Article

Ultrasound Guidance Decreases Complications and Improves the Cost of Care Among Patients Undergoing Thoracentesis and Paracentesis

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Abstract

Ultrasound guidance enables visualization of the needle insertion site for thoracentesis and paracentesis. The improved accuracy of needle placement using ultrasound may reduce risk of complications and their costs associated with these procedures. Using claims data from the Premier Perspective hospital database from January 1, 2007, through December 31, 2008, we conducted an observational cohort study examining the effect of ultrasound guidance on risk of pneumothorax among patients undergoing thoracentesis and on risk of bleeding complications after paracentesis. Patients at elevated risk of these outcomes for reasons beyond the procedure of interest were excluded. Adjusted risk of events was assessed using multivariate logistic regression controlling for patient and hospitalization characteristics. Hospitalization cost and length of stay (LOS) were estimated using multivariate ordinary least squares regression of log-transformed values. We analyzed 61,261 thoracentesis and 69,859 paracentesis patient records. Approximately 45% of these procedures were ultrasound guided. Pneumothorax occurred in 2.7% (n = 1,670) of patients undergoing thoracentesis. Of patients undergoing paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk of pneumothorax after thoracentesis by 19% (OR, 0.81; 95% CI, 0.74-0.90) and by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). Pneumothorax increased the total cost of hospitalization by $2,801 (P < .001) and LOS by 1.5 days (P < .001). Bleeding complications increased cost by $19,066 (P < .0001) and LOS by 4.3 days (P < .0001). The data indicate that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis. These complications resulted in measurable increases in hospitalization costs and LOS.

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... Several publications suggest, that performing ultrasound, before paracentesis procedures in adults, reduces complications and improves the number of successful drain insertions, compared to a "blind" technique using physical examination only. [2][3][4][5] Physical examination techniques used to detect ascites in patients with abdominal distension include the "anatomical landmark technique," "percussion wave palpation," and eliciting "flank dullness" and "shifting dullness." [9,10] The who underwent paracentesis attempts without ultrasound assistance. ...
... One of the potentially life-threatening complications of paracentesis is a severe hemorrhage. [4][5][6] In a large study (n = 69,859), the risk of bleeding complications with ultrasound guidance was 0.27%, compared to 1.25% without. [4] Of those with significant hemorrhage, mortality was 12.9%, of those without 3.7%. ...
... [4][5][6] In a large study (n = 69,859), the risk of bleeding complications with ultrasound guidance was 0.27%, compared to 1.25% without. [4] Of those with significant hemorrhage, mortality was 12.9%, of those without 3.7%. [4] The use of color flow Doppler and power Doppler has been described to reduce this complication. ...
Article
Complications of diagnostic and therapeutic paracentesis include bowel perforation, hemorrhage, and death. At present, medical practitioners identify an area for paracentesis using either physical examination alone or with the addition of ultrasound. The preferable method is still debated within the medical literature. This case series compares photographs of patients with abdominal distension, diagnosed as ascites by physical examination, to the respective ultrasound findings. The ultrasound images show a variety of findings: large volume ascites, bowel loops extending to the abdominal wall (unilaterally or bilaterally), and distended bowel loops due to intestinal obstruction in the absence of substantial ascites. Studies have shown that performing ultrasound before ascites paracentesis procedures improves the procedure success rate and reduces complications. This case series illustrates examples of why ultrasound-assisted paracentesis has a better safety profile and a lower procedure failure rate, compared to physical examination techniques alone.
... Therefore, ultrasound is best employed as static guidance in pneumothorax evacuation (67). The use of ultrasound guidance in identification of thoracic landmarks prior to performing thoracentesis or the use of ultrasound guidance for real time thoracentesis in adult patients have been shown to decrease complications such as pneumothorax, inadvertent placement into the abdominal viscera and failed attempts (68,69). The procedure can be safely performed even in patients on mechanical ventilation with a low rate of pneumothorax (70). ...
... Ultrasound guidance is frequently used in performing paracentesis and placement of abdominal drains. Mercardi et al., found that ultrasound guided paracentesis decreased the rate of complications such as bleeding and the associated patient care costs (68). ...
Article
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Ultrasonography has been widely used in medicine for decades but often by specific users such as cardiologists, obstetricians, and radiologists. In the last several years, the use of this imaging modality has moved to the bedside, with clinicians performing and interpreting focused point of care ultrasonography to aid in immediate assessment and management of their patients. The growth of point of care ultrasonography has been facilitated by advancement in ultrasound-related technology and emerging studies and protocols demonstrating its utility in clinical practice. However, considerable challenges remain before this modality can be adopted across the spectrum of disciplines, primarily as it relates to training, competency, and standardization of usage. This review outlines the history, current state, challenges and the future direction of point of care ultrasonography specifically in the field of pediatric critical care medicine.
... A retrospective study of more than 62,000 thoracocenteses for all-cause PE showed that chest ultrasound reduced the risk for pneumothorax by 19% (OR � 0.81; 95% CI � 0.74-0.90) [16]. erefore, it is recommended that thoracic ultrasound, which has no associated complications, is performed prior to thoracentesis. ...
... e AMPLE study compared the length of hospital stay from the procedure (IPC versus talc pleurodesis) until death or at 12 months in 146 patients with MPE. In the first group, the median hospital stay was 10 days (interquartile range 3-17) versus 12 (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21) in the second group (p � 0.03). Although the clinical relevance of this difference is uncertain, these findings may guide the therapeutic decision [54]. ...
Article
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Symptomatic malignant pleural effusion is a common clinical problem. This condition is associated with very high mortality, with life expectancy ranging from 3 to 12 months. Studies are contributing evidence on an increasing number of therapeutic options (therapeutic thoracentesis, thoracoscopic pleurodesis or thoracic drainage, indwelling pleural catheter, surgery, or a combination of these therapies). Despite the availability of therapies, the management of malignant pleural effusion is challenging and is mainly focused on the relief of symptoms. The therapy to be administered needs to be designed on a case-by-case basis considering patient's preferences, life expectancy, tumour type, presence of a trapped lung, resources available, and experience of the treating team. At present, the management of malignant pleural effusion has evolved towards less invasive approaches based on ambulatory care. This approach spares the patient the discomfort caused by more invasive interventions and reduces the economic burden of the disease. A review was performed of the diagnosis and the different approaches to the management of malignant pleural effusion, with special emphasis on their indications, usefulness, cost-effectiveness, and complications. Further research is needed to shed light on the current matters of controversy and help establish a standardized, more effective management of this clinical problem.
... tions arising specifically from nonoperative procedures range from 0 to 19%, 16 although these data do not distinguish technical errors from unpreventable adverse events nor the degree to which hospitalists contributed to these complications. Second, hospitalists in academic medical centers might be ill equipped to function as supervisors of trainees performing procedures, which could perpetuate a cycle of suboptimal technical skills. ...
... The increased availability of POCUS allows formally trained hospitalists to perform procedures more safely under imaging guidance. 16 The literature on procedures performed by hospitalists, although limited, has focused on POCUS, systems innovations such as medical procedure services (MPS), and policy recommendations for procedural credentialing. Most studies on effective procedural instructional approaches have been conducted among trainees, who are procedural novices. ...
Article
Background: As general internists practicing in the inpatient setting, hospitalists at many institutions are expected to perform invasive bedside procedures, as defined by professional standards. In reality, hospitalists are doing fewer procedures and increasingly are referring to specialists, which threatens their ability to maintain procedural skills. The discrepancy between expectations and reality, especially when hospitalists may be fully credentialed to perform procedures, poses significant risks to patients because of morbidity and mortality associated with complications, some of which derive from practitioner inexperience. Methods: We performed a structured search of the peer-reviewed literature to identify articles focused on hospitalists performing procedures. Results: Our synthesis of the literature characterizes contributors to hospitalists' procedural competency and discusses: (1) temporal trends for procedures performed by hospitalists and their associated referral patterns, (2) data comparing use and clinical outcomes of procedures performed by hospitalists compared with specialists, (3) the lack of nationwide standardization of hospitalist procedural training and credentialing, and (4) the role of medical procedure services, although limited in supportive evidence, in concentrating procedural skill and mitigating risk in the hands of a few well-trained hospitalists. Conclusion: We conclude with recommendations for hospital medicine groups to ensure the safety of hospitalized patients undergoing bedside procedures.
... Overview of the evidence and current practice The increased use of TUS has transformed the scope of procedures the interventional pulmonologist is able to offer. Studies have consistently demonstrated that TUS is safer than clinical examination in direct comparison [219], and reduces risk and cost of iatrogenic complications [220][221][222]. The current position of most international guidelines is that all pleural procedures (for fluid) should be performed under TUS guidance [3]. ...
Article
Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures, and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training, and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multi-centre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.
... In a previous study reviewing hemorrhagic complications following paracentesis in 4,729 cases, severe hemorrhage occurred in 0.2% of all procedures in patients with liver disease [20]. In addition, US-guided paracentesis is safer than bedside procedures [21,22]. All paracentesis procedures were performed under US guidance in our study, which resulted in no major complications following paracentesis. ...
Article
Background: This study was performed to evaluate periprocedural factors, complications, and repuncture rate of the newly developed puncture needle and compare it with the routinely used puncture needle for ultrasound (US)-guided paracentesis. Methods: We retrospectively identified 137 patients who underwent US-guided paracentesis between July 2018 and March 2019. Among them, 82 patients underwent US-guided paracentesis with a newly developed puncture needle. The other 55 patients underwent US-guided paracentesis with a routinely used puncture needle. The periprocedural factors, complications, and repuncture rate were compared between the two groups using the Mann-Whitney U test and Fisher exact test. The repuncture-associated factors were assessed using logistic regression analysis. Results: There were no major or minor complications in either group. The rate of repuncture was significantly lower in the group using the newly developed puncture needle compared with the group using the routinely used puncture needle (p=0.01). The duration of the procedure was significantly shorter with the newly developed puncture needle compared with the routinely used puncture needle (p=0.01). In univariate analysis, the thickness of the abdominal wall (p=0.04) and the use of the newly developed puncture needle (p=0.01) were significantly associated with the rate of repuncture. In multivariate analysis, only the use of the newly developed puncture needle was significantly associated with the rate of repuncture. Conclusion: Using this novel puncture needle with a hard plastic sheath and plastic wings, the rate of repuncture and the duration of the procedure were decreased without complications of US-guided paracentesis.
... With the advent of ultrasound-guided thoracentesis, the overall incidence and risk of post-procedural complications have been significantly reduced, especially pneumothorax rates. 11 In this study, the overall incidence of iatrogenic pneumothorax following interventional radiology-performed ultrasound-guided thoracentesis was 0.69%. Previous studies have reported the incidence of thoracentesis-related pneumothorax ranging from 4 to 39% without the use of ultrasound 2,3 and more recent, smaller investigations have found the pneumothorax rates ranging from 0 to 3% with the use of ultrasound. ...
Article
Full-text available
Purpose The aim of this study was to report the utility of chest radiography following interventional radiology-performed ultrasound-guided thoracentesis. Materials and Methods A total of 3,998 patients underwent thoracentesis between 2003 and 2018 at two institutions. A total of 3,022 (75.6%) patients were older than 18 years old, underwent interventional radiology-performed ultrasound-guided thoracentesis, and had same-day post-procedure chest radiograph evaluation. Patient age (years), laterality of thoracentesis, procedural technical success, volume of fluid removed (mL), method of post-procedure chest imaging, absence or presence of pneumothorax, pneumothorax size (mm), pneumothorax management measures, and clinical outcomes were recorded. Technical success was defined as successful aspiration of pleural fluid. Post-procedure clinical outcomes included new patient-perceived dyspnea and hypoxia (oxygen saturations < 90% on room air). Costs associated with radiographs were estimated using Medicare and Medicaid fee schedules. Results Mean age was 56.7 ± 15.5 years. Interventional radiology-performed ultrasound-guided thoracentesis was performed on the left (n = 1,531; 50.7%), right (n = 1,477; 48.9%), and bilaterally (n = 14; 0.5%) using 5-French catheters. Technical success was 100% (n = 3,022). Mean volume of 940 ± 550 mL of fluid was removed. Post-procedure imaging was performed in the form of posteroanterior (PA) (2.6%; 78/3,022), anteroposterior (AP) (17.0%; 513/3,022), PA and lateral (77.9%; 2,355/3,022), or PA, lateral, and left lateral decubitus (2.5%; 76/3,022) chest radiographs. Post-procedural pneumothorax was identified in 21 (0.69%) patients. Mean pneumothorax size, measured on chest radiograph as the longest distance from the chest wall to the lung, was 18.8 ± 10.2 mm (range: 5.0–35.0 mm). Of the 21 pneumothoraces, 7 (33.3%) were asymptomatic, resolved spontaneously, and had a mean size of 6.4 ± 2.4 mm. Fourteen pneumothoraces, of mean size 25.0 ± 5.8 mm, required management with a pleural drainage catheter (66.6%). The overall incidence of pneumothorax requiring pleural drainage catheter placement following interventional radiology-performed ultrasound-guided thoracentesis was 0.46% (14/3,022). Of the patients requiring drainage catheter placement, 12/14 (85.7%) and 13/14 (92.9%) had dyspnea and hypoxia, respectively. Potential costs to Medicare and Medicaid, for chest radiographs, in this study, were $27,547 and $10,581, respectively. Conclusion The incidence of clinically significant pneumothorax requiring catheter drainage following interventional radiology-operated ultrasound-guided thoracentesis is exceedingly low (0.46%), and routine post-procedure chest radiographs in asymptomatic patients provide little value. Reserving post-procedure chest radiographs for patients with post-procedure dyspnea or hypoxia will result in more efficient resource utilization and health care cost savings.
... Even in unexperienced hands, US is more accurate than physical examination and chest X-ray [13]. Moreover, it can guide free fluid punctures raising the success rate [15] and reducing complications [16] when compared with the traditional landmark technique. Point-of-care ultrasonography (POCUS) is characterised by the bedside use of US by the front-line physician to answer focused clinical questions, guide procedures, and monitor therapies [17]. ...
Article
Full-text available
Physical examination (PE) has always been a corner stone of medical practice. The recent advances in imaging and fading of doctors’ ability in performing it, however, raised doubts on PE usefulness. Point-of-care ultrasonography (POCUS) is gaining ground in medicine with the detection of free fluids being one of its main applications. To estimate physicians’ confidence and use of PE and POCUS for the detection of abdominal or pleural free fluid, we conducted a cross-sectional survey. In all, 246 internal and emergency medicine physicians answered to the survey (197 in-hospital physicians and 49 general practitioners; response rate 28.5%). Almost all declared to perform PE in case of suspected ascites or pleural effusion (88% and 90%, respectively). The highest rates of confidence were observed in conventional PE signs (91% for diminished breath sounds, 80% for dullness to thorax percussion, and 66% for abdominal flank dullness). For the remaining signs, rates of confidence were less than 53%. Physicians with > 15 years of experience and POCUS-naïve doctors reported higher confidence in PE. Most of emergency and almost half of internal medicine physicians (78% and 44%, respectively) attended a structured POCUS course. POCUS use was higher among trained physicians for both ascites (84% vs 50%, p < 0.001) and pleural effusion (80% vs 34%, p < 0.001). Similarly, higher POCUS use was observed in younger physicians. In conclusion, PE is frequently performed and rates of confidence are low for most PE signs, especially among young doctors and POCUS users. This detailed inventory suggests an ongoing shift towards POCUS integration in clinical practice.
... Another study reported the rate of hemorrhage from paracentesis at 0-0.97%, with risk factors for hemorrhage including renal disease, lack of operator experience, and lack of ultrasound guidance (76). Ultrasound guidance has been shown to reduce the risk of bleeding after paracentesis by 3-fold compared to paracentesis performed without ultrasound (75). One retrospective study including 3,000 paracenteses performed with ultrasound guidance by radiologists found that significant post-paracentesis hemorrhage occurred in only 0.19% of patients, with only a single case requiring embolization despite the fact that INR was over 2 in 14% of cases and platelets were under 50×10^3/ μL in 12% of cases (77). ...
Article
Iatrogenic injury is unfortunately a leading cause of morbidity and mortality for patients worldwide. The etiology of iatrogenic injury is broad, and can be seen with both diagnostic and therapeutic interventions. While steps can be taken to reduce the occurrence of iatrogenic injury, it is often not completely avoidable. Once iatrogenic injury has occurred, prompt recognition and appropriate management can help reduce further harm. The objective of this narrative review it to help reader better understand the risk factors associated with, and treatment options for a broad range of potential iatrogenic injuries by presenting a series of iatrogenic injury cases. This review also discusses rates, risk factors, as well as imaging and clinical signs of iatrogenic injury with an emphasis on endovascular and minimally invasive treatments. While iatrogenic vascular injury once required surgical intervention, now minimally invasive endovascular treatment is a potential option for certain patients. Further research is needed to help identify patients that are at the highest risk for iatrogenic injury, allowing patients and providers to reconsider or avoid interventions where the risk of iatrogenic injury may outweigh the benefit. Further research is also needed to better define outcomes for patients with iatrogenic vascular injury treated with minimally invasive endovascular techniques verses conservative management or surgical intervention.
... In a large observational database study of 70,000 patients undergoing paracentesis, ultrasonographic guidance signifi cantly reduced bleeding complications. 65,66 In addition, a linear probe can help identify underlying vasculature, including the inferior epigastric artery, further minimizing major bleeding risk. ...
Article
Point-of-care ultrasonography (POCUS) has emerged as a vital tool in medicine. Initially used for procedural guidance, POCUS is now used for diagnostics and monitoring of the lung, heart, abdomen, and deep vein thrombosis. This wide applicability makes it an essential tool for hospitalists in daily clinical practice. This article provides an overview of the clinical integration of POCUS and basic image interpretation.
... Possible approaches to the superior sulcus lesions other than the craniocaudal approach include the conventional intercostal approach and transscapular approach. Although the safety and efficacy of the conventional intercostal approach are established, reaching the superior sulcus lesion is sometimes difficult because of the existence of normal lung parenchyma [6]. The transscapular approach has been reported to reach the superior sulcus lesions [7]. ...
Article
Full-text available
Purpose To evaluate the feasibility and safety of the craniocaudal approach for superior sulcus lesions of the thorax. Material and Methods Between October 2010 and December 2020, the data from 22 consecutive patients who underwent drainage or biopsy using a craniocaudal trajectory were retrospectively reviewed. The craniocaudal approach was applied for patients in which the fluid collection or tumor was limited to the superior thoracic sulcus lesion or otherwise inaccessible owing to intervening structures such as pleural dissemination. The indications for this procedure were drainage in 20 patients and biopsy in 2 patients. Technical success, procedure time, complications, and clinical success were evaluated. Results Technical and clinical success were achieved in all patients, and no major complications were found. The median procedure time was 25 min (range 15–40 min). This procedure was performed with fluoroscopic guidance in 11 patients and ultrasound guidance in 11 patients. The routes of needle passage were the first intercostal space ( n = 16), the second intercostal space ( n = 5), and between the clavicle and the first rib ( n = 1). Conclusion The craniocaudal approach for superior sulcus lesions might be a safe and feasible option for patients in which the conventional intercostal approach is difficult. Level of Evidence Retrospective cohort study. Level 4.
... In addition to its value in diagnosing thepleural effusion, it can also evaluate theechogenicity of the fluid and the presence and degree ofseptation, which are key parameters in stratifying pleural infections and choosing the optimum treatment pathway (5) . Given its real-time potential, US has the advantage of safely guiding pleural procedures, leading to lower complicationrates and reduced healthcare costs which has been translated in recent guidelines for pleural procedures (6) . ...
Article
Full-text available
Background: Pleural effusion disease became widely distributed nowadays with multiple pathogenic mechanisms.
... Pleural ultrasound is valuable in detecting pleural fluid with high sensitivity and in separating it from underlying consolidated lung or elevated hemidiaphragm. Pleural ultrasound can detect septations or loculations to guide drainage procedures (27,44,45) and is recommended by clinical guidelines for management of pleural effusions. Patients with septated effusions on ultrasonography have longer hospitalisation and more likely require fibrinolytic therapy or surgery (46). ...
Article
Full-text available
Over 1.5 million patients are admitted to hospital with pneumonia in the United States each year. Up to 50% of them can develop a parapneumonic effusion which is associated with higher mortality. The incidence of pleural infection continues to rise, particularly in the elderly and those with comorbidities. Parapneumonic effusions cover a spectrum of presentations from a free-flowing 'simple parapneumonic effusion' to a septated 'complicated parapneumonic effusion' (CPE) (usually from bacterial pleural invasion) and 'empyema' (presence of pleural pus). Pleural infection is defined as either CPE or empyema, and usually requires evacuation of the infected fluid. Laboratory investigations play an essential part of the diagnosis and management of pleural infection. A parapneumonic effusion is typically a neutrophil-rich exudate. Presence of bacteria from culture of the fluid defines pleural infection but conventional culture methods have a low yield. Surrogate pleural fluid markers are often employed to confirm a CPE, including low pleural fluid pH (<7.2) or glucose (<3.3 mmol/L) and elevated lactate dehydrogenase (LDH). Measurement of pleural fluid triglyceride and chylomicrons (for chylothorax) and cholesterol (for pseudochylothorax) may be needed to separate lipid pleural effusions from empyema. Tuberculous pleural effusions usually result from a hypersensitivity pleuritis and are lymphocyte predominant with elevated pleural fluid adenosine deaminase (ADA) and interferon gamma levels. Culture yield of mycobacteria is typically low. Caseating granulomas on pleural tissue biopsy is often considered diagnostic. Common organisms for community-acquired pleural infection include Streptococcus pneumoniae, Streptococcus anginosus group bacteria and Staphylococcus aureus. Hospital-acquired pleural infections have higher mortality and are often polymicrobial which can include S. aureus, Enterobacteriaceae and anaerobes. Antibiotics and evacuation of the infected fluid, usually by chest tube drainage, remain the mainstay of treatment. Intrapleural fibrinolytic and deoxyribonuclease therapy, or occasionally surgical drainage, may be required. © Journal of Laboratory and Precision Medicine. All rights reserved.
... Echo-guided pericardiocentesis with extended catheter drainage are considered as primary management strategy for clinically significant pericardial effusions in paediatrics patients [2]. Use of ultrasound for thoracentesis & paracentesis is associated with decreased risk of pneumothorax & bleeding complications respectively [3]. Ultrasound guided percutaneous dilatational tracheostomy provide a more safety than unguided tracheostomy [4]. ...
Article
Use of bedside ultrasound by intensive care provider is increasing for vascular access, invasive procedural real time guidance, diagnostic, therapeutic, and progress during critical/Intensive care unit stay. Multiple of literatures are available on ultrasound uses in critical care setting. We review the recent literature related to vascular access, lung ultrasound, echocardiography, use in trauma patients, airway examinations, fo
... Point-of-care ultrasound (PoCUS) has been used frequently and variously in emergency clinical practice because it can reduce cost [1] and can be used as an additional diagnostic test [2] that provides important clinical information in a very short time. Procedures have also been proven to benefit from PoCUS, e.g., both guidance and confirmation [3,4]. ...
Article
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Background Point-of-care ultrasound is one of useful diagnostic tools in emergency medicine practice and considerably depends on physician’s performance. This study was performed to evaluate performance improvements and favorable attitudes through structured cardiac ultrasound program for emergency medicine residents. Methods Retrospective observational study using the point-of-care ultrasound (PoCUS) database in one tertiary academic-teaching hospital emergency department has been conducted. Cardiac ultrasound education and rotation program has been implemented in emergency medicine residency program. Structured evaluation sheet for cardiac ultrasound and questionnaire toward PoCUS have been developed. An early-phase and a late-phase case were selected randomly for each participant. Two emergency medicine specialists with expertise in PoCUS evaluated saved images independently. We used a paired t-test to compare the performance score of each phase and the results of the questionnaire. Multivariable linear regression analysis was conducted to evaluate the association between the characteristics of participants and performance improvements. Results During the study period, a total of 1,652 bedside cardiac ultrasounds were administered. Forty-six examinations conducted by 23 emergency medicine residents were randomly selected for analysis. The performance score increased from 39.5 to 56.1 according to expert A and 45.3 to 62.9 according to expert B (p-value <0.01 for both). The average questionnaire score, which was analyzed for 17 participants, showed improvement from 18.9 to 20.7 (p-value <0.01). In multivariable linear regression analysis, younger age, higher early-phase score and higher confidence had a negative association with a greater improvement of performance, while the number of examinations had a positive association. Conclusions Bedside cardiac ultrasound performance and attitudes toward PoCUS have been improved through structured residency program.
... A proportion of patients with lung cancer develop pleural effusion, which would require formal assessment and if causing symptoms therapeutic interventions. Thoracic ultrasound has become an important technique for imaging and guiding of the pleural procedures as it has shown to improve their outcomes and to reduce their complications such as pneumothorax by around 19% [20][21][22]. When diagnostic pleural biopsy is requited a local anaesthetic thoracoscopy forms an important procedural option with relatively low levels of complications [23,24]. ...
... A growing body of literature supports that the use of ultrasound in the emergency department (ED) improves procedural success while decreasing complications, reduces ED length of stay, improves diagnostic accuracy, and decreases mortality. [1][2][3][4][5][6][7][8][9] The American College of Emergency Physicians (ACEP) supports the use of POCUS as a fundamental skill in the practice of EM, and the Accreditation Council of Graduate Medical Education identifies POCUS as a core competency required in EM residency training. 10,11 Despite these guidelines, many EDs in the United States continue to have limited access to ultrasound machines and do not use POCUS as recommended by the ACEP. ...
... To date, there have been only a few small studies which demonstrated use of POCUS in outpatient palliative care settings [13,[17][18][19][20]. These smaller studies report on successful assessments using POCUS in hospice settings, as well as preventing unnecessary procedures and trips to the hospital [21][22][23]. One retrospective chart review reported on patients with ascites in non-hospital settings such as hospice, residential care, and patient homes [13]. ...
Preprint
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Background: The use of Point-Of-Care Ultrasound (POCUS) has increased rapidly across various medical disciplines due to technological advancements providing high quality POCUS units. POCUS can help clinicians at the bed side with information regarding patient management in real time. However, literature reveals scant evidence of POCUS use in Palliative Care. This study’s objective was to examine the use of POCUS in a specialist palliative care setting. Methods: A retrospective chart review was conducted from January 2018 to June 2019 to evaluate characteristics of patients for whom POCUS was utilized. These patients were identified through pre-existing logs and descriptive information was collected from the electronic health records. This included demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS and, if applicable, volume of fluid drained. Results: We identified 126 uses of POCUS in 89 unique patients. 62 patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from GI, Lung and Breast pathologies. 61 POCUS cases (48.4%) were in the outpatient setting. 81 POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance. Conclusion: We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient & caregiver satisfaction and health care utilization in palliative care patients receiving POCUS.
... A randomised controlled trial revealed that CT-guided biopsy improved the diagnostic yield of 40% by comparison with unassisted CPB in patients with MPE (87% vs. 47%) [12]. In terms of safety, another observational cohort study demonstrated that performing ultrasound-guided thoracentesis could reduce the risk of pneumothorax by 19% and bleeding complications by 68% [13]. Nonetheless, there are still UPE patients of 8%-25% [14], probably as image-guided biopsy allows limited access to adequate quantities of tissue by comparison with thoracoscopy, particularly for those that additional molecular analysis is required or histological diagnosis is challenging. ...
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Background: Pleural effusions are caused by various reasons, whose diagnosis remains challenging in spite of various means of diagnosis. Medical thoracoscopy, greatly improves the diagnostic efficacy and gets preference for managements, especially undiagnosed pleural effusions. This study aimed to assess the diagnostic efficacy and safety of medical thoracoscopy in patients with pleural effusion of different causes. Methods: Between January 1st 2012 and April 30th 2021, patients with pleural effusion underwent medical thoracoscopy in the Department of Respiratory Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University. According to the discharge diagnosis, patients were grouped into three, including malignant, tuberculous and inflammatory group. General information, tuberculosis-related and effusion-related indices of three groups were analyzed. The diagnostic yield, diagnostic accuracy, performance under thoracoscopy and complications of patients were compared in three groups. Then, the significant factors for predictive diagnosis between the malignant and tuberculous group were analyzed. Results: During this 10-year study, 106 patients were included, with 67 males and 39 females, mean age 57.1±14.184 years. In 74 patients confirmed under thoracoscopy, 41 patients (38.7%) were malignant, 21 patients (19.8%) tuberculous and 32 patients (30.2%) undiagnostic. The diagnostic yield of medical thoracoscopy is 69.8%, and 75.9% in the malignant, 48.8% in the tuberculous, and 75.0% in the inflammatory. The diagnostic accuracies are 100%, 87.5%, and 75.0%, respectively. Under thoracoscopy, we observed single or multiple pleural nodules in 81.1%, pleural adhesions in 34.0% of patients with pleural effusions. The most common complication was chest pain (41.5%), following by chest tightness (11.3%), fever (10.4%). Multivariate logistic regression analysis showed that effusion appearance (OR=0.001, 95%CI: 0.000-0.204, P=0.010), CEA (OR=0.243, 95%CI: 0.081-0.728, P=0.011) were significant in the differentiation of malignant and tuberculous pleural effusion. Conclusion: Medical thoracoscopy is an effective, safe, less invasive procedure with high diagnostic yield for the pleural effusion of different causes. Medical thoracoscopy has a promising prospect.
... 22 A large cohort study showed that abdominal ultrasound-guided paracentesis reduced bleeding complications by 68% following the procedure and is strongly recommended (if available). 23 Generally, paracentesis is a relatively safe procedure with a low risk of complications such as abdominal wall hematoma (1%), hemoperitoneum (< 0.1%), bowel perforation (< 0.1%), and infection (< 0.1%). 24 Assess all ascitic fluid samples for color, consistency, cell count and differential, albumin, and total protein. ...
Article
Combined serum and ascites fluid measurements point to the cause of ascites. For patients with modest edema, a reduced weight-loss target with diuresis may be acceptable.
... However, the incidence of post-procedural complications was very low. In particular, the rate of iatrogenic pneumothorax documented in our experience was even lower than that reported in the current literature, ranging from 0.97% to 4.9% [12][13][14][37][38][39]. This optimal result was certainly possible thanks to the support of the ultrasound examination in several stages of the procedure. ...
Article
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Purpose: The purpose of the present study was to specifically evaluate the effectiveness and safety of real-time ultrasound-guided thoracentesis in a case series of pleural effusion. Patients and methods: An observational prospective study was conducted. From February 2018 to December 2019, a total of 361 consecutive real-time transthoracic ultrasound (TUS)-guided thoracentesis were performed in the Unit of Diagnostic and Interventional Ultrasound of the Research Hospital "Fondazione Casa Sollievo della Sofferenza" of San Giovanni Rotondo, Foggia, Italy. The primary indication for thoracentesis was therapeutic in all the cases (i.e., evacuation of persistent small/moderate pleural effusions to avoid super-infection; drainage of symptomatic moderate/massive effusions). For completeness, further diagnostic investigations (including chemical, microbiological, and cytological analysis) were conducted. All the procedures were performed by two internists with more than 30 years of experience in interventional ultrasound using a multifrequency convex probe (3-8 MHz). For pleural effusions with a depth of 2-3 cm measured at the level of the costo-phrenic sinus was employed a dedicated holed convex-array probe (5 MHz). Results: In all the cases, the attempts at thoracentesis were successful, allowing the achievement of the therapeutic purpose of the procedure (i.e., the complete drying of the pleural space or the withdrawal of fluid till a "safe" quantity [a mean of 1.5 L, max 2 L] producing relief from symptoms) regardless of the initial extent of the pleural effusion. There were only 3 cases of pneumothorax, for a prevalence rate of complications in this population of 0.83%. No statistical difference was recorded in the rate of pneumothorax according to the initial amount of pleural fluid in the effusion (p = 0.12). All the pleural effusions classified as transudates showed an anechoic TUS appearance. Only the exudative effusions showed a complex nonseptated or a hyperechoic TUS appearance. However, an anechoic TUS pattern was not unequivocally associated with transudates. Some chronic transudates have been classified as exudates by Light's criteria, showing also a complex nonseptated TUS appearance. The cytological examination of the drained fluid allowed the detection of neoplastic cells in 15.89% cases. On the other hand, the microbiological examination of effusions yielded negative results in all the cases. Conclusions: Real-time TUS-guided thoracentesis is a therapeutically effective and safe procedure, despite the diagnostic yield of the cytological or microbiological examinations on the collected liquid being very low. Future blinded randomized studies are required to definitely clarify the actual benefit of the real-time TUS-guided procedure over percussion-guided and other ultrasound-based procedures.
... Likewise, the incidence of post thoracentesis pneumothorax is significantly reduced with TUS use. 14,15 Recently, different properties of the ultrasound devices have made possible to use the technique of elastography to the pleural effusion. Ultrasound elastography gives information of tissue elasticity and stiffness, and could be used as a diagnostic tool. ...
Article
Pleural malignancies are among the most common causes of pleural disease and form the basis of our daily pleural practice. There has been significant research and increase in both diagnostic and therapeutic management of malignant pleural diseases in the last decade. Good-quality data have led to a paradigm shift in the management options of pleural malignancies, and indwelling pleural catheter is now recommended and widely used as first-line intervention. Several trials compared different treatment modalities for pleural malignancies and continue to emphasize the need to reduce hospital length of stay and unnecessary pleural intervention, and the importance of patient choice in clinical decision making. This practical review aims to summarize the current knowledge for the management of pleural malignancies, and the understanding of the steps that we still have to climb to optimize management and reduce morbidity.
... Likewise, the incidence of post thoracentesis pneumothorax is significantly reduced with TUS use. 14,15 Recently, different properties of the ultrasound devices have made possible to use the technique of elastography to the pleural effusion. Ultrasound elastography gives information of tissue elasticity and stiffness, and could be used as a diagnostic tool. ...
Article
Pleural malignancies are among the most common causes of pleural disease and form the basis of our daily pleural practice. There has been significant research and increase in both diagnostic and therapeutic management of malignant pleural diseases in the last decade. Good-quality data have led to a paradigm shift in the management options of pleural malignancies, and indwelling pleural catheter is now recommended and widely used as first-line intervention. Several trials compared different treatment modalities for pleural malignancies and continue to emphasize the need to reduce hospital length of stay and unnecessary pleural intervention, and the importance of patient choice in clinical decision making. This practical review aims to summarize the current knowledge for the management of pleural malignancies, and the understanding of the steps that we still have to climb to optimize management and reduce morbidity.
... It allows for evaluation of symptom improvement, rate of reaccumulation, and the re-expandability of the lung, all of which inform further management options [12,13,58]. The routine use of ultrasound guidance for thoracentesis is recommended as pooled data from multiple studies have shown that the safety of thoracentesis is improved with a lower associated cost [59,60]. ...
Article
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Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality. Treatment is mainly palliative, with symptomatic management achieved via effusion drainage and pleurodesis. Pleurodesis may be hastened by administering a sclerosing agent through a thoracostomy tube, thoracoscopy, or an indwelling pleural catheter (IPC). Over the last decade, several randomized controlled studies shaped the current management of MPE in favor of an outpatient-based approach with a notable increase in IPC usage. Patient preferences remain essential in choosing optimal therapy, especially when the lung is expandable. In this article, we reviewed the last 10 to 15 years of MPE literature with a particular focus on the diagnosis and evolving management.
... For example, in a retrospective study of 69,859 paracenteses, ultrasound guidance reduced the risk of bleeding complications by 68%, an odds ratio of 0.32 (95% CI, 0.25-0.41). 17 More research is needed to assess procedural bleeding risks in the context of current practice standards. This article focuses on a subset of bedside procedures most commonly performed by hospitalists. ...
... Recently, the use of thoracic ultrasound and/or CT to provide real-time image guidance has been increasingly adopted , which should be the best practice to optimize diagnostic yield and patients' safety, avoiding subsequent invasive procedures such as MT, which are unequivocally supported by national guidelines [14]. A randomized controlled trial revealed that CT-guided biopsy improves the diagnostic yield of 40% compared with unassisted CPB in patients with MPE (87% vs 47%) [15]. In terms of safety, another observational cohort study demonstrated that performing ultrasound-guided thoracentesis could reduce the risk of pneumothorax by 19% and bleeding complications by 68% [16]. ...
Article
Background: Pleural effusions occur for various reasons, and their diagnosis remains challenging despite the availability of different diagnostic modalities. Medical thoracoscopy (MT) can be used for both diagnostic and therapeutic purposes, especially in patients with undiagnosed pleural effusion. Aim: To assess the diagnostic efficacy and safety of MT in patients with pleural effusion of different causes. Methods: Between January 1, 2012 and April 30, 2021, patients with pleural effusion underwent MT in the Department of Respiratory Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University (Shaanxi, China). According to the discharge diagnosis, patients were divided into malignant pleural effusion (MPE), tuberculous pleural effusion (TBPE), and inflammatory pleural effusion (IPE) groups. General information, and tuberculosis- and effusion-related indices of the three groups were analyzed. The diagnostic yield, diagnostic accuracy, performance under thoracoscopy, and complications of patients were compared among the three groups. Then, the significant predictive factors for diagnosis between the MPE and TBPE groups were analyzed. Results: Of the 106 patients enrolled in this 10-year study, 67 were male and 39 female, with mean age of 57.1 ± 14.184 years. Among the 74 thoracoscopy-confirmed patients, 41 (38.7%) had MPE, 21 had (19.8%) TBPE, and 32 (30.2%) were undiagnosed. Overall diagnostic yield of MT was 69.8% (MPE: 75.9%, TBPE: 48.8%, and IPE: 75.0%, with diagnostic accuracies of 100%, 87.5%, and 75.0%, respectively). Under thoracoscopy, single or multiple pleural nodules were observed in 81.1% and pleural adhesions in 34.0% with pleural effusions. The most common complication was chest pain (41.5%), followed by chest tightness (11.3%) and fever (10.4%). Multivariate logistic regression analyses showed effusion appearance [odds ratio (OR): 0.001, 95%CI: 0.000-0.204; P = 0.010] and carcinoembryonic antigen (OR: 0.243, 95%CI: 0.081-0.728; P = 0.011) as significant for differentiating MPE and TBPE, with area under the receiver operating characteristic curve of 0.977 (95%CI: 0.953-1.000; P < 0.001). Conclusion: MT is an effective, safe, and minimally invasive procedure with high diagnostic yield for pleural effusion of different causes.
... Point-of-care ultrasound should be used to perform a paracentesis. A study has shown that bleeding-related complications decreased after the use of point-of-care ultrasound as compared to blind drainage [12]. ...
Article
It is rare for patients to have hemorrhagic complications after abdominal paracentesis. Abdominal wall hematomas and hemoperitoneum are the most common hemorrhagic complications of paracentesis. The incidence rate of hemorrhage-related complications is unknown. The risk of hemorrhage-related complications can be elevated in patients with underlying kidney disease and those who are thrombocytopenic or coagulopathic. However, there is no correlation between the degree of thrombocytopenia or coagulopathy and the risk of bleeding. It is important to identify the high-risk patients to prevent these hemorrhage-related complications. In rare instances, secondary complications can develop from hemoperitoneum. We present a case of a cirrhotic patient who underwent a diagnostic paracentesis leading to subsequent intra-abdominal hematoma followed by small bowel obstruction (SBO) due to large abdominal hematoma compressing small bowel loops.
... POCUS education is associated with improved student attitude, confidence, and ability to perform physical exams and improved evaluation of these exam skills in Objective Standardized Clinical Examination (OSCE) scores [17][18][19][20]. POCUS education has also been associated with increased student confidence in performance of bedside procedures [19,[21][22][23]. Kondrashov et al. evaluated the impact of an US course on anatomy knowledge, however a pre-and post-test created specifically for the course was used for assessment [24]. ...
Article
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Introduction Point-of-care ultrasound (US) is used in clinical practice across many specialties. Ultrasound (US) curricula for medical students are increasingly common. Optimal timing, structure, and effect of ultrasound education during medical school remains poorly understood. This study aims to retrospectively determine the association between participation in a preclinical, longitudinal US curriculum and medical student academic performance. Methods All first-year medical students at a medical school in the Midwest region of the United States were offered a voluntary longitudinal US curriculum. Participants were selected by random lottery. The curriculum consisted of five three-hour hands on-sessions with matching asynchronous content covering anatomy and pathologic findings. Content was paired with organ system blocks in the standard first year curriculum at our medical school. Exam scores between the participating and non-participating students were compared to evaluate the objective impact of US education on performance in an existing curriculum. We hypothesized that there would be an association between participation in the curriculum and improved medical student performance. Secondary outcomes included shelf exam scores for the surgery, internal medicine, neurology clerkships and USMLE Step 1. A multivariable linear regression model was used to evaluate the association of US curriculum participation with student performance. Scores were adjusted for age, gender, MCAT percentile, and science or engineering degree. Results 76 of 178 students applied to participate in the curriculum, of which 51 were accepted. US curriculum students were compared to non-participating students (n = 127) from the same class. The US curriculum students performed better in cardiovascular anatomy (mean score 92.1 vs. 88.7, p = 0.048 after adjustment for multiple comparisons). There were no significant differences in cumulative cardiovascular exam scores, or in anatomy and cumulative exam scores for the gastroenterology and neurology blocks. The effect of US curriculum participation on cardiovascular anatomy scores was estimated to be an improvement of 3.48 points (95% CI 0.78-6.18). No significant differences were observed for USMLE Step 1 or clerkship shelf exams. There were no significant differences in either preclinical, clerkship or Step 1 score for the 25 students who applied and were not accepted and the 102 who did not apply. Conclusions Participation in a preclinical longitudinal US curriculum was associated with improved exam performance in cardiovascular anatomy but not examination of other cardiovascular system concepts. Neither anatomy or comprehensive exam scores for neurology and gastrointestinal organ system blocks were improved.
... While significant morbidity and mortality is rare, it can be easily avoided. In general, ultrasound-guided paracentesis can reduce bleeding complications by 68% [5]. ...
Article
Percutaneous pericardiocentesis remains a challenging and potentially dangerous procedure, particularly in small, critically ill patients. We present outcomes of the PLANE (pericardiocentesis using long-axis in-plane real-time echocardiography) technique for pediatric pericardiocentesis compared with a standard echocardiography (ECHO) guidance cohort. This was a retrospective chart review of all children undergoing percutaneous pericardiocentesis from March 2013 to February 2021 at a single center. A total of 78 procedures were performed, 52 utilizing PLANE technique and 26 utilizing standard ECHO-guidance technique. There was 100% technical success rate with only one minor complication for the entire cohort. Procedures were evenly split between the bedside intensive care unit and cardiac catheterization laboratory. PLANE technique was utilized in significantly younger (1.4 vs. 8.4 years, p = 0.008) and smaller (11.1 vs. 31.8 kg, p = 0.007) patients, as well as in most patients deemed high risk (postoperative < 7 days, extracorporeal membrane oxygenation (ECMO) support, and/or weight less than 5 kg; 19/22, p = 0.021). Other patient characteristics were similar between the two groups. There was a trend toward PLANE technique utilization by noncardiology trained operators. The PLANE technique for pediatric pericardiocentesis is safe and effective and can be effectively utilized in small and high-risk patient populations. The technical similarity to other long-axis ultrasound-guided procedures may facilitate adoption and mastery by critical care trained operators.
Article
Objectives To develop a generic and objective tool for assessing competence in percutaneous ultrasound-guided procedures.Methods Interventional ultrasound experts from the Nordic countries were invited to participate in a three-round Delphi process. A steering committee was formed to manage the process. In round 1, the experts were asked to suggest all aspects to consider when assessing competence in US-guided procedures. Suggestions were analyzed and condensed into assessment items. In round 2, the expert panel rated these items on a 1–5 scale and suggested new items. Items with a mean rating of ≤ 3.5 were excluded. In round 3, the expert panel rated the list items and suggested changes to the items.ResultsTwenty-five experts were invited, and response rates in the three rounds were 68% (17 out of 25), 100% (17 out of 17), and 100% (17 out of 17). The three-round Delphi process resulted in a 12-item assessment tool, using a five-point rating scale. The final assessment tool evaluates pre-procedural planning, US technique, procedural technique, patient safety, communication, and teamwork.Conclusions Expert consensus was achieved on a generic tool for assessment of competence in percutaneous ultrasound-guided procedures—the Interventional Ultrasound Skills Evaluation (IUSE). This is the initial step in ensuring a valid and reliable method for assessment of interventional US skill.Key Points • Through a Delphi process, expert consensus was achieved on the content of an assessment tool for percutaneous ultrasound-guided procedures—the Interventional Ultrasound Skills Evaluation (IUSE) tool. • The IUSE tool is comprehensive and covers pre-procedural planning, US technique, procedural technique, patient safety, communication, and teamwork. • This is an important step in ensuring valid and reliable assessment of interventional US skills.
Article
Point of care ultrasound (PoCUS) with pocket-size devices is an efficient and safe imaging modality that became a standard of care in various clinical settings. However, its implementation in hematology has never been evaluated so far. We conducted a prospective monocentric study aiming to harvest data on its usage and to assess its diagnostic and interventional performance in improving the accuracy of basic physical examination in hematological patients. After a focused training program, six hematologists were trained and conducted this study. Sixty-two patients were included. Only in 19 cases, further specialized imaging was required, whereas, in 43 patients PoCUS was sufficient to address the clinical inquiries. The use of PoCUS devices was assessed for its performance difficulty and usefulness perception with satisfactory outcomes. This study represents a proof-of-concept application of PoCUS in hematology, suggesting benefits over the physical examination. • KEY POINTS • PoCUS is particularly attractive in a hematological setting because able to improve the accuracy of physical examination. • A hematology-focused training in PoCUS using handheld devices can allow hematologists to perform bed-side diagnostic and interventional US-based exams.
Chapter
For decades, the drainage of air or fluid from the pleural cavity has been accomplished using a variety of physical exam techniques. However, lacking in sensitivity, physical exam is unable to match the diagnostic accuracy of modern imaging modalities, particularly ultrasound. It is therefore unsurprising that thoracentesis guided by point of care ultrasound, either used statically or dynamically, is becoming increasingly prevalent and in some cases is now widely considered the standard of care. While the thoracentesis procedure itself is unchanged – ultimately resulting in a needle being safely inserted into the pleural space, draining the target collection – the addition of ultrasonography has allowed for increased procedural safety and efficacy without added risk to the patient or provider and minimal time added to the procedure.
Article
Objectives: Procedural complications are a common source of adverse events in hospitals, especially where bedside procedures are often performed by trainees. Medicine procedure services (MPS) have been established to improve procedural education, ensure patient safety and provide additional revenue for services that are typically referred. Prior descriptions of MPS have reported outcomes over one to two years. We aim to describe implementation and five year outcomes of a hospitalist-run MPS. Methods: We identified all patients referred to our MPS for a procedure over the five-year span between 2014-2018. We manually reviewed all charts for complications of paracentesis, thoracentesis, central venous catheterization, and lumbar punctures performed by the MPS in both inpatient and outpatient settings. Annual charges for these procedures were queried using Current Procedural Terminology (CPT) codes. Results: We identified 3,634 MPS procedures. Of these, ultrasound guidance was used in 3224 (88.7%) and trainees performed 2701 (74%). Complications identified included pneumothorax (3.7%, n=16) for thoracentesis, post-dural puncture headache (13.9%, n=100) and bleeding (0.1%, n=1) for lumbar puncture, ascites leak for diagnostic (1.6%, n=8) and large volume (3.7%, n=56) paracentesis, and bleeding (3.5%, n=16) for central venous catheter placement. Prior to initiation of the MPS, total annual procedural charges were $90,437. After MPS implementation, charges increased to a mean of $787,352 annually in the last 4 years of the study period. Conclusion: Implementation of a hospitalist-run, academic MPS resulted in a large volume of procedures, high rate of trainee participation, low rates of complications, and significant increase in procedural charges over five years. Wider adoption of this model has the potential to further improve patient procedural care and trainee education.
Article
Purpose To study trends in volume and reimbursement for paracentesis and thoracentesis by physicians and advanced practice providers (APPs) after the introduction of discreet Current Procedural Terminology codes for image-guidance. Methods Medicare claims for 2012 to 2018 (paracentesis) and 2013 to 2018 (thoracentesis) were extracted using Current Procedural Terminology codes for blind and image-guided paracentesis and thoracentesis. Total volumes were analyzed by provider specialty. Nonfacility reimbursement and relative value units were compared. Results For blind paracentesis, volume decreased from 17,393 to 12,226 procedures from 2012 to 2018. Conversely, volume of image-guided paracentesis increased from 171,631 to 253,834 procedures. Radiology performed the majority of image-guide paracentesis (83.9% in 2012 and 77.1% in 2018). Volume and relative share for APPs dramatically increased (from 10.2% to 15.8%). For blind thoracentesis, volume decreased from 26,716 to 15,075 procedures from 2013 to 2018. Conversely, volume of image-guided thoracentesis increased from 187,168 to 222,673 procedures. Radiology performed the majority of image-guided thoracentesis (73.6% in 2013 and 66.2% in 2018). Volume and relative share for APPs dramatically increased (from 7.7% to 12.9%). Although reimbursement for both image-guided paracentesis and thoracentesis decreased, their reimbursement remained higher than that of blind paracentesis and thoracentesis throughout the study period. Conclusion A higher percentage of these procedures are being performed using image guidance; radiologists performed a growing number but declining percentage of image-guided paracentesis and thoracentesis. APPs are playing an increasing role, particularly using image-guidance. Given decreasing reimbursement for these procedures, APPs can provide a large cost advantage in procedural radiology practices.
Chapter
The use of bedside ultrasound (also called point-of-care ultrasound or clinical ultrasound) can enhance the ability of the clinician to diagnose and manage life-threatening illnesses in critically ill oncology patients. With appropriate training, practice, and credentialing for this skill, clinicians can use bedside ultrasound to diagnose a wide variety of conditions that frequently cause emergent presentations in cancer patients. Appropriate technique along with typical findings of pericardial effusion with cardiac tamponade, acute heart failure, pulmonary edema, pulmonary infection, pleural effusion, ascites, bowel obstruction, venous thromboembolism, and septic shock will be reviewed.
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Roughly 150,000 malignant pleural effusions (MPE) are diagnosed in the United States each year. The majority of cases are caused by lung and breast cancer, and since MPE represents advanced disease, the prognosis is generally poor. In this article we review the pathophysiology, epidemiology, and prognosis of MPE. We then discuss the approach to diagnosis of MPE including the role of imaging, pleural fluid analysis, and medical thoracoscopy. Current management strategies for symptomatic MPE include repeated thoracentesis for patients with very limited life expectancy as well as more definitive procedures such as chemical pleurodesis, tunneled indwelling pleural catheters, and novel combined approaches. The choice of intervention is guided by the efficacy, local expertise, and risk, as well as patient factors and preferences.
Article
Resumen La ecografía es una muy buena herramienta para la guía de los diferentes procedimientos intervencionistas del tórax. Es la técnica ideal para el manejo de las patologías del espacio pleural y permite la realización de procedimientos como la toracocentesis, la biopsia o el drenaje. En el pulmón, tan solo aquellas lesiones que contacten con la pleura costal serán accesibles al intervencionismo con guía ecográfica. En este tipo de lesiones pulmonares, la ecografía es igual de efectiva que la tomografía computarizada como guía para estas intervenciones, pero con menor tasa de complicaciones y menor tiempo de ejecución.
Article
Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.
Article
Objectives Focused thoracic ultrasound (TUS) provides an increased safety profile when undertaking invasive pleural procedures. This has led to the requirement for defined curricula, high quality teaching and robust, validated assessment tools among physicians to ensure patient safety and clinical excellence. Current UK practice is based almost exclusively on expert consensus, but assessment methods employed have been shown to have low reliability and validity and are potentially open to bias. As a result, several assessment tools have been developed, although each has its own limitations. Methods This study aimed to develop and validate an assessment tool corresponding to those skills associated with the most basic level of practice, defined recently as an emergency level operator in the British Thoracic Society Training Standards for Thoracic Ultrasound. Results A total of 27 candidates were enrolled by two examiners based in Belfast and Oxford over a 10-month period between February and November 2019. Mean score of the inexperienced group was 44.3 (95% CI 39.2–49.4, range 28–54) compared with 74.9 (95% CI 72.8–77, range 64–80) in the experienced group providing an estimated mean difference of 30.7 between the two groups (95% CI 24.7–36.7; p < .001). Conclusions This tool appears to discriminate between trainees with limited experience of TUS performance and those with no experience. It has the potential to form part of the assessment strategy for trainees in the United Kingdom and beyond, alongside well established assessment tools in postgraduate training.
Article
Background Cardiopulmonary ultrasound has shown varying results in the diagnosis of pulmonary embolism patients around the world. Hence, the current review was done to assess the diagnostic accuracy of cardiopulmonary ultrasound for diagnosis of pulmonary embolism among suspected patients. Methods We conducted a systematic search for all studies reporting the diagnostic accuracy of cardiopulmonary ultrasound for pulmonary embolism in the databases of MEDLINE, EMBASE, MEDLINE, SCOPUS, and Cochrane library from inception till May 2021. Meta-analysis was performed using STATA software “midas” package. Results Ten studies with 4216 patients were included. The pooled sensitivity was 77% (95% CI, 50–92%) and specificity was 99% (95% CI, 97–100%), respectively. The pooled DOR was 382 (95% CI, 77–1883). Pooled LRP was 90 (95% CI, 24–326) and pooled LRN was .23 (.09–.58). There was significant heterogeneity found with the outcome with significant chi-square test and I2 statistic > 75%. Conclusion Cardiopulmonary ultrasound has the ability to be used as an adjunct to CTPA especially in resource constrained settings. Further reviews comparing multiple non-invasive imaging modalities are required to pick the best tool for diagnosis of pulmonary embolism.
Article
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Spontaneous bacterial peritonitis (SBP) is a common complication in patients with liver cirrhosis, with an increased risk of mortality. For this reason, a diagnostic paracentesis should be performed in all patients with ascites and clinical features with high diagnostic suspicion. Although literature data abound in identifying new diagnostic markers in serum or ascites, they have not yet been validated. The final diagnosis requires the analysis of ascites and the presence of > 250 mm3 neutrophil polymorphonuclear (PMN) in ascites. If previous data showed that the most common microorganisms identified were represented by gram-negative bacteria, we are currently facing an increase in gram-positive bacteria and multi-drug resistant bacteria. Although prompt and effective treatment is required to prevent outcomes, this becomes challenging as first-line therapies may become ineffective leading to worsening prognosis and increased inhospital mortality. In this paper we will make a brief review of existing data on the diagnosis and treatment of SBP.
Article
Ultrasonography is a very good tool for guiding different interventional procedures in the chest. It is the ideal technique for managing conditions involving the pleural space, and it makes it possible to carry out procedures such as thoracocentesis, biopsies, or drainage. In the lungs, only lesions in contact with the costal pleura are accessible to ultrasound-guided interventions. In this type of lung lesions, ultrasound is as effective as computed tomography to guide interventional procedures, but the rate of complications and time required for the intervention are lower for ultrasound-guided procedures.
Article
Pleural disease incidence is continuing to rise internationally and management is becoming increasingly complex. There are now many more options for patients, with access to thoracic ultrasound, image-guided biopsies, indwelling pleural catheters, and local-anesthetic pleuroscopy (thoracoscopy). Safety reports have also highlighted the need for specialist operator knowledge and skill. Consequently, the development of a specialized pleural service can manage patients entirely as an outpatient, limit the number of procedures, and improve patient safety, it also fosters opportunities to enhance specialist procedural skills, engage in clinical research, and reduce the costs of care.
Article
Aims/Background To analyse data from a bedside ultrasound-assisted ascites procedure service in a National Health Service District General Hospital and compare them to results of studies in the medical literature. Methods A retrospective review of audit data collected (January 2013 to December 2019) of the practice of paracentesis in a National Health Service District General hospital. All adult patients referred to the ascites assessment service were included. Bedside ultrasound detected location and volume of ascites, if present. Abdominal wall diameters were determined in order to select the appropriate needle length for procedures. Results and scan images were recorded on a pro-forma. Patients who underwent a procedure were followed up for 7 days, with complications documented. Results Seven hundred and two scans were performed on 282 patients – 127 (45%) male and 155 (55%) female. In 127 (18%) patients, an intervention was avoided. Five hundred forty-five (78%) patients underwent a procedure: 82 (15%) were diagnostic aspirations and 463 (85%) were therapeutic (large volume) paracentesis. Most scans were performed between 08:00–17:00. Average time from patient assessment to diagnostic aspiration was 4 hours 21 minutes. Complications included three failed procedures (0.6%) and one iatrogenic peritonitis (0.2%), but no bowel perforation, no major haemorrhage or death. Conclusion It is possible to introduce a bedside ultrasound-assisted ascites procedure service to a National Health Service District General Hospital with a high success and low complication rate.
Article
Background: Paracentesis is a bedside procedure to obtain ascitic fluid from the peritoneum. Point-of-care ultrasound (POCUS) improves the safety of some medical procedures. However, the evidence supporting its utility in paracentesis is limited. Objective: We aimed to assess if POCUS would yield a user-preferred site for needle insertion compared to conventional landmarking, defined as a ≥ 5 cm change in location. Design: This was a prospective non-randomized trial comparing a POCUS-guided site to the conventional anatomic site in the same patient. Participants: Adult patients at Kingston Health Sciences Centre undergoing paracentesis were included. Interventions: Physicians landmarked using conventional technique and compared this to a POCUS-guided site. The paracentesis was performed at whatever site was deemed optimal, if safe to do so. Main measures: Data collected included the distance from the two sites, depth of fluid pockets, and anatomic considerations. Key results: Forty-five procedures were performed among 30 patients and by 24 physicians, who were primarily in their PGY 1 and 2 years of training (33% and 31% respectively). Patients' ascites was mostly due to cirrhosis (84%) predominantly due to alcohol (47%) and NAFLD (34%). Users preferred the POCUS-guided site which resulted in a change in needle insertion ≥ 5 cm from the conventional anatomic site in 69% of cases. The average depth of fluid was greater at the POCUS site vs. the anatomic site (5.4±2.8 cm vs. 3.0±2.5 cm, p < 0.005). POCUS deflected the needle insertion site superiorly and laterally to the anatomic site. The POCUS site was chosen (1) to avoid adjacent organs, (2) to optimize the fluid pocket, and (3) due to abdominal wall considerations, such as pannus. Six cases landmarked anatomically were aborted when POCUS revealed inadequate ascites. Conclusions: POCUS changes the needle insertion site from the conventional anatomic site for most procedures, due to optimizing the fluid pocket and safety concerns, and helped avoid cases where an unsafe volume of ascites was present.
Chapter
The clinical use of ultrasound in the evaluation of the pleura and pleural cavity has substantially increased in recent years and has become an important imaging adjunct for diagnosing and managing pleural disease in children. Compared to other imaging modalities, ultrasound is safe, does not require ionizing radiation, is relatively inexpensive, and provides blood flow-related information even without contrast administration. It is useful in the assessment of pleural diseases at the bedside, especially in the Emergency Room and in the Intensive Care Unit. In this chapter, up-to-date practical ultrasound imaging techniques as well as fundamental embryology and normal anatomy of the pleura are reviewed. Common and rare but important pleural disorders in the pediatric population are discussed with an emphasis on characteristic ultrasound imaging findings.
Article
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Objectives Acute breathlessness is a common and distressing symptom experienced by patients presenting to the emergency department (ED). Adoption of clinician-performed bedside ultrasound could promote accurate, early diagnosis and treatment to acutely breathless patients. This may be particularly pertinent in low resource settings with limited human resources and lack of access to advanced (gold standard) diagnostic testing. The aim of the study was to explore the experience of point-of-care ultrasound (PoCUS) users in the emergency department, and to understand the facilitators and constraints of PoCUS incorporation into patient investigation pathways. Materials and Methods This was an exploratory qualitative study. Data collection entailed key informant interviews using a semi-structured interview guide between September 2019 and February 2020. Participants were purposively sampled according to role and responsibility in the acute care system at Kenyatta National Hospital, including front-line health practitioners and mid-level clinical hospital managers. Data collection proceeded until no new concepts emerged (thematic saturation). The analytical framework method was used for the thematic analysis of interview transcripts. Results At individual level, the lack of training on the use of PoCUS, as well as fears and beliefs impacted on capability and motivation of the clinicians to perform PoCUS for clinical diagnosis. Hospital level influencers such as hospital norms, workloads, and staffing influenced the use of PoCUS by impacting on the clinician’s capability, motivation, and opportunity. General health system influencers such as relationships and power dynamics between clinical specialties and key stakeholders, and the lack of policy and practice guidelines challenged the uptake of the bedside ultrasound by the clinicians. Conclusion Lack of PoCUS training for clinicians, limited resources and a fragmented health system structure impacted the clinician’s capability, motivation, and opportunity in performing PoCUS in diagnostics. PoCUS for diagnosis of acute breathlessness requires: (1) Well-maintained and accessible equipment; (2) highly trained individuals with time to perform the examination with access to ongoing support for the operators; and (3) finally, researchers must more accurately identify the optimal scope of ultrasound examination, the diagnostic benefits, and the opportunity costs. All three will be required to ensure patient’s benefit.
Article
超音波装置の小型化とベッドサイドへの普及により,超音波検査は救急現場で積極的に利用されるようになった。医療従事者がベッドサイドで観察範囲を絞り,臨床決断と侵襲的手技の質向上のために実施する超音波検査はpoint–of–care ultrasonography(POCUS)と呼ばれる。その概念は世界中で広く共有されるようになったが,本邦ではfocused assessment with sonography for trauma(FAST)と超音波ガイド下中心静脈穿刺を除き,POCUSに関する正式な指針はこれまで存在しなかった。日本救急医学会Point–of–Care超音波推進委員会では,POCUSを用いた救急診療の質向上について議論を繰り返し,日本救急医学会からの認証を得て救急point–of–care超音波診療指針としてまとめた。この指針では,背景,救急科専門医の到達目標,その論文的根拠,領域横断的な活用について述べる。到達目標の主要項目には,超音波の基礎,上気道,胸部,心臓,腹部,深部静脈,ガイド下手技,症候別評価が含まれる。また将来主要項目になる可能性があるものは付加項目として広く言及した。この指針は救急科専門医にとっての超音波検査の概要と方向性を示すものであり,救急超音波教育のために利用できる。この指針をきっかけに,本邦の救急診療の現場で超音波検査が効果的に利用されることを願う。 Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision–making and improving the quality of invasive procedures is now called point–of–care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound–guided central venous cannulation. The Committee for the Promotion of Point–of–Care Ultrasonography in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the “Clinical Guidance for Emergency and Point–of–Care Ultrasonography” was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, upper airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound–guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.
Article
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irrhosis, most frequently caused by hepatitis c or alcoholism, was the 12th leading cause of death in the United States in 2000, accounting for more than 25,000 deaths. 1 Ascites is the most common complication of cirrhosis and is associated with a poor quality of life, increased risks of infections and renal failure, and a poor long-term outcome. 2,3 In recent years, important advances have been made in the management of cirrhosis and ascites. The chief factor contributing to ascites is splanchnic vasodilatation. 4 Increased hepatic resistance to portal flow due to cirrhosis causes the gradual development of portal hy-pertension, collateral-vein formation, and shunting of blood to the systemic circulation. As portal hypertension develops, local production of vasodilators, mainly nitric oxide, increases, leading to splanchnic arterial vasodilatation. 5 In the early stages of cirrhosis, splanchnic arterial vasodilatation is moderate and has only a small effect on the effec-tive arterial blood volume, which is maintained within normal limits through increases in plasma volume and cardiac output. 4 In the advanced stages of cirrhosis, splanchnic ar-terial vasodilatation is so pronounced that the effective arterial blood volume decreases markedly, and arterial pressure falls. As a consequence, arterial pressure is maintained by homeostatic activation of vasoconstrictor and antinatriuretic factors, resulting in so-dium and fluid retention. The combination of portal hypertension and splanchnic arteri-al vasodilatation alters intestinal capillary pressure and permeability, facilitating the accumulation of retained fluid within the abdominal cavity. As the disease progresses, there is marked impairment in renal excretion of free water and renal vasoconstriction — changes that lead to dilutional hyponatremia and the hepatorenal syndrome, respec-tively 4,6 (Fig. 1).
Article
The smearing estimate is proposed as a nonparametric estimate of the expected response on the untransformed scale after fitting a linear regression model on a transformed scale. The estimate is consistent under mild regularity conditions, and usually attains high efficiency relative to parametric estimates. It can be viewed as a low-premium insurance policy against departures from parametric distributional assumptions. A real-world example of predicting medical expenditures shows that the smearing estimate can outperform parametric estimates even when the parametric assumption is nearly satisfied.
Article
Abdominal paracentesis is commonly performed for diagnostic, therapeutic, and palliative indications, but the use of ultrasound guidance for these procedures is relatively recent, variable, and not well documented. A retrospective database analysis of abdominal paracentesis procedures was performed to determine whether ultrasound guidance was associated with differences in adverse events (AEs) or hospital costs, compared to procedures without ultrasound guidance. The hospital database maintained by Premier was used to identify patients with abdominal paracentesis International Classification of Diseases - 9th Revision - Clinical Modification (ICD-9 code 54.9, Common Procedural Terminology CPT-4 codes 49080, 49081) in 2008. Use of ultrasound guidance was determined via patient billing data. The incidence of selected AEs and patients' hospitalization costs were calculated for two groups: procedures with ultrasound guidance and those without. Univariate and multivariable analyses were performed to evaluate differences between groups. This study identified 1297 abdominal paracentesis procedures, 723 (56%) with ultrasound and 574 (44%) without. The indications for paracentesis were similar between the two groups. The incidence of AEs was lower in ultrasound-guided procedures: all AEs (1.4% vs 4.7%, p = 0.01), post-paracentesis infection (0.41% vs 2.44%, p = 0.01), hematoma (0.0% vs 0.87%, p = 0.01), and seroma (0.14% vs 1.05%, p = 0.03). Analyses adjusted for patient and hospital covariates revealed significant reductions in AEs (OR = 0.349, 95% CI = 0.165, 0.739, p = 0.0059) and hospitalization costs ($8761 ± $5956 vs $9848 ± $6581, p < 0.001) for procedures with ultrasound guidance vs those without. There are several limitations to using claims data for clinical analyses; causality cannot be determined, the possibility of miscoded or missing data, and the inability to control for elements not captured in claims data that may influence clinical outcomes. The use of ultrasound guidance in abdominal paracentesis procedures is associated with fewer AEs and lower hospitalization costs than procedures where ultrasound is not used.
Article
PURPOSE.: We performed an analysis of hospitalizations involving thoracentesis procedures to determine whether the use of ultrasonographic (US) guidance is associated with differences in complications or hospital costs as compared with not using US guidance. METHODS.: We used the Premier hospital database to identify patients with ICD-9 coded thoracentesis in 2008. Use of US guidance was identified using CPT-4 codes. We performed univariate and multivariable analyses of cost data and adjusted for patient demographics, hospital characteristics, patient morbidity severity, and mortality. Logistic regression models were developed for pneumothorax and hemorrhage adverse events, controlling for patient demographics, morbidity severity, mortality, and hospital size. RESULTS.: Of 19,339 thoracentesis procedures, 46% were performed with US guidance. Mean total hospitalization costs were $11,786 (±$10,535) and $12,408 (±$13,157) for patients with and without US guidance, respectively (p < 0.001). Unadjusted risk of pneumothorax or hemorrhage was lower with US guidance (p = 0.019 and 0.078, respectively). Logistic regression analyses demonstrate that US is associated with a 16.3% reduction likelihood of pneumothorax (adjusted odds ratio 0.837, 95% CI: 0.73-0.96; p= 0.014), and 38.7% reduction in likelihood of hemorrhage (adjusted odds ratio 0.613, 95% CI: 0.36-1.04; p = 0.071). CONCLUSIONS.: US-guided thoracentesis is associated with lower total hospital stay costs and lower incidence of pneumothorax and hemorrhage. © 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011.
Article
Little is known about the factors related to the development of pneumothorax following thoracentesis. We aimed to determine the mean pneumothorax rate following thoracentesis and to identify risk factors for pneumothorax through a systematic review and meta-analysis. We reviewed MEDLINE-indexed studies from January 1, 1966, through April 1, 2009, and included studies of any design with at least 10 patients that reported the pneumothorax rate following thoracentesis. Two investigators independently extracted data on the pneumothorax rate, risk factors for pneumothorax, and study methodological quality. Twenty-four studies reported pneumothorax rates following 6605 thoracenteses. The overall pneumothorax rate was 6.0% (95% confidence interval [CI], 4.6%-7.8%), and 34.1% of pneumothoraces required chest tube insertion. Ultrasonography use was associated with significantly lower risk of pneumothorax (odds ratio [OR], 0.3; 95% CI, 0.2-0.7). Lower pneumothorax rates were observed with experienced operators (3.9% vs 8.5%, P = .04), but this was nonsignificant within studies directly comparing this factor (OR, 0.7; 95% CI, 0.2-2.3). Pneumothorax was more likely following therapeutic thoracentesis (OR, 2.6; 95% CI, 1.8-3.8), in conjunction with periprocedural symptoms (OR, 26.6; 95% CI, 2.7-262.5), and in association with, although nonsignificantly, mechanical ventilation (OR, 4.0; 95% CI, 0.95-16.8). Two or more needle passes conferred a nonsignificant increased risk of pneumothorax (OR, 2.5; 95% CI, 0.3-20.1). Iatrogenic pneumothorax is a common complication of thoracentesis and frequently requires chest tube insertion. Real-time ultrasonography use is a modifiable factor that reduces the pneumothorax rate. Performance of thoracentesis for therapeutic purposes and in patients undergoing mechanical ventilation confers a higher likelihood of pneumothorax. Experienced operators may have lower pneumothorax rates. Patient safety may be improved by changes in clinical practice in accord with these findings.
Article
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.
Article
In a sample of 30,195 randomly selected hospital records, we identified 1133 patients (3.7 percent) with disabling injuries caused by medical treatment. We report here an analysis of these adverse events and their relation to error, negligence, and disability. Two physician-reviewers independently identified the adverse events and evaluated them with respect to negligence, errors in management, and extent of disability. One of the authors classified each event according to type of injury. We tested the significance of differences in rates of negligence and disability among categories with at least 30 adverse events. Drug complications were the most common type of adverse event (19 percent), followed by wound infections (14 percent) and technical complications (13 percent). Nearly half the adverse events (48 percent) were associated with an operation. Adverse events during surgery were less likely to be caused by negligence (17 percent) than nonsurgical ones (37 percent). The proportion of adverse events due to negligence was highest for diagnostic mishaps (75 percent), noninvasive therapeutic mishaps ("errors of omission") (77 percent), and events occurring in the emergency room (70 percent). Errors in management were identified for 58 percent of the adverse events, among which nearly half were attributed to negligence. Although the prevention of many adverse events must await improvements in medical knowledge, the high proportion that are due to management errors suggests that many others are potentially preventable now. Reducing the incidence of these events will require identifying their causes and developing methods to prevent error or reduce its effects.
Article
This study is a retrospective survey of the variables that may influence the development of pneumothorax after thoracentesis. In a 30-month period, a computer search of hospital records identified 342 thoracenteses, of which 154 were done with conventional techniques by the clinical services, and 188 were done with sonographic guidance. Other factors surveyed included the patients' age, sex, underlying pulmonary disease, and overall clinical condition; the size of the effusion; the type of tap (diagnostic or therapeutic); the amount and type (exudate or transudate) of fluid acquired; and the size of the needles used. The technique used was the most significant single risk factor affecting the development of pneumothorax (18% for clinical vs 3% for sonography-guided thoracenteses). The incidence of pneumothorax decreased when a smaller amount of pleural fluid was aspirated (mean, 246 ml aspirated from patients who did not vs 472 ml from those who did develop pneumothorax) and when thin needles were used (4% pneumothorax with 20-gauge or smaller and 18% with larger than 20-gauge needles). The other factors surveyed did not influence the development of pneumothorax. Our results show that sonography-guided thoracentesis is complicated by pneumothorax significantly less often than is thoracentesis done with conventional techniques. Use of the smallest possible needle and aspiration of the smallest possible amount of fluid will also result in fewer cases of pneumothorax.
Article
To determine what role the technique plays in complications associated with thoracentesis performed by physicians in training, we undertook a prospective study of thoracentesis in the medical service at our institution in which the sampling method was randomized among needle, needle with catheter, and needle with direct sonographic guidance. Fifty-two spontaneously breathing, cooperative patients with free-flowing effusions obliterating more than half of the hemidiaphragm on an upright, posteroanterior chest roentgenogram were randomized. When we analyzed those complications that were potentially life-threatening (eg, pneumothorax) and/or placed patients at increased risk for further morbidity (eg, pneumothorax, dry tap, inadequate tap), the sonography-guided method was associated with significantly fewer serious complications (0 of 19) than the needle-catheter (9 of 18) or needle-only methods (5 of 15). The sonography-guided method was associated with fewer pneumothoraces (0 of 19) than the needle-catheter (7 of 18) or needle-only methods (3 of 15). The difference between needle-catheter and needle-only methods was not significant. From our results, we conclude that the method by which thoracentesis was performed significantly influenced the spectrum and frequency of complications, and the sonography-guided method was the safest.
Article
To determine the importance of procedure-related complications on a general medical service. A retrospective cohort study with one-to-one matching. Complications were identified through chart review by nurse-technicians using standard definitions. The internal medicine service of a 900-bed university hospital. One hundred seven cases with noninfectious, procedure-related complications and 107 closely matched controls who underwent the same procedures without complication. None. The mortality rate was 28% for cases compared with 11% for controls, resulting in an excess mortality rate of 17% (p = 0.02). Cases who survived to discharge had an excess length of stay of seven days (p = 0.001). The excess cost per case was $12,913. Importantly, median reimbursement was only $2,064 higher for cases than for controls. Adjusting for age and APACHE II (severity of illness) score, procedure-related complications were associated with a 3.4-fold increase in the relative risk of in-hospital mortality (95% CI: 1.5 to 7.7). Surveillance data were useful in directing quality improvement activities that resulted in a 66% reduction in the rate of pneumothorax following thoracentesis. Procedure-related complications were associated with prolonged and expensive hospitalization and were a marker for patients at high risk for in-hospital mortality. Programs to reduce complications on the general medical service have an enormous potential to benefit both patients and hospitals.
Article
The incidence of hemorrhagic complications from large volume paracentesis in patients with cirrhosis and portal hypertension is unknown. We have reviewed the cases of 179 outpatients undergoing large volume paracentesis at our institution during a 1-yr period. Of these 179 patients, four developed severe hemorrhagic complications requiring hospital admission and blood transfusion. Three of these patients developed intraperitoneal hemorrhage, one of which was localized to the paracentesis puncture site. One patient experienced an abdominal wall hematoma, localized by ultrasound. The symptoms and signs of hemorrhage became evident anywhere from hours up to 1 wk after completion of the paracentesis procedure. The mechanism of delayed hemorrhage is not known but may relate to the the rupture of large intra-abdominal venous collaterals in these patients. The literature does not support a correlation between degree of coagulopathy or thrombocytopenia and risk of bleeding in this setting. To promote early detection of this potentially life-threatening complications, a mechanism should exist for close outpatient follow-up of patients after large volume paracentesis.
Article
Hemoperitoneum resulting from rupture of mesenteric varices is a rare complication of portal hypertension with a high mortality of up to 70%. This case report describes the symptoms, clinical course, and treatment of 4 patients with acute hemoperitoneum caused by mesenteric variceal bleeding after large-volume paracentesis. Abdominal pain and/or hemorrhagic shock developed in 4 patients (age, 48-68 years), admitted for refractory ascites, 3 hours to 4 days after 1-4 large-volume paracenteses (> 4000 mL). Duplex sonography, performed in 3 of the 4 patients before onset of bleeding, showed retrograde flow in the mesenteric veins, suggesting large-caliber mesenteric collateralization. Treatment consisted of surgical ligation followed by transjugular intrahepatic portosystemic shunt (TIPS) (2 patients) and emergency TIPS with embolization of the bleeding vessel (1 patient). One patient died before any intervention could be initiated. In these 4 patients, the concurrence of large-volume paracentesis and hemoperitoneum suggests their causal relationship. The mechanism may be a sudden reduction in intraperitoneal pressure increasing the pressure gradient across the wall of the mesenteric varices, resulting in rupture and bleeding. The awareness of this complication may accelerate the diagnostic process and treatment.
Article
To identify issues related to the quality of health care in the United States, including its measurement, assessment, and improvement, requiring action by health care professionals or other constituencies in the public or private sectors. The National Roundtable on Health Care Quality, convened by the Institute of Medicine, a component of the National Academy of Sciences, comprised 20 representatives of the private and public sectors, practicing medicine and nursing, representing academia, business, consumer advocacy, and the health media, and including the heads of federal health programs. The roundtable met 6 times between February 1996 and January 1998. It explored ongoing, rapid changes in health care and the implications of these changes for the quality of health and health care in the United States. Roundtable members held discussions with a wide variety of experts, convened conferences, commissioned papers, and drew on their individual professional experience. At the end of its deliberations, roundtable members reached consensus on the conclusions described in this article by a series of discussions at committee meetings and reviews of successive draft documents, the first of which was created by the listed authors and the Institute of Medicine project director. The drafts were revised following these discussions, and the final document was approved according to the formal report review procedures of the National Research Council of the National Academy of Sciences. The quality of health care can be precisely defined and measured with a degree of scientific accuracy comparable with that of most measures used in clinical medicine. Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as underuse, overuse, or misuse, occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result. Quality of care is the problem, not managed care. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how we deliver health care services, educate and train clinicians, and assess and improve quality.
Article
Thoracentesis in a ventilated patient is rarely performed because of the risk of pneumothorax. We have evaluated the safety of this procedure when aided by ultrasound. Prospective study. Medical intensive care unit, university-affiliated hospital. 45 procedures were performed in 40 consecutive patients with ultrasound signs of pleural effusion, all mechanically ventilated. Pleural effusion was defined on ultrasound as a collection of fluid between parietal and visceral pleura leading to variations in interpleural distance during breathing. When the interpleural distance was >/= 15 mm and visible over three intercostal spaces, a needle (16 or 21 G) was inserted after ultrasound localization in a patient in either dorsal or lateral decubitus. No complication occurred in the 45 thoracenteses. Fluid was obtained in 44 of 45 procedures, thus confirming the diagnosis of pleural effusion. The procedure was immediate (less than 10 s) in 40 of 45 cases. It was easy (i. e., keeping the patient supine) in 22 of 45 procedures. In 44 cases where fluid was obtained, only 27 bedside radiographs revealed signs of effusion, whereas 17 showed absence of a visible effusion. Ultrasound thus appeared more efficient than bedside X-ray in detecting pleural effusion. If basic rules are followed, ultrasound localization makes thoracentesis a safe, easy and simple procedure in patients on mechanical ventilation.
Article
The objectives of this study are as follows: (1) to determine the incidence of complications from thoracentesis performed under ultrasound guidance by interventional radiologists in a tertiary referral teaching hospital; (2) to evaluate the incidence of vasovagal events without the use of atropine prior to thoracentesis; and (3) to evaluate patient or radiographic factors that may contribute to, or be predictive of, the development of re-expansion pulmonary edema after ultrasound-guided thoracentesis. Prospective descriptive study. Saint Thomas Hospital, a tertiary referral teaching hospital in Nashville, TN. All patients referred to interventional radiology for diagnostic and/or therapeutic ultrasound-guided thoracentesis between August 1997 and September 2000. A total of 941 thoracenteses in 605 patients were performed during the study period. The following complications were recorded: pain (n = 25; 2.7%), pneumothorax (n = 24; 2.5%), shortness of breath (n = 9; 1.0%), cough (n = 8; 0.8%), vasovagal reaction (n = 6; 0.6%), bleeding (n = 2; 0.2%), hematoma (n = 2; 0.2%), and re-expansion pulmonary edema (n = 2; 0.2%). Eight patients with pneumothorax received tube thoracostomies (0.8%). When > 1,100 mL of fluid were removed, the incidence of pneumothorax requiring tube thoracostomy and pain was increased (p < 0.05). Fifty-seven percent of patients with shortness of breath during the procedure were noted to have pneumothorax on postprocedure radiographs, while 16% of patients with pain were noted to have pneumothorax on postprocedure radiographs. Vasovagal reactions occurred in 0.6% despite no administration of prophylactic atropine. Re-expansion pulmonary edema complicated 2 of 373 thoracenteses (0.5%) in which > 1,000 mL of pleural fluid were removed. The complication rate with thoracentesis performed by interventional radiologists under ultrasound guidance is lower than that reported for non-image-guided thoracentesis. Premedication with atropine is unnecessary given the low incidence of vasovagal reactions. Re-expansion pulmonary edema is uncommon even when > 1,000 mL of pleural fluid are removed, as long as the procedure is stopped when symptoms develop.
Article
Large-volume paracentesis, the preferred treatment for patients with symptomatic tense ascites due to cirrhosis, has traditionally been performed by physicians as an inpatient procedure. Our objectives were to determine (1) whether large-volume paracentesis could be performed safely and effectively by gastrointestinal endoscopy assistants and as an outpatient procedure, (2) whether the risk of bleeding was associated with either thrombocytopenia or prolongation of the prothrombin time, and (3) the resources used for large-volume paracentesis. Gastrointestinal endoscopy assistants performed 1,100 large-volume paracenteses in 628 patients, 513 of whom had cirrhosis of the liver. The preprocedure mean international normalized ratio for prothrombin time was 1.7 +/- 0.46 (range, 0.9-8.7; interquartile range, 1.4-2.2), and the mean platelet count was 50.4 x 10(3)/microL, (range, 19 x 10(3)/microL - 341 x 10(3)/microL; interquartile range, 42-56 x 10(3)/microL). Performance of 3 to 7 supervised paracenteses was required before competence was achieved. There were no significant procedure-related complications, even in patients with marked thrombocytopenia or prolongation in the prothrombin time. The mean duration of large-volume paracentesis was 97 +/- 24 minutes, and the mean volume of ascitic fluid removed was 8.7 +/- 2.8 L. In conclusion, large-volume paracentesis can be performed safely as an outpatient procedure by trained gastrointestinal endoscopy assistants. Ten supervised paracenteses would be optimal for training the operators carrying out the procedure. The practice guideline of the American Association for the Study of Liver Diseases which states that routine correction of prolonged prothrombin time or thrombocytopenia is not required is appropriate when experienced personnel carry out paracentesis.
Article
To assess whether thoracenteses performed with sonographic guidance are associated with a lower rater of pneumothorax and tube thoracostomy than those performed without sonographic guidance. We reviewed the medical records of 523 subjects undergoing their initial diagnostic thoracentesis at our institution from July 1, 2001, to June 30, 2002. We excluded 73 subjects in whom no chest imaging had been performed within 5 days of thoracentesis or who had pre-existing chronic hydropneumothorax. Of the 450 thoracenteses performed, 305 (67.8%) were performed with sonographic guidance and 145 (32.2%) were performed without. On postthoracentesis imaging in all subjects, 30 pneumothoraces (6.7%) were found (23 inpatients, 7 out-patients). Eight patients required a tube thoracostomy for their pneumothorax. Pneumothorax occurred in 15 of 305 procedures (4.9%) performed with sonographic guidance and 15 of 145 procedures (10.3%) performed without (p < 0.05). Tube thoracostomy was performed in 0.7% of patients whose thoracentesis was performed with sonographic guidance and in 4.1% in those that were not (p < 0.05). We found no correlation between pneumothorax after thoracentesis and age, inpatient status, loculation of effusion, or volume of pleural fluid removed. The routine use of sonography during diagnostic thoracentesis is associated with a reduced rate of pneumothorax and tube thoracostomy.
Article
Pneumothorax following ultrasound-guided thoracentesis is rare. Our goal was to explain the mechanisms of pneumothorax following ultrasound-guided thoracentesis in a setting where pleural manometry is routinely used. We reviewed the patient records and procedure reports of 401 patients who underwent ultrasound-guided thoracentesis. When manometry was performed, pleural space elastance was determined. A model assuming dependence of the pleural space elastic properties on respiratory system elastic properties was used to isolate cases with presumed normal pleural space elastance. Elastance outside mean +/- SD x 2 of the isolated sample was considered abnormal. Four radiographic criteria of unexpandable lung were used: visceral pleural peel, lobar atelectasis, basilar pneumothorax, and pneumothorax with ipsilateral shift. There were 102 diagnostic thoracenteses, 192 therapeutic thoracenteses with pleural manometry, and 73 therapeutic thoracenteses without manometry. There was one pneumothorax that occurred from lung puncture and eight unintentional pneumothoraces, all of which showed radiographic evidence of unexpandable lung. Four of eight unintentional pneumothoraces had abnormal elastance; none had excessively negative pleural pressure (< -25 cm H(2)O). Unintentional pneumothoraces cannot be prevented by monitoring for symptoms or excessively negative pressure. These pneumothoraces were drainage related rather than due to penetrating lung trauma or external air introduction. We speculate that unintentional pneumothoraces are caused by transient, parenchymal-pleural fistulae caused by nonuniform stress distribution over the visceral pleura that develop during large-volume drainage if the lung cannot conform to the shape of the thoracic cavity in some patients with unexpandable lung. These fistulae appear to be pressure dependent, and the resulting pneumothoraces rarely require treatment. Drainage-related pneumothorax is an unavoidable complication of ultrasound-guided thoracentesis and appears to account for the vast majority of pneumothoraces occurring in a procedure service.