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Tue Jan 29 18:28:40 GMT 2008

The paper purports to demonstarte an actionable benefit. They say so in
their title and conclusion. I do not believe that the authors take the
appraoch you have outlined that this retrospective study is meant to =
raise a
question for further intense study.=20

I'm not sure what you mean by "pragmatic research," but in my opinion =
any
meaningful research needs a null hypothesis and a methodology that can
withstand criticism. Our basic science PhD colleagues often scoff at =
what we
put forward as research, and rightly so.=20

Finally.....Data mining is not evidence.=20

Jeffrey Hammond MD, MPH, FACS

-----Original Message-----
From: trauma-list-bounces at trauma.org =
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Coats Tim - Professor of Emergency Medicine
Sent: Tuesday, January 29, 2008 12:09 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: [ccm-l] PA catheters in trauma.

In their Conclusion the authors seem to give a very balanced view of =
what
their analysis may or may not mean. For pragmatic research you don't =
need to
give a reason, so I don't see many grounds for criticising the way that =
they
present this work.

It is retrospective etc, I don't think that I will change my practice =
now,
but doesn't it make you think? The point of this sort of analysis is not
proof, it is hypothesis generation. I would have predicted the opposite
result (worse outcomes in the PA group) and am always interested when
evidence goes against my pre-conceptions.

Tim. Coats

Professor of Emergency Medicine
Leicester University.

-----Original Message-----
From: Robert F. Smith [mailto:rfsmithmd at comcast.net]
Sent: 29 January 2008 14:07
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: [ccm-l] PA catheters in trauma.

>From reading only the abstract, it is somewhat amazing that the authors =

>seem
to feel that the presence of a piece of plastic somehow confers an =
improved
survival rate in severely injured patients. No mechanism is suggested. =
It
would be fascinating if in the paper they proposed there was some kind =
of
universally accepted algorithm for how this piece of plastic is to be =
used.
Or even what the plastic truly and accurately does. And I doubt the =
patients
with an ISS of 75 received much benefit from it, lol.=20

Rob Smith MD, MPH
Chicago

-----Original Message-----
From: trauma-list-bounces at trauma.org =
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Jeffery Hammond
Sent: Monday, January 21, 2008 11:20 AM
To: 'Ivan Hronek'; trauma-list at trauma.org
Cc: ccm-l at ccm-l.org
Subject: RE: [ccm-l] PA catheters in trauma.

This is a totally unsupportable conclusion.
=20
The NTDB is an unaudited data repository. This paper is retrospective,
uncontrolled, descriptive epidemiology at best. Throwing a bunch of =
numbers
around and subjecting them to some mathematical manipulation doesn't
magically turn them into actionable data.
=20
Jeffrey Hammond MD, MPH
New Brunswick, NJ

  _____ =20

From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On Behalf =
Of
Ivan Hronek
Sent: Sunday, January 20, 2008 10:11 PM
To: trauma-list at trauma.org
Cc: ccm-l at ccm-l.org
Subject: [ccm-l] PA catheters in trauma.

Pulmonary artery catheter use is associated with reduced mortality in
severely injured patients: A National Trauma Data Bank analysis of =
53,312
patients

Critical Care Medicine - Volume 34, Issue 6 (June 2006)  -

=20
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/s0090349306611061.pdf> PDF =
version of
article=20

Feature Articles
Pulmonary artery catheter use is associated with reduced mortality in
severely injured patients: A National Trauma Data Bank analysis of =
53,312
patients

Randall S. Friese, MD
Shahid Shafi, MD
Larry M. Gentilello, MD=20

  _____ =20

>From Parkland Memorial Hospital, Division of Burn, Trauma, Critical=20
>Care
Department of Surgery, University of Texas Southwestern Medical Center =
at
Dallas, TX
  _____ =20

The authors do not have any financial interests to disclose.

PII S0090-3493(06)61106-1

  _____ =20

 Objective:=20

To evaluate the association between pulmonary artery catheter (PAC) use =
and
mortality in a large cohort of injured patients. We hypothesized that =
PAC
use is associated with improved survival in critically injured trauma
patients.

Design:=20

Retrospective database analysis.

Setting:=20

A total of 268 level 1 trauma centers from across the United States.

Patients:=20

A total of 53,312 patients admitted to the intensive care units of the
trauma centers participating in the National Trauma Data Bank maintained =
by
the American College of Surgeons.

Measurements and Main Results:=20

The National Trauma Data Bank was queried to identify patients aged =
16=A8C90
yrs with complete data on base deficit, and Injury Severity Score (n =3D
53,312). Patients were initially divided into two groups: those managed =
with
a PAC (n =3D 1,933) and those managed without a PAC (n =3D 51,379). =
Chi-square
and Student's t-test analysis were utilized to explore group differences =
in
mortality. In a second analysis, groups were stratified by base deficit,
Injury Severity Score, and age to further explore the influence of =
injury
severity on PAC use and mortality. In addition, a logistic regression =
model
was developed to assess the relationship between PAC use and mortality =
after
adjusting for differences in age, mechanism, injury severity, injury
pattern, and co-morbidities. Overall, patients managed with a PAC were =
older
(45.8 =A1=C0 21.3 yrs), had higher Injury Severity Score (28.4 =A1=C0 =
13.5), worse
base deficit (-5.2 =A1=C0 6.5), and increased mortality (PAC, 29.7%; no =
PAC,
9.8%; p < .001). However, after stratification for injury severity, PAC =
use
was associated with a survival benefit in four subgroups of patients. =
Each
of these groups had advanced age or increased injury severity. =
Specifically,
patients aged 61=A8C90 yrs, with arrival base deficit worse than -11 and
Injury Severity Score of 25=A8C75, had a decrease in the risk of death =
with
PAC use (odds ratio, 0.33; 95% confidence interval, 0.17=A8C0.62). Three
additional groups had a similar decrease in the risk of death with PAC =
use:
odds ratio, 0.60 (95% confidence interval, 0.43=A8C0.83), 0.82 (95% =
confidence
interval, 0.44=A8C1.52), and 0.63 (95% confidence interval, =
0.40=A8C0.98).
Logistic regression analysis demonstrated a decreased mortality when a =
PAC
was used in the management of patients with the following severe injury
characteristics: Injury Severity Score of 25=A8C75, base deficit of less =
than
-11, or age of 61=A8C90 yrs (odds ratio, 0.593; 95% confidence interval, =
0.437
=A8C0.805).

Conclusions:=20

Trauma patients managed with a PAC are more severely injured and have a
higher mortality. However, severely injured patients (Injury Severity =
Score,
25=A8C75) who arrive in severe shock, and older patients, have an =
associated
survival benefit when managed with a PAC. This is the first study to
demonstrate a benefit of PAC use in trauma patients.

  _____ =20

Key Words:=20

    	 pulmonary artery catheter	     =09
    	 complication 	    =09
    	 injury	     =09
    	 trauma	     =09
    	 mortality 	    =09
    	 National Trauma Data Bank 	    =09

Retrospective analyses of large databases and of several randomized
controlled trials have demonstrated either no benefit or an increased =
risk
of death in patients who are managed with a pulmonary artery catheter =
(PAC)
(
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061001>  [1] , =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061002> [2] ,  =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI&sp=3D=
16240415
&sid=3D664762510/N/535610/1.html#r06611061003> [3] ,
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061004> [4] ,  =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI&sp=3D=
16240415
&sid=3D664762510/N/535610/1.html#r06611061005> [5] ,
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061006> [6] ,  =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI&sp=3D=
16240415
&sid=3D664762510/N/535610/1.html#r06611061007> [7] ). For these reasons,
several authors have questioned the utility of the PAC, and its use in
critically injured patients has been called into question.

However, most studies on PAC use were composed largely or entirely of
patients with medical illnesses (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061001>  [1] , =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061003> [3] ,  =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI&sp=3D=
16240415
&sid=3D664762510/N/535610/1.html#r06611061004> [4] ). Although PAC =
trials in
surgical patients have been conducted, they evaluated perioperative use =
in
high-risk patients or tested specific management techniques such as
supranormal oxygen delivery protocols (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061002>  [2] , =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061006> [6] ,  =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI&sp=3D=
16240415
&sid=3D664762510/N/535610/1.html#r06611061007> [7] ,
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061008> [8] ,  =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI&sp=3D=
16240415
&sid=3D664762510/N/535610/1.html#r06611061009> [9] ). No study has been
conducted to determine whether PAC use is associated with an increase in
survival after injury.

Trauma patients are different from medical patients. Medical patients
typically undergo PAC placement for management of organ failure or =
sepsis.
Trauma patients may receive a PAC for these same reasons, but may also
undergo PAC insertion as a means of guiding resuscitation. Therefore, =
the
outcomes associated with PAC use in trauma patients may be different. =
The
purpose of this study was to evaluate the association between PAC use =
and
mortality in a large cohort of injured patients. We hypothesized that =
PAC
use is associated with improved survival in critically injured trauma
patients.

MATERIALS AND METHODS=20

The National Trauma Data Bank is an on-going project of the American =
College
of Surgeons that collects data from participating trauma centers around =
the
country in a standardized format. For the time period of our analysis, =
the
National Trauma Data Bank contained the records of >450,000 patients =
from
268 trauma centers, 20% of whom were admitted to the intensive care =
unit.
This provides an opportunity to explore the association between PAC use =
and
outcomes in an age- and severity-adjusted contemporaneous cohort of =
trauma
patients managed with and without a PAC.

Data were obtained for the period of January 1994 through December 2001.
Patients were included if they survived for >48 hrs, underwent at least =
one
diagnostic or therapeutic procedure, and were 16=A8C90 yrs of age with
complete information on survival, Injury Severity Score (ISS), and =
initial
base deficit. These criteria identified 53,312 patients. The study
population was divided into two groups: those who underwent insertion of =
a
PAC during hospital stay (n =3D 1,933) and those who did not (n =3D =
51,379).

Patients were first compared by age, preexisting conditions, injury =
type,
injury severity, and complications using chi-square analysis. Injury
severity was estimated by ISS (anatomic measurement) and emergency
department (ED) base deficit (physiologic measurement). Stratified =
analysis
was then conducted based on age, ISS, and ED base deficit. The =
relationship
between PAC use and survival was measured within each stratum using
chi-square or Fisher's exact test.

We chose ISS, which systematically incorporates injuries from multiple =
body
regions into an overall score, as an anatomic marker of injury severity
because it is a well-validated method of stratifying patients after =
injury
and has a strong correlation with mortality (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061010>  [10] ,
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061011> [11] ). The
strength of this correlation is improved when it is coupled with a
physiologic measurement of injury severity, such as the base deficit (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061012>  [12] ,
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061013> [13] ).

Logistic regression analysis was used to develop a parsimonious model =
that
predicted mortality after injury. The factors included in the model were =
PAC
use, age, ED base deficit, ISS, presence of co-morbid conditions (liver,
kidney, or heart disease), mechanism of injury (blunt vs. penetrating), =
and
specific injury pattern (head, chest, or abdominal injury) as quantified =
by
the Abbreviated Injury Scale (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061014> [14]). =
Using the
patient characteristics associated with more severe injury (advanced =
age,
elevated ISS, and abnormal ED base deficit), the study population was
divided into two groups: those with severe injury characteristics and =
those
without. The model was then applied to each of these two groups to =
determine
the influence of injury severity on the association between PAC use and
mortality.

Data are presented as mean =A1=C0 sd for continuous variables and as =
proportions
for categorical variables; p < .05 was considered significant for all
analyses. SPSS (SPSS, Chicago, IL) for Windows and SAS (SAS Institute, =
Cary,
NC) for Windows were used for data management and analysis. This =
research
was approved by the Institutional Review Board at the University of =
Texas
Southwestern Medical Center.

RESULTS=20

Overall, patients managed with a PAC were older, had higher ISS, greater =
ED
base deficit (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl1> Table 1), and =
higher
mortality (PAC, 29.7%; no PAC, 9.8%; odds ratio, 3.58; 95% confidence
interval, 3.26=A8C3.93).

Table 1   --  Demographics, injury, and patient characteristics

 	  	 PAC	 No PAC	 p Value=09
Demographics (n =3D 53,312)=09
 	 n	 1,933	 51,379	  =09
 	 Age, yrs	 45.8 =A1=C021.3	 39.5 =A1=C018.3	 <.001=09
 	 Injury Severity Score	 28.4 =A1=C013.5	 15.9 =A1=C012.3	 <.001=09
 	 Initial base deficit	 -5.3 =A1=C06.5	 -1.4 =A1=C08.0	 <.001=09
Injury characteristics
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl1fn1> [a] (n =3D =
47,654)=09
 	 n	 1,829	 45,825	  =09
 	 Spinal Injury,% (n =3D8,138)	 24.9	 16.8	 <.001=09
 	 Abdominal injury,% (n =3D12,134)	 39.1	 24.9	 <.001=09
 	 Head injury,% (n =3D21,101)	 60.4	 43.6	 <.001=09
 	 Chest injury,% (n =3D18,608)	 65.3	 38.0	 <.001=09
 	 At least one AIS of =A1=DD3,% (n =3D34,702)	 96.9	 71.9	 <.001=09
Preexisting conditions
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl1fn2> [b] (n =3D =
16,722)=09
 	 n	 1,574	 15,148	  =09
 	 Cardiac disease,% (n =3D13,209)	 96.1	 77.2	 <.001=09
 	 Diabetes,% (n =3D1,252)	 4.8	 7.8	 <.001=09
 	 Pulmonary disease,% (n =3D993)	 4.2	 6.1	 .002=09
 	 Obesity,% (n =3D258)	 1.1	 1.6	 .177=09
 	 Hepatic disease,% (n =3D126)	 0.6	 0.8	 .569=09
 	 Renal disease,% (n =3D46)	 0.2	 0.3	 .501=09
Complications
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl1fn3> [c] (n =3D =
8,288)=09
 	 n	 1,000	 7,288	  =09
 	 Infection,% (n =3D4,661)	 62.3	 55.4	 <.001=09
 	 Pneumonia,% (n =3D3,760)	 56.9	 43.8	 <.001=09
 	 ARDS,% (n =3D1,089)	 22.3	 11.9	 <.001=09
 	 Renal failure,% (n =3D587)	 13.0	 6.3	 <.001=09
 	 MI,% (n =3D559)	 8.2	 6.5	 .05=09
 	 VTE,% (n =3D507)	 5.4	 6.2	 .313=09

PAC, pulmonary artery catheter; AIS, Abbreviated Injury Score; ARDS, =
acute
respiratory distress syndrome; MI, myocardial infarction; VTE, venous
thromboembolism.

a    	A total of 5,658 patients with incomplete data for injury
characteristics were excluded;=09
b    	36,590 patients with incomplete data for pre-existing conditions
were excluded;=09
c    	45,024 patients with incomplete data for complication conditions
were excluded.=09

Patients with spine, abdominal, chest, or head injury and those with at
least one Abbreviated Injury Scale score of =A1=DD3, were more likely to =
be
managed with a PAC (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl1> Table 1). In those =
patients
with a preexisting condition (n =3D 16,722), cardiac disease was the =
most
common in both groups (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl1> Table 1). Those =
patients
who developed complications (n =3D 8,288), such as infection, pneumonia, =
acute
respiratory distress syndrome, acute renal failure, or myocardial
infarction, were more likely to have been managed with a PAC (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl1> Table 1).

PAC use was associated with increased mortality in all subgroups of ISS, =
ED
base deficit, and age (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#t0661106102> Table 2). =
However,
as age, base deficit, and ISS increased, the risk of death associated =
with
PAC use decreased, and an apparent benefit of PAC use emerged ( =
<http://www.
mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&source=3DMI&sp=3D=
16240415
&sid=3D664762510/N/535610/1.html#t0661106102> Table 2). As shown in
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#t0661106103> Table 3, =
severely
injured patients (ISS =A1=DD 25) with a large base deficit (less than or =
equal
to -11) had a reduction in mortality if they were managed with a PAC. =
The
reduction in mortality associated with PAC use for severely injured =
patients
in shock persisted across all age groups, although this effect did not =
reach
significance for the age group of 41=A8C60 yrs. In addition, PAC use in =
older
patients was associated with improved survival, even if the base deficit =
was
only moderately abnormal (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#f06611061001> Fig. 1,
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#t0661106104> Table 4). In
contrast, less severely injured trauma patients (ISS, 16=A8C24) and =
severely
injured patients without a high admission base deficit (more than -5) =
have
an increased mortality if they undergo PAC placement, regardless of age =
(
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#f06611061002> Fig. 2,
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#t0661106105> Table 5).

Table 2   --  Patient mortality by Injury Severity Score, base deficit, =
and
age

 	  	 Mortality With PAC,% (n =3D 1,933)	 Mortality Without
PAC,% (n =3D 51,379)	 Odds Ratio	 95% Confidence Interval=09
Mortality by Injury Severity Score=09
 	 1=A8C8 (n =3D 13,111)	 17.3	 1.0	 19.4	 9.64=A8C39.0=09
 	 9=A8C15 (n =3D 15,997)	 21.1	 2.8	 8.46	 6.27=A8C11.4=09
 	 16=A8C24 (n =3D 10,809)	 19.9	 7.9	 2.71	 2.17=A8C3.38=09
 	 25=A8C75 (n =3D 13,395)	 35.6	 30.0	 1.25	 1.12=A8C1.41=09
Mortality by initial base deficit=09
 	 =A1=DD0 (n =3D 18,157)	 29.4	 6.0	 6.10	 4.86=A8C7.66=09
 	 -1 to -5 (n =3D 23,924)	 27.3	 6.5	 4.88	 4.20=A8C5.68=09
 	 -6 to -10 (n =3D 7,682)	 27.1	 15.8	 1.87	 1.56=A8C2.24=09
 	 -11 or less (n =3D 3,549)	 40.9	 42.0	 0.96	 0.77=A8C
1.19=09
Mortality by age, yrs=09
 	 16=A8C40 (n =3D 31,431)	 26.3	 7.8	 3.94	 3.42=A8C4.54=09
 	 41=A8C60 (n =3D 13,441)	 29.3	 9.6	 3.60	 2.97=A8C4.36=09
 	 61=A8C90 (n =3D 8,440)	 35.5	 18.2	 2.29	 1.95=A8C2.70=09

PAC, pulmonary artery catheter.

Table 3   --  Subgroup analysis

Stratification	 Mortality With PAC,% (n)	 Mortality Without PAC,%
(n)	 Odds Ratio	 95% Confidence Interval=09
Decreased mortality with PAC=09
 	 Age, 16=A8C40=09
 	  	 BD, -11 or less	 42.2	 56.7	 0.60	 0.43=A8C
0.83=09
 	  	 ISS, 25=A8C75	 (132)	 (1,093)	  	  =09
 	 Age, 41=A8C60=09
 	  	 BD, -11 or less	 54.1	 59.4	 0.82	 0.44=A8C
1.52=09
 	  	 ISS, 25=A8C75	 (37)	 (438)	  	  =09
 	 Age, 61=A8C90=09
 	  	 BD, -11 or less	 56.7	 83.5	 0.33	 0.17=A8C
0.62=09
 	  	 ISS, 25=A8C75	 (30)	 (206)	  	  =09
 	 Age, 61=A8C90=09
 	  	 BD, -6 to -10	 39.7	 53.7	 0.63	 0.40=A8C0.98=09
 	  	 ISS, 25=A8C75	 (68)	 (309)	  	  =09
Increased mortality with PAC=09
 	 Age, 16=A8C40=09
 	  	 BD, -1 to -5	 15.2	 2.6	 5.98	 3.16=A8C11.3=09
 	  	 ISS, 16=A8C24	 (66)	 (2,968)	  	  =09
 	 Age, 16=A8C40=09
 	  	 BD, -1 to -5	 28.1	 16.6	 1.85	 1.41=A8C2.42=09
 	  	 ISS, 25=A8C75	 (235)	 (2,999)	  	  =09
 	 Age, 16=A8C40=09
 	  	 BD, 0 or BE	 31.1	 19.6	 1.79	 1.11=A8C2.88=09
 	  	 ISS, 25=A8C75	 (74)	 (1,539)	  	  =09
 	 Age, 41=A8C60=09
 	  	 BD, -1 to -5	 32.5	 20.8	 1.73	 1.20=A8C2.49=09
 	  	 ISS, 25=A8C75	 (117)	 (1,218)	  	  =09
 	 Age, 61=A8C90=09
 	  	 BD, -1 to -5	 28.9	 18.2	 1.71	 1.07=A8C2.71=09
 	  	 ISS, 16=A8C24	 (76)	 (692)	  	  =09

PAC, pulmonary artery catheter; BD, base deficit; ISS, Injury Severity
Score; BE, base excess.

=20
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/If06611061001.fig#top>  Figure 1
Decreased mortality with pulmonary artery catheter (PAC) use. *p < .05.=20

Table 4   --  Subgroups demonstrating improved survival with pulmonary
artery catheter use after injury

Group	 Age, yrs	 Base Deficit	 Injury Severity Score	 p
Value=09
1	 16=A8C40	 Worse than -11	 25=A8C75	 <.002=09
2	 41=A8C60	 -11	 25=A8C75	 .53=09
3	 61=A8C90	 -11	 25=A8C75	 <.001=09
4	 61=A8C90	 -6 to -10	 25=A8C75	 .036=09

=20
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/If06611061002.fig#top>  Figure 2
Increased mortality with pulmonary artery catheter (PAC) use. *p < .05.=20

Table 5   --  Subgroups demonstrating decreased survival with pulmonary
artery catheter use after injury

Group	 Age, yrs	 Base Deficit	 Injury Severity Score	 p
Value=09
5	 16=A8C40	 -1 to -5	 16=A8C24	 <.001=09
6	 16=A8C40	 -1 to -5	 25=A8C75	 <.001=09
7	 16=A8C40	 0 or base excess	 25=A8C75	 .0016=09
8	 41=A8C60	 -1 to -5	 25=A8C75	 .003=09
9	 61=A8C90	 -1 to -5	 16=A8C24	 .024=09

Logistic regression analysis identified the following factors as =
independent
predictors of mortality after injury: age, ED base deficit, ISS, use of =
a
PAC, penetrating mechanism, head injury, and chest injury (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl6> Table 6). Hosmer =
and
Lemeshow goodness of fit for this model was 0.47. Odds ratio for PAC use
demonstrated an increase in the risk of death after injury (1.294; 95%
confidence interval, 1.059=A8C1.580). However, when the model was =
applied to
severely injured patients, a benefit to PAC use was uncovered (odds =
ratio,
0.593; 95% confidence interval, 0.437=A8C0.805) (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl6> Table 6).

Table 6   --  Logistic regression analysis

 	  	 Odds Ratio for Mortality	 95% Confidence
Intervals=09
Parameter: stepwise analysis (n =3D 53,312)=09
 	 PAC used	 1.294	 1.059=A8C1.580=09
 	 Age	 1.026	 1.024=A8C1.028=09
 	 ED base deficit	 0.949	 0.942=A8C0.955=09
 	 ISS	 1.059	 1.056=A8C1.063=09
 	 Penetrating injury	 1.474	 1.213=A8C1.792=09
 	 Head injury	 1.418	 1.213=A8C1.656=09
 	 Chest injury	 0.642	 0.551=A8C0.748=09
 	 Abdominal injury	 0.971	 0.831=A8C1.135=09
 	 Co-morbidity present	 1.408	 0.891=A8C2.226=09
Patient group: effect of PAC use by injury severity
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl6fn1> [a]=09
 	 Severe injury characteristics present (n =3D 2,313)	 0.593=09
0.437=A8C0.805=09
 	 Severe injury characteristics absent (n =3D 50,999)	 1.885=09
1.478=A8C2.404=09

PAC, pulmonary artery catheter; ED, emergency department; ISS, Injury
Severity Score.

a    	Severe injury characteristics: ISS of 25=A8C75, base deficit less =
than
-11, or age of 61=A8C90 yrs.=09

DISCUSSION=20

This study found that the use of a PAC in the management of critically
injured patients presenting to the ED in severe shock is associated with =
a
survival benefit. Conversely, those who are initially stable at arrival, =
as
defined by normal base deficit, have increased mortality when a PAC is
required during their hospital course.

One potential explanation for these findings is that severely injured
patients who arrive in shock undergo early PAC insertion to guide
resuscitation. Conversely, patients who arrive without evidence of shock =
do
not have an immediate indication for PAC use and are more likely to =
undergo
insertion later in their hospital course. This latter group most likely
undergoes late PAC placement due to the development of complications =
from
their injuries, such as sepsis or organ failure, and are a different =
group
of patients than those undergoing PAC placement acutely due to the =
presence
of severe shock at arrival to the ED.

Although PAC use was associated with an increase in mortality overall, =
it
was associated with a protective effect in patients with severe shock,
regardless of age, and in older patients with moderate shock. We also =
found
that the highest risk of death associated with PAC use was in younger
patients who arrived at the ED without a significant base deficit. =
Moreover,
no survival benefit was detected with PAC use in patients arriving at =
the ED
without evidence of shock. Overall, these findings support the =
hypothesis
that PAC use in trauma patients with the presence of severe shock at the
time of admission provides a survival benefit.

Our results are similar to those reported by Chittock et al. (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061015> [15]) in an
observational study of >7,000 critically ill patients in which the =
highest
risk of death associated with PAC use occurred in those with the lowest
Acute Physiology and Chronic Health Evaluation (APACHE) II scores, but a
survival benefit was associated with PAC use when APACHE II scores were =
very
high. Our results contrast with those of Connors et al. (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061001> [1]), who =
reported
an increase in 30-day mortality for critically ill patients managed with =
a
PAC. In the latter study, a propensity score was developed to determine =
the
likelihood of PAC placement. Patients managed with a PAC were compared =
with
a control group of patients with similar propensity scores who did not
undergo PAC insertion. However, the propensity score has never been
validated as a predictor of PAC use. Moreover, this study did not =
stratify
patients by severity of illness, as did our study and the study reported =
by
Chittock et al (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061015> [15]).

In addition, we found that patients with preexisting cardiac disease and
those patients developing complications after injury (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#tbl1> Table 1) were more =
likely
to be managed with a PAC. The more frequent use of a PAC in patients =
with
underlying co-morbidities or complications may account for the increase =
in
overall mortality in patients managed with a PAC after admission for =
injury.

Another potential reason why the PAC has been associated with higher
mortality is that most previous studies were conducted in hospitals with
open intensive care units, where any physician on the medical staff =
could
admit a patient to the unit and place a PAC. Most trauma surgeons caring =
for
critically injured patients are experts in intensive care management and
have added qualifications in surgical critical care. Lack of knowledge =
about
appropriate PAC use and misinterpretation of PAC data may offset any
potential benefit associated with PAC use (
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061016>  [16] ,
<http://www.mdconsult.com/das/article/body/86122664-5/jorg=3Djournal&sour=
ce=3DMI
&sp=3D16240415&sid=3D664762510/N/535610/1.html#r06611061017> [17] ).

The findings of our study must be interpreted within the context of its
limitations. The first limitation is that although the National Trauma =
Data
Bank contained >450,000 patients at the time of this analysis, only =
53,000
patients met inclusion criteria. Most were excluded due to missing data
points. Those patients surviving for <48 hrs were excluded to eliminate
patients with nonsurvivable injuries. This raises the possibility of
survivor bias. In addition, although this analysis contained >50,000
patients, its retrospective design and subgroup analysis is not best =
suited
for hypothesis testing and is more appropriate for the generation of new
hypotheses. Lastly, neither the timing of PAC placement nor cause of =
death
could be ascertained with certainty by analysis of the National Trauma =
Data
Bank. Therefore, we cannot be certain that patients with signs of severe
shock and high injury severity had better survival with a PAC as a =
result of
early insertion.

Despite these limitations, we believe the findings of this study have
important implications for trauma care. Unlike general medical patients =
who
typically undergo PAC insertion to manage complications, injured =
patients
may derive benefit from PAC-guided resuscitation to avert complications
related to persistent perfusion deficits. This analysis is consistent =
with
this hypothesis and suggests that guidelines and consensus documents =
that
question the utility of the PAC may not apply to critically injured
patients.

CONCLUSIONS=20

In summary, mortality was greater in trauma patients managed with a PAC.
However, when other factors that may influence injury severity were
considered, such as age, severity of shock, and anatomic injury scoring, =
PAC
use was associated with a decrease in mortality. The results of our =
study
suggest that PAC insertion is associated with improved outcome in =
critically
injured patients with severe shock at admission and in elderly patients =
with
moderate shock. A prospective randomized, controlled trial of immediate =
PAC
insertion to guide fluid resuscitation in severely injured or elderly =
trauma
patients requiring intensive care unit admission is needed to confirm =
these
findings.

  _____ =20

REFERENCES:

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NCHOR=3Dabs> Abstract=20

=20
Ivan Hronek MD=20

SFMC, Los Angeles

cell: 310 487-3288

ivanhronek at yahoo.com

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