Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: Conclusion

In: Surgical Patients

17 Mar 2015

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: ConclusionBlood pressure, heart rate, hematocrit, CVI? ECG, urine output, and blood gases are conventional measurements that are well recognized descriptors of acute crises as well as the end stages of circulatory failure. Although these variables should be monitored and corrected if abnormal, they are neither sensitive nor accurate descriptors of circulatory decompensation in the perioperative period. However, the use of PA catheters in surgical patients is considered to be highly controversial because of the lack of adequately controlled clinical trials. Recently, Robin has called attention to the fact that use of PA catheters has assumed epidemic proportions without clinical trials establishing improved outcome from their use. Moreover, hospitals and third-party payers view PA catheterization in the surgical patient as a potentially morbid and unnecessary expense.

The present study reaches the opposite conclusion; PA catheterization is highly efficacious in terms of both patient outcome and cost containment when used as part of a management plan to augment physiologic circulatory function in the perioperative period. Nonetheless, the overwhelming majority of PA catheterizations performed in general surgical patients are not used to obtain the right heart catheterization data crucial to evaluation of oxygen transport; in fact, about 95 percent of such perioperative catheterizations are used only to obtain WP data (personal communication, Helmut F. Kaspar, MD, Medicare Physician Support Section, Transamerica-Occidental Insurance Co., August 1985). Under these conditions of use, the present study suggests that PA catheterization is not better than CVP monitoring when normalization of hemodynamic values is the therapeutic goal.
We conclude that “normal” hemodynamic values are appropriate for normal unstressed subjects, but the cardiorespiratory patterns of postoperative patients who have survived critical illnesses are more appropriate goals for selected high-risk postoperative patients. The PA catheter is an efficacious and cost-effective tool in the perioperative management of critically ill surgical patients when systemic oxygen transport data is used to augment, rather than simply normalize, the patients circulatory status. We believe that in the high-risk patient, PA catheterization should be instituted preoperatively and that the important cardiorespiratory values be prophylactically augmented beginning in the preoperative and continued into the intraoperative and immediate postoperative periods. There is a compelling need for this approach, despite the current medical-economic climate encourages less frequent use of invasive procedures. Our study suggests that this conservative approach to patients undergoing high-risk surgical procedures is a false economy both fiscally and in terms of patient outcome.

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