prohibitive, albeit nonfiscal, costs is amniocentesis. Until recently, we have not considered pulmonary arterial catheterization to be risky except for the complications associated with central venous cannulation. However, a series of recent studies have challenged the safety of the PAC. As a result, we must now consider both the real financial costs and the safety issues associated with pulmonary arterial catheterization as an adjunct to cardiac surgery.
The authors of this manuscript have done a commendable job of attempting to make some objective observations about what types of CABG patients are likely to benefit from the additional information provided by the PAC in the immediate perioperative period. While admittedly retrospective, the data pertains to a large group of patients that is diverse both in terms of preoperative risk factors and post-operative outcomes and representative of the STS database of CABG patients. As a result, we have an opportunity to consider the utility of the PAC in several discrete subsets and to make reasoned extrapolations to our own practices.
While further, prospective, multi-institutional studies are clearly warranted, we can comfortably conclude from the data in this study that PACs are not a prerequisite for good outcomes in most uncomplicated cardiac revascularization procedures.
Related Article
Ann. Thorac. Surg. 2002 73: 1394-1401.
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