Critical Care Medicine-Neurologic Disorders>>>>>Shock States
Question 6#

A 54-year-old man with ischemic cardiomyopathy (last known ejection fraction 0.4) and coronary artery disease status post prior three-vessel coronary artery bypass grafting presents to his primary care doctor with fatigue and is found to be hypotensive with BP 85/55 mm Hg. He is triaged to the emergency department where he remains hypotensive with initial BP 90/48 mm Hg and is found to be febrile with temperature 39°C with HR 110 beats per minute. He reports fevers at home over the last 48 hours with one episode of rigors. He receives 2 L of IV fluids and is started on norepinephrine.

Which of the following is most accurate regarding placement of a pulmonary artery (PA) catheter in this patient?

A. Use of PA catheters is associated with improved outcomes in cardiogenic shock
B. Use of PA catheters is associated with improved outcomes in septic shock
C. PA catheters are demonstrated to be useful in early goal-directed therapy for sepsis
D. PA catheters are useful in distinguishing cardiogenic shock and vasodilatory shock
E. The most frequent complication of PA catheters is significant bleeding

Correct Answer is D

Comment:

Correct Answer: D

Multiple trials have shown no benefit to use of PA catheters in patients with shock; retrospective study data in patients with cardiogenic shock is conflicting with respect to association between PA catheter use and outcomes (answers A and B are incorrect). Additionally, although the early goal-directed therapy was first developed using a PA catheter, there has been no trial that demonstrates that PA catheters increase the likelihood of meeting resuscitation goals in sepsis (answer C is incorrect). However, PA catheters are useful in distinguishing between cardiogenic and vasodilatory shock and are recommended in the management of cardiogenic shock when a vasodilatory or septic component is suspected (answer D is correct). Bleeding complications from PA catheters are uncommon even in critically ill patients (answer E is incorrect).

References:

1. Richard C, Warszawski J, Anguel N, et al; French Pulmonary Artery Catheter Study Group. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2003;290:2713-2720.
2. Connors AF Jr, Speroff T, Dawson NV. et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT investigators. JAMA. 1996;276:889-897.
3. Rossello X, Vila M, Rivas-Lasarte M, et al. Impact of pulmonary artery catheter use on short- and long-term mortality in patients with cardiogenic shock. Cardiology. 2017;136:61-69.
4. van Diepen S, Katz JN, Albert NM, et al. Contemprorary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2017;136:e232-e268.