Study objective: To assess the impact of substituting
noninvasive diagnostic studies for Swan-Ganz catheter (SGC) placement
in the evaluation of acutely ill patients.
Modified decision analysis.
Methods: Using published
studies that define effectiveness of clinical examination,
echocardiography, and SGC placement to diagnose pulmonary edema, an
analysis of the impact of substituting three diagnostic approaches
using (1) clinical assessment (CA), (2) M-mode two-dimensional
transthoracic echocardiography (EC), or (3) CA then EC if necessary for
SGC placement was considered.
Patients with acute respiratory distress and radiographic findings of
pulmonary edema, and ICU patients with hypotension and/or pulmonary
edema without acute cardiac ischemia.
Three approaches using noninvasive studies were substituted for
placement of SGC in the initial evaluation of pulmonary edema.
Measurements and results: The number of SGCs placed, the
number of tests needed to diagnose (NTND) all cases of volume overload,
and the total number of procedure-related adverse events were
calculated for each diagnostic approach and compared to SGC placement.
EC, and CA then EC approaches produced fewer procedure-related serious
complications and deaths, compared to the SGC approach; however, these
approaches also produced a higher NTND and total procedures performed
than did the SGC or CA approaches. The CA approach led to reduced NTND
and procedure-related adverse events.
Substituting noninvasive studies for SGC placement in the initial
evaluation of acutely ill patients may slightly reduce
procedure-related adverse events, but it may also increase the number
of procedures performed. Studies of SGC use are warranted and need to
include a clinical assessment control group and an analysis of resource