PAFC: the yellow snake of death?

Sandham JD, Hull RD, Brant RF et al.  A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. New England Journal of Medicine 2003; 348: 5-14.

RHH Journal Club. May 23th, 2013. Dr Kris Sivarajan

Full-text article (if available)

Does the use of a PA catheter improve in hospital mortality in surgical patients?

Study design:

  • Multicentre Randomised Control Trial
  • Canadian Hospitals



  • >60yrs old
  • ASA III or IV
  • Elective or urgent Major Surgery


  • Randomised to PAC or standard care
  • PAC inserted prior to surgery
  • Set aims and intervention with fixed priority
  • 24 hr ICU stay

Primary outcome:

  • In hospital mortality of any cause

Secondary outcomes:

  • 6 or 12 month mortality
  • In hospital morbidity


  • Did groups start with a similar prognosis?  Yes
  • Numbers involved: 997 standard care, 997 PAC. Eligible 3803
  • Randomisation – concealed
  • Blinded – Observers blinded to intervention
  • Intention to treat principle applied.
  • Follow up complete similar numbers lost to follow up.



Primary outcome:

  • No difference in hospital mortality

Secondary outcomes:

  • No difference 6/12 month mortality
  • No difference morbidity except PE – 7pts PAC group 0 standard care

Take home message/application of this research:

  • No benefit to PAC in general surgical patients
  • Potential for further large number studies with PA catheters

One thought on “PAFC: the yellow snake of death?

  1. Interesting study. I was a cardiology and ITU SHO prior to the publication of this study, and PAFC insertion was relatively routine in the very unwell patient. By the time I had finished my training in 2009, most of the SHOs had never seen a PAFC! This study therefore was a game changer.

    It is worth considering whether the lack of benefit seen in the study was due to the PAFC or the targets set. These targets are based on Schumaker’s work which (as far as I am aware) no-one has been able to reproduce. Modern goal-directed therapy is now targeted at SV improvements rather than DO2.

    I think with modern, minimally invasive cardiac output monitors (eg LiDCO) I may never inserted another PAFC in my career.


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