New horizons (Baltimore, Md.)
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To review the literature addressing ethical issues related to clinical research and the pulmonary artery catheter (PAC). ⋯ Randomized clinical trails of pulmonary artery catheterization can ethically be conducted.
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To review the literature addressing use of the pulmonary artery catheter (PAC) in patients with sepsis and septic shock. ⋯ Based largely upon expert opinion, PAC use may be appropriate in patients with septic shock unresponsive to early resuscitative measures. Maintenance of normal hemodynamics in this group of patients appears to be the appropriate goal. Research is needed to determine the proper role of the PAC in patients with sepsis/septic shock.
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To review the literature addressing use of the pulmonary artery catheter (PAC) to augment oxygen delivery to supranormal levels in critical illness. ⋯ Further research must be performed before a recommendation can be made about goal-oriented hemodynamic intervention utilizing the PAC to augment oxygen delivery to supranormal levels prior to high-risk surgery. PAC-guided hemodynamic intervention to augment oxygen delivery to supranormal values in patients with SIRS-related organ dysfunction from sepsis, trauma, or postoperative complications is not recommended at this time. Carefully designed, multicenter, randomized, controlled trials are needed to establish whether augmenting oxygen delivery improves organ-specific outcomes and survival under each of these circumstances.
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To review the literature addressing the new pulmonary artery catheters: continuous venous oximetry, right ventricular ejection fraction, and continuous cardiac output. ⋯ Clinician misinterpretation and misapplication of the data appear to be the greatest impediment to using pulmonary artery catheterization to alter pathophysiologic processes and improve outcome in critically ill patients. Future research should first document effectiveness or lack of effectiveness of the "standard" pulmonary artery catheter (PAC). Pending these results, outcome and cost/benefit studies should be performed comparing "standard" with new PACs.
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To review the literature addressing the use of the pulmonary artery catheter (PAC) in victims of blunt and penetrating trauma and examine the available evidence that supports or refutes the claim that PAC use alters outcome in this patient population. Furthermore, to determine what additional research should be done in this area. ⋯ Hemodynamic data obtained from the PAC appear to be beneficial for the following indications: a) to ascertain the status of underlying cardiovascular performance and/or the need for improvement; b) to direct therapy when noninvasive monitoring may be inadequate, misleading, or the endpoints of resuscitation difficult to define; c) to assess response to resuscitation; d) to potentially decrease secondary injury when severe closed-head or acute spinal cord injuries are components of multisystem trauma; e) to augment clinical decision-making when major trauma is complicated by severe adult respiratory distress syndrome, progressive oliguria/anuria, myocardial ischemia, congestive heart failure, or major thermal injury; and f) to establish futility of care.