Trends in the use of pulmonary artery catheterization in the aneurysmal subarachnoid hemorrhage population

Pulmonary artery catheter receipt among cardiac surgery patients from the national inpatient sample (1999-2019): Prevalence, predictors and hospitalization charges

Despite limited evidence to support its efficacy, use of pulmonary artery catheter (PAC), a relatively expensive medical device, for monitoring clinical status and guiding therapeutic interventions, has become standard of care in many settings, and especially during and after cardiac surgery. We examined the prevalence and predictors of PAC use and its association with hospitalization charges among cardiac surgery patients generally and for each selected subgroup of high-risk or complex surgical procedures. We conducted an analysis on 1,442,528 records from the National Inpatient Sample (1999-2019) that included cardiac surgery patients ≥18 years of age. Subgroups were categorized based on the presence of specific disorders like tricuspid or mitral valve disease, pulmonary hypertension, heart failure, or cardiac surgery combinations. Multivariable regression models were constructed to assess predictors of PAC use as well as PAC use as a predictor of loge hospitalization charges controlling for patient and hospital characteristics. Based on International Classification of Diseases procedure codes, PAC use was prevalent among 7.15 % of cardiac surgery hospitalizations, and hospitalization charges were estimated at $191,345, with no differences according to PAC use. Overall, being female, having Charlson comorbidity index (CCI) > 0, and non-payer (versus Medicare) status were independently associated with PAC use. Among the subgroup with the selected conditions, being female, having CCI>0, and being a Medicaid (versus Medicare) recipient were independently associated with PAC use, whereas elective admission was inversely related to PAC use. Among the subgroup without the selected conditions, having a CCI >0, elective admission, and non-payer (vs. Medicare) status were independently associated with PAC use. PAC use was not independently related to hospitalization charges overall or among subgroups. In conclusion, approximately 7 % of cardiac surgery hospitalizations received a PAC, with no differences in charges according to PAC use and disparities in PAC use driven by sex, elective admission, CCI and health insurance status. Large randomized trials are required to characterize the safety, efficacy, and cost-effectiveness of PAC use among distinct groups of patients undergoing cardiac surgery.

Association of pulmonary artery catheter with in-hospital outcomes after cardiac surgery in the United States: National Inpatient Sample 1999-2019

To examine associations of pulmonary artery catheter (PAC) use with in-hospital death and hospital length of stay (days) overall and within subgroups of hospitalized cardiac surgery patients. Secondary analyses of 1999-2019 National Inpatient Sample data were performed using 969,034 records (68% male, mean age: 65 years) representing adult cardiac surgery patients in the United States. A subgroup of 323,929 records corresponded to patients with congestive heart failure, pulmonary hypertension, mitral/tricuspid valve disease and/or combined surgeries. We evaluated PAC in relation to clinical outcomes using regression and targeted maximum likelihood estimation (TMLE). Hospitalized cardiac surgery patients experienced more in-hospital deaths and longer stays if they had ≥ 1 subgroup characteristics. For risk-adjusted models, in-hospital deaths were similar among recipients and non-recipients of PAC (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.96, 1.12), although PAC was associated with more in-hospital deaths among the subgroup with congestive heart failure (OR 1.14, 95% CI 1.03, 1.26). PAC recipients experienced shorter stays than non-recipients (β =  - 0.40, 95% CI - 0.64, - 0.15), with variations by subgroup. We obtained comparable results using TMLE. In this retrospective cohort study, PAC was associated with shorter stays and similar in-hospital death rates among cardiac surgery patients. Worse clinical outcomes associated with PAC were observed only among patients with congestive heart failure. Prospective cohort studies and randomized controlled trials are needed to confirm and extend these preliminary findings.

Insights into Hemodynamic Features of Survivors and the Deceased with Acute Brain Injury: A Step Forward Tailored Treatment

BACKGROUND

Pulmonary artery catheters are widely used for hemodynamical monitoring in critically ill patients. Acute brain injury is among the severe conditions treated in an intensive care unit. The advanced monitoring of hemodynamical parameters, fluid balance and adequate administered treatment based on those values are components of goal-directed therapy.

METHODS

A prospective observational study included adult patients who were hospitalized in the ICU due to acute bran injury, excluding brain oedema after cardiac arrest. Each patient had PAC inserted and hemodynamic data were collected during the first 3 days of the ICU stay every 6 h. Patients were divided into two groups based on the endpoint: the survivors and the deceased.

RESULTS

Length of stay in hospital differed between patiens. All patients, regardless of their outcome, had noradrenaline administered. The initial values of PAP differed between the groups (p = 0.05). There were positive correlations noticed between noradrenaline dose, CVP and fluid balance when compared to PCWP in a group of survivors and a positive correlation in the fluid balance when compared to PAP and PVRI. Lactate serum concentrations presented a correlation with the dose of noradrenaline in both groups.

CONCLUSIONS

Upon acute brain injury, values of PVRI and PAP increase. This is corelated with fluid load and worsened by an excessive fluid treatment in the case of an inconsiderate approach for stabilizing the patient hemodynamically. PAC may present limited advantages in terms of PAP and PVRI control during the treatment.

Racial and Ethnic Disparities in Treatment Outcomes of Patients with Ruptured or Unruptured Intracranial Aneurysms

OBJECTIVE

The aim of this study is to examine how health outcomes varied by treatment selection and race/ethnicity among hospitalized US patients with ruptured or unruptured IAs.

METHODS

A retrospective cohort study was conducted using a sample of 62,224 hospital discharges from the 2002-2012 Nationwide Inpatient Sample. Logistic regression models evaluated treatment selection as predictor of in-hospital survival (IHS: "yes," "no") and length of stay (LOS ≤ 7 days, > 7 days), overall and across racial/ethnic groups, taking hospital- and patient-level confounders into account, while stratifying by IA rupture status.

RESULTS

Compared to surgical clipping, endovascular coiling was associated with better IHS, after controlling for confounders. Compared to surgical clipping, LOS ≤ 7 days was less likely in patients with combination of treatments and more likely among patients with endovascular coiling as well as balloon- or stent-assisted coiling. Observed relationships varied significantly by race and ethnicity for IHS, but not for LOS ≤ 7 days. Whereas combination of treatments were associated with worse IHS than surgical clipping among Blacks alone, endovascular coiling was associated with better IHS than surgical clipping among White and Other racial/ethnic subgroups. These relationships were for the most part consistent among patients with and without IA rupture.

CONCLUSIONS

Racial and ethnic subgroups of IA patients experienced differential IHS by treatment selection, irrespective of IA rupture status. Prospective cohort studies are needed to further elucidate these racial and ethnic disparities, while collecting data on IA size, location, and morphology as well as Hunt and Hess grade for ruptured IA.