Reducing Iatrogenic Risk in Thoracentesis Establishing Best Practice Via Experiential Training in a Zero-Risk Environment

Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
Chest (Impact Factor: 7.48). 11/2008; 135(5):1315-20. DOI: 10.1378/chest.08-1227
Source: PubMed


We studied the reasons why patients undergoing thoracenteses performed in our outpatient pulmonary clinic had a higher frequency of iatrogenic pneumothorax compared to that in the concurrent radiology practice in our institution, which utilizes ultrasound guidance. We reviewed our practice model and implemented a unique experiential training paradigm in a zero-risk simulation environment to improve efficacy, timeliness, service orientation, and safety.
We retrospectively determined the rate of clinically significant pneumothoraces in our practice (phase I, July 1, 2001, to June 30, 2002). The training system redesign included the following: (1) a designated group of pulmonologist instructors dedicated to treating pleural disease and reducing the number of iatrogenic complications; (2) the use of ultrasound image guidance for all thoracenteses; and (3) structured proficiency and competency standards for proceduralists. Postintervention (phase II) data were prospectively collected (January 2005 to December 2006) and compared with our baseline data.
The baseline rate of pneumothorax was 8.6% (5 of 58 patients) in our pulmonary practice. Following intervention (phase II), the rate of pneumothorax declined to 1.1% (p = 0.0034). During phase II, the number of thoracenteses performed increased (186 vs 58 per year, respectively; p < 0.05). The iatrogenic pneumothorax rate was stable in the 2 years following intervention (2005, 0.7% [1 of 137 pneumothoraces]; 2006, 1.3% [3 of 226 pneumothoraces]; p > 0.9). Postintervention complications included procedure-related pain (n = 19), cough (n = 4), and hypotension (n = 10).
An improvement program that included simulation, ultrasound guidance, competency testing, and performance feedback reduced iatrogenic risk to patients. We recommend application of this process to procedural practices.

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    • "Potential complications of thoracentesis are pain (5%), cough (24%), shortness of breath (15%), vasovagal reaction (3%), and pneumothorax (20% to 39%) [1]. "
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    ABSTRACT: Background: Malignant pleural effusion (MPE) is an extremely common problem affecting cancer patients, and thoracentesis is an essential procedure in an attempt to delineate the etiology of the fluid collections and to relieve symptoms in affected patients. One of the most common complications of thoracentesis is pneumothorax, which has been reported to occur in 20% to 39% of thoracenteses, with 15% to 50% of patients with pneumothorax requiring tube thoracostomy.The present study was carried out to assess whether thoracenteses in cancer patients performed with ultrasound (US) guidance are associated with a lower rates of pneumothorax and tube thoracostomy than those performed without US guidance. Methods: A total of 445 patients were recruited in this retrospective study. The medical records of 445 consecutive patients with cancer and MPE evaluable for this study, undergoing thoracentesis at the Oncology-Hematology and Internal Medicine Departments, Piacenza Hospital (Italy) were reviewed. Results: From January 2005 to December 2011, in 310 patients (69.66%) thoracentesis was performed with US guidance and in 135 (30.34%) without it. On post-thoracentesis imaging performed in all these cases, 15 pneumothoraces (3.37%) were found; three of them (20%) required tube thoracostomy. Pneumothorax occurred in three out of 310 procedures (0.97%) performed with US guidance and in 12 of 135 procedures (8.89%) performed without it (P<0.0001). It must be emphasized that in all three patients with pneumothorax requiring tube thoracostomy, thoracentesis was performed without US guidance. Conclusions: The routine use of US guidance during thoracentesis drastically reduces the rate of pneumothorax and tube thoracostomy in oncological patients, thus improving safety as demonstrated in this study.
    World Journal of Surgical Oncology 05/2014; 12(1):139. DOI:10.1186/1477-7819-12-139 · 1.41 Impact Factor
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    • "This is an observational study describing a new technique to perform thoracentesis. Although in literature there are no prospective studies comparing ‘blind’ to ‘echoguided’ pleural drainage, evidence exists regarding how echographic support reduces thoracentesis risks and complications both in the spontaneously breathing patient and in the mechanically ventilated patient [23,34-36]. The purpose of this study, in fact, was not a comparison between blind and echoguided techniques as advantages of the second one have already been well appointed and would not be ethically supportable at this time. "
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    ABSTRACT: Background: The aim of this study is to evaluate feasibility, safety and efficacy of accessing the pleural space with the patient supine or in lateral recumbent position, under constant ultrasonic guidance along the costophrenic sinus. Methods: All patients with pleural effusion, referred to thoracentesis or pleural drainage from February 2010 to January 2011 in two institutions, were drained either supine or in lateral recumbent position through an echomonitored cannulation of the costophrenic sinus. The technique is described in detail and an analysis of safety and feasibility is carried out. Results: One hundred and one thoracenteses were performed on 76 patients and 30 pigtail catheters were inserted in 30 patients (for a total of 131 pleural procedures in 106 patients enrolled). The feasibility of the procedures was 100% and in every case it was possible to follow real time needle tip passage in the pleural space.Ninety eight thoracenteses (97%) and all catheter drainages were successfully completed. Four thoracenteses were stopped because of the appearance of complications while no pigtail drainage procedure was stopped. After 24 hour follow up, one chest pain syndrome (1.3% of completed thoracenteses) and two pneumothoraces (1.4%) occurred. The mean acquisition time of pleural space was 76 ± 9 seconds for thoracentesis and 185 ± 46 seconds for drainage insertion (p < 0.05). Conclusions: This study highlights the safety and efficacy of this technique of real time echo-monitored pleural space puncture, that offers a more comfortable patient position, an easier approach for the operator, a very low rate of complications with short acquisition time of pleural space.
    Multidisciplinary respiratory medicine 03/2013; 8(1):18. DOI:10.1186/2049-6958-8-18 · 0.15 Impact Factor
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    • "Anesthesia physicians' comfort and use of ultrasound for central vein cannulation increased after a training workshop using varying homemade models of rubber tubes mimicking vessels [11]. Pulmonologist demonstrated competence in ultrasound-guided thoracentesis after completing a half-day workshop utilizing cadaveric and inanimate models under supervision, while doing a minimum of 10 procedures on real patients [12]. Data regarding models for teaching ultrasound guided paracentesis is limited. "
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    ABSTRACT: Few internal medicine residency programs provide formal ultrasound training. This study sought to assess the feasibility of simulation based ultrasound training among first year internal medicine residents and measure their comfort at effectively using ultrasound to perform invasive procedures before and after this innovative model of ultrasound training. A simulation based ultrasound training module was implemented during intern orientation that incorporated didactic and practical experiences in a simulation and cadaver laboratory. Participants completed anonymous pre and post surveys in which they reported their level of confidence in the use of ultrasound technology and their comfort in identifying anatomic structures including: lung, pleural effusion, bowel, peritoneal cavity, ascites, thyroid, and internal jugular vein. Survey items were structured on a 5-point Likert scales (1 = extremely unconfident, 5 = extremely confident). Seventy-five out of seventy-six interns completed the pre-intervention survey and 55 completed the post-survey. The mean confidence score (SD) increased to 4.00 (0.47) (p < 0.0001). The mean (SD) comfort ranged from 3.61 (0.84) for peritoneal cavity to 4.48 (0.62) for internal jugular vein. Confidence in identifying all anatomic structures showed an increase over the pre-intervention means (p < 0.002). A simulation based ultrasound learning module can improve the self-reported confidence with which residents identify structures important in performing invasive ultrasound guided procedures. Incorporating an ultrasound module into residents' education may address perceived need for ultrasound training, improve procedural skills, and enhance patient safety.
    BMC Medical Education 09/2011; 11(1):75. DOI:10.1186/1472-6920-11-75 · 1.22 Impact Factor
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