Outcome of hemodynamic instability therapy guided by pulmonary artery catheter in immunocompromised ICU patients

Objectives

The aim of this study is to evaluate the outcome of the therapy guided by pulmonary artery catheter (PAC) in immunocompromised ICU patients.

Setting

A kidney transplant specialized ICU in a 90-bed public hospital.

Methods

We prospectively followed (from May 2000 to November 2001) kidney transplant recipients admitted to ICU who developed hemodynamic instability which required vasoactive drugs administration and PAC insertion in order to optimize therapy. After catheter insertion, based on hemodynamic profile, the patients were classified in one of the following types of shock: distributive, cardiogenic, obstructive and hypovolemic. ICU resource utilization, catheter-related complications and 28-day mortality were recorded.

Results

In the period of study, our institution had 2021 kidney transplant recipients in ambulatory management, performed 690 kidney transplant surgeries and the ICU admitted 289 kidney transplant recipients (not in postoperative period). There were 13 consecutive patients (3 F/10 M) who fulfilled inclusion criteria. The mean age was 45.4 ± 10.3. Of these patients 12 (92%) were in the first year of transplantation and all patients were receiving immunosuppression therapy at ICU admission. The mean Apache II score was 22 ± 8. The PAC was inserted within 24 hours of the beginning of hemodynamic instability in all patients. There were nine (70%) patients classified as distributive shock (sepsis) and the mortality in this group was 78% (n = 7). There were two (15%) patients with cardiogenic shock (acute myocardial infarction) and the mortality was 50% (n = 1). There were two (15%) patients with hypovolemic shock (acute drug-induced pancreatitis, nephrotic syndrome) and the mortality was 50% (n = 1). The mean permanence of CAP was 4.5 ± 2.6 days. In one (7.5%) patient there were complications related to catheterization procedure (pneumohemothorax). The mean length of ICU stay was 12.9 ± 15.1 days and of mechanical ventilation was 10.5 ± 15.6 days. In nine (70%) patients there was need for renal replacement therapy.

Conclusion

Based on these preliminary results, distributive shock associated with sepsis is more frequent and carries a higher mortality than cardiogenic and hypovolemic shock in immunocompromised patients.