Deferring Arterial Catheterization in Critically Ill Patients with Shock

Area of Science:

• Critical Care Medicine
• Cardiovascular Physiology
• Clinical Trials

Background:

• Uncertainty exists regarding the efficacy of noninvasive blood pressure monitoring versus arterial catheters in patients with shock.
• Arterial catheters are the recommended standard for blood pressure monitoring in shock, despite potential risks.

Purpose of the Study:

• To determine if noninvasive blood pressure monitoring is noninferior to early arterial catheter insertion in patients with shock.
• To compare 28-day mortality rates between invasive and noninvasive blood pressure monitoring strategies in shock patients.

Main Methods:

• A multicenter, open-label, noninferiority trial randomized 1010 shock patients to early arterial catheter (invasive) or automated brachial cuff (noninvasive) monitoring.
• Patients in the noninvasive group could receive an arterial catheter later if safety criteria were met.
• The primary outcome was all-cause death at 28 days, with a noninferiority margin of 5 percentage points.

Main Results:

• 28-day mortality was 34.3% in the noninvasive group and 36.9% in the invasive group (adjusted risk difference: -3.2%; P=0.006 for noninferiority).
• Arterial catheter insertion occurred in 14.7% of the noninvasive group vs. 98.2% of the invasive group.
• Pain or discomfort was reported by 13.1% in the noninvasive group vs. 9.0% in the invasive group; catheter-related hematoma/hemorrhage occurred in 1.0% vs. 8.2%.

Conclusions:

• Management of shock patients without early arterial catheter insertion is noninferior to early catheterization regarding 28-day mortality.
• Noninvasive monitoring strategies appear safe and effective, potentially reducing invasive procedure-related complications and patient discomfort.