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Ultrasound Guidance Decreases Complications and Improves the Cost of Care Among Patients Undergoing Thoracentesis and Paracentesis
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.
... [11]. Аналогичные результаты со снижением риска пневмоторакса на 19% продемонстрировали и C.J. Mercaldi et al. (2013) (odds ratio=0,81; 95%CI=0,74-0,90) [17]. ...
... [11]. Аналогичные результаты со снижением риска пневмоторакса на 19% продемонстрировали и C.J. Mercaldi et al. (2013) (odds ratio=0,81; 95%CI=0,74-0,90) [17]. ...
... После появления современных наборов для плевральных процедур (игл, дренажей, катетеров) и особенно с внедрением ультразвуковой навигации их частота по данным мета-анализа 24 исследований (n=6605) снизилась до 6,0% в целом, и до 4,0% при использовании УЗИ: (4,0% vs. 9,3%; odds ratio=0,3, 95%CI:0,2-0,7). В более позднем крупном ретроспективном когортном исследовании, опубликованном в 2013 г. (n=62261) общий риск пневмоторакса оценивался в 2,7%, также показано, что УЗИ снижает его на 19% (odds ratio=0,81, 95%CI:0,74-0,90) [11,17,18]. ...
Pleural effusion accompanying malignant lesions of the pleura is often a marker of the spread of the tumour process. Effusion is associated with the limited opportunities of the local control and as a consequence with poor long-term results. The morphological, immunohistochemical, and molecular features of the tumour are important prognostic and predictive factors that largely determine the therapeutic tactics. Clinical guidelines in the vast majority of cases with pleural effusion indicate that the treatment goal is palliation. The main goal in these patients is to reduce symptoms and improve quality of life. Asymptomatic pleural effusion does not require treatment. Thoracentesis or symptomatic drainage provides immediate relief. With low exudate volumes and accumulation rate, rare relapses and the expected response from the systemic treatment, or, on the other hand, a short expectancy of life, it is possible to limit the management of such cases with symptomatic drainage only. In selected individuals with pleural effusion minimally invasive or surgical interventions are also recommended. These include the installation of indwelling pleural catheters, the implementation of various pleurodesis techniques. In selected subgroups, the local control can reach 87-96%. The introduction of modern surgical techniques for pleural procedures has reduced the incidence of adverse events rate to 2,7-4%. There is no doubt that it is necessary to improve algorithms and search for alternate ve solutions, including those based on combined approaches to the treatment of patients with malignant neoplastic lesions of the pleura.
... 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. ...
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.
... Moreover, the vessels can be displaced and stretched because of the ascitic distension of the abdomen or overweight/obesity, becoming more exposed to injuries [20]. The most common cause of hemorrhage is the injury of the inferior epigastric artery (IEA) or its branches [21][22][23]. However, lesions of other vessels such as deep circumflex inferior artery (DCIA) or its branches are also reported [11,24]. ...
... Based on this analysis, ultrasound guidance was associated with a 68% reduction in the risk of bleeding complications from paracentesis and lower rates in the costs and length of hospitalization were observed. Furthermore, these findings demonstrate a higher benefit from ultrasound guidance in a cohort of outpatients [21]. ...
Paracentesis is a validated procedure for diagnosing and managing ascites. Although paracentesis is a safe procedure with a 1–2% risk of complications such as bleeding, it is necessary to inform the patient about the possible adverse events. We would like to share our experience with two cases of bleeding after paracentesis. In our unit, two major hemorrhagic complications occurred in 162 procedures performed over the year 2020 (frequency of bleeding complications: 1.2%). We report two clinical cases of post-paracentesis abdominal wall hematomas. Despite a similar clinical presentation, the management approach was different: in the first case, embolization of the epigastric artery supplying the hematoma was performed. In the second case, conservative treatment was adopted. Our report aims to provide food for thought about a potentially challenging hemorrhagic complication, even with the risk of adverse outcomes.
... [38]. The use of ultrasound for thoracentesis and chest tube placement leads to fewer complications and increased procedural success [37•, 38,39]. Complications following thoracentesis, such as pneumothorax, are associated with longer hospitalizations and overall increased hospital costs [39,40]. ...
... The use of ultrasound for thoracentesis and chest tube placement leads to fewer complications and increased procedural success [37•, 38,39]. Complications following thoracentesis, such as pneumothorax, are associated with longer hospitalizations and overall increased hospital costs [39,40]. Therefore, reducing complications by utilizing POCUS to guide the procedure has both medical and financial implications. ...
Purpose of Review
This publication will review the numerous uses for procedural point-of-care ultrasound (POCUS), and its supporting literature, specifically for pediatric patients admitted to the cardiac intensive care unit.
Recent Findings
Procedural POCUS can be applied broadly to critically ill children with congenital and acquired heart disease and there is longstanding, supporting evidence for procedures such as central venous catheter placement and thoracentesis. Recently, studies have demonstrated the success of innovative POCUS-guided procedures, including transpyloric enteric tube placement and endotracheal intubation, which are frequently performed in this high-risk population.
Summary
POCUS, a non-invasive, bedside imaging modality, can be used to guide high-risk procedures in vulnerable populations, such as critically ill children with congenital and acquired heart disease. The use of POCUS guidance for procedures in the pediatric cardiac intensive care unit is associated with increased procedural success and fewer complications, thereby enhancing patient safety and, ultimately, outcomes.
... 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). ...
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.
... Table 1 summarizes the studies included for analysis. [7][8][9][10][11][12][13][14][15][16][17][18][19] Iatrogenic Pneumothorax ...
... The rate of iatrogenic pneumothorax (PTX) ranged from 0% to 6.9% (mean, 3.3%; 95% CI, 3.2-3.4). 7,[9][10][11][12][13][14][15][16][17][18] When only studies that explicitly stated the use of ultrasound were included and studies that did not differentiate PTX from nonexpansile lung (NEL) are excluded, it ranged from 0% to 3% (mean, 0.6%; 95% CI, 0.5-0.8). 7,9,13,15 Where studies have elaborated further, the mean incidence of iatrogenic PTX that required intervention (chest tube drainage) was 0.3% (95% CI, 0.2-0.4). ...
Pleural disease is a common presentation and spans a heterogenous population across broad disease entities but a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. Here follows a narrative review based on a structured search of the literature. Searches were limited to 2010 onwards, in recognition of the sea-change in procedural complications following the mainstream use of thoracic ultrasound (US). Procedures of interest were limited to thoracocentesis, intercostal drains (ICD), indwelling pleural catheters (IPC) and local anaesthetic thoracoscopy (LAT). 4308 studies were screened, to identify 48 studies for inclusion. Iatrogenic pneumothorax (PTX) remains the commonest complication following thoracocentesis: 3.3% (95% CI, 3.2-3.4), though PTX requiring intervention was rare: 0.3% (95% CI, 0.2-0.4) when the procedure was US guided. Drain blockage and displacement are the commonest complications following ICD insertion (6.3%, and 6.8%, respectively). IPC related infections can be a significant problem: 5.8% (95% CI, 5.1-6.7), however most cases can be managed without removal of the IPC. LAT has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodological problems and novel methods to study this topic bears consideration. Whilst complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events, to ensure high quality and above all, safe care.
... In patients with pneumothorax, ultrasound is generally not required (as the CXR provides sufficient information and ultrasound does not permit assessment of lung position) but can be useful in locating a site for chest drain insertion in cases of loculated pneumothorax/tethered lung. 26 The use of ultrasound requires training and expertise as described in the British Thoracic Society Training Standards for TUS. 25 CT guidance may be required in some situations, including loculated pneumothorax with tethered lung, the presence of bullae, or posteriorly loculated pleural fluid collections, where sonographic views are not optimal. ...
... It has been reported that performing paracentesis under an ultrasound guide reduces the risk of bleeding after paracentesis, thus reducing hospital stay length, hospitalization complications, and related costs (22,37,38). Ultrasound scanning using a pocket ultrasound device as a physical examination for pre-paracentesis evaluation has been demonstrated to effectively prevent post-operative complications. ...
Background:
Large-volume paracentesis has become the first treatment choice for patients with severe and refractory ascites. The studies have reported several complications after therapeutic paracentesis. But there are few published data on the complications with or without Albumin therapy. We aimed to analyze the safety and complications of large-volume paracentesis in children with or without albumin therapy.
Methods:
This study was conducted on children with severe ascites with chronic liver disease who underwent large-volume paracentesis. They were divided into albumin-infused and albumin non-infused groups. In the case of coagulopathy, no adjustment was made. Albumin was not administered after the procedure. The outcomes were monitored to evaluate the complications. To compare two groups, a t-test was utilized, and the ANOVA test was used to compare several groups. If the requirements for using these tests were not met, Mann-Whitney and Kruskal-Wallis tests were applied.
Results:
Decreased heart rate was observed in all time intervals and was meaningful six days after paracentesis. MAP also decreased statistically at 48 hours and six days after the procedure (P < 0.05). Other variables did not show any meaningful change.
Conclusion:
Children having tense ascites with thrombocytopenia, prolonged PT, Child-Pugh class C, and encephalopathy can undergo large-volume paracentesis without any complication. Albumin administration before the procedure in patients with low levels of Albumin (<2.9) can effectively overcome the problems of tachycardia and increased mean arterial pressure. There will be no need for Albumin administration after paracentesis.
... 18).Výkony pod ultrazvukovou navigacíPOCUS v rámci vnitřního lékařství nepředstavuje pouze diagnostický nástroj, ale představuje dnes již nezbytnou pomůckou při provádění řady invazivních výkonů. Punkce či drenáž výpotků (fluidothoraxu či ascitu, a případně také perikardiální tekutiny) jsou jednoznačně bezpečnější s ultrazvukovou navigací a bez ní by neměly být prováděny(13). Na jednotkách intenzivní péče využíváme ultrazvuk v každodenní praxi rovněž při zajištění cévních vstupů pod přímou nebo nepřímou UZ kontrolou -při přímé kontrole během procedury přímo sledujeme zavedení jehly, vodiče a kanyly do žíly/arterie, při nepřímé kontrole kanylujeme minimálně po předchozím ozřejmění průběhu cévy (Obr. ...
Point-of-Care ultrasound (POCUS) is bedside ultrasound examination performed by a clinician. POCUS is a suitable tool for rapid diagnosis and monitoring of the condition of many patients examined by internists in emergency departments and inpatient departments. POCUS allows the examining physician to supplement the physical examination with additional information obtained in real time, and is a useful tool for differential diagnosis of a number of acute conditions (shock, shortness of breath, etc.). Chest POCUS includes an indicative assessment of cardiac function and evaluation of the lung parenchyma, including exclusion of pericardial effusion, pneumothorax or fluidothorax. One of the most common applications of POCUS is to assess the state of the venous filling by examining the inferior vena cava. When examining the abdomen, the internist should at least be able to diagnose fluid in the abdominal cavity and exclude congestion in the hollow system of the kidney. POCUS for internists also includes examination of main venous trunks to rule out proximal venous thrombosis. Even when performing conventional invasive procedures, we cannot do without ultrasound at the bedside, whether it is a puncture of ascites or pleural effusion, or cannulation of the central vein. The advantage of POCUS is the immediate availability of the examination and the possibility to repeat scans when needed for monitoring the patient's condition.
... It also allows the operator to visualize the needle and surrounding structures and identify the most accessible area of pleural fluid reducing the risk of potential complications (i.e., iatrogenic pneumothorax, puncture site bleeding, chest wall haematoma, haemothorax). An observational study of approximately 60,000 thoracenteses showed that POCUS decreased the risk of pneumothorax by 19% [79,80]. ...
Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.
... This imaging modality is highly useful for guiding targeted drug injections and catheter placement [7] . The improved accuracy of 2 needle placement using ultrasound reduces the risk of complications and their costs associated with these procedures [8] . Hyaluronidase is widely used in ophthalmologic nerve blocks for better spread of the drug. ...
... 29 In a large retrospective observational study that included nearly 70,000 paracenteses collected from more than 600 hospitals the use of POCUS reduced the odds of post-procedural bleeding by as much as 68%. 30 There are other areas where the use of POCUS may offer benefit in patients with abdominal symptoms. It has been demonstrated to have good sensitivity (89%) and specificity (88%) for the detection of cholelithiasis, 31 and can also detect biliary sludge, which is the initial stage of gallstone formation. ...
Point of care ultrasound (POCUS) represents an exciting tool for current and future acute care practitioners. POCUS has come a long way in a short space of time and its widespread implementation may well be one of the biggest changes seen in acute medicine across the next decade. This narrative review explores the increasing evidence base for the accuracy of POCUS use in various acute scenarios, whilst also addressing current gaps in the evidence and areas for potential future POCUS development.
... With the use of speckle tracking imaging analysis and M-mode, entrapped lung can be identified prior to effusion drainage, allowing upfront choice of the definitive management option [32,45]. Complications, in particular, pneumothorax and bleeding (hematoma, hemothorax, hemorrhage), are less common with ultrasound guidance which also has been shown to increase clinical efficacy [46]. ▶ The role of handheld ultrasound in palliative care patients with suspected ascites ...
Due to the severity of their disease, palliative care patients often present
complex clinical symptoms and complaints like pain, shortness of breath, nausea,
loss of appetite, and fatigue. Solely relying on the information available from
the history and physical examination often causes uncertainty among palliative
care physicians regarding treatment decisions during home visits, potentially
leading to unnecessary hospitalizations or transfer to cross-sectional imaging
in radiological practices. A rational approach is essential to avoid diagnostic
aggressiveness while still providing the imaging information required for
optimal palliative care. Bedside use of handheld ultrasound (HHUS) has the
potential to expand the diagnostic and therapeutic spectrum in the case of
symptom exacerbation but is still underutilized. In this review, we evaluate the
potential uses of HHUS in home care settings to provide a more accurate
diagnosis of the most common symptoms in palliative patients and to guide
bedside interventions such as bladder catheterization, thoracentesis,
paracentesis, venous access, and regional anesthesia. Specific training programs
for ultrasound in palliative care are currently not available. Adequate
documentation is warranted but fraught with technological and privacy issues.
Expert supervision and quality assurance are necessary. Despite its limitation
and challenges, we suggest that HHUS leads to improved clinical decision-making,
expedited symptom relief, and reduced complications without burdening of the
patient and costly transfer to hospital or specialty consultations.
... Another admonition, however, is that we would suggest that bedside ultrasound can greatly increase the safety and effectiveness of percutaneous drainage and we would assume all clinicians caring for the critically ill should be familiar with these techniques. It will never be known whether the eventual stricture causing the small bowel obstruction was related to a potential injury at blind paracentesis, a criticism that can now be completely mitigated by using real-time ultrasound guidance (21). editorial ©2016 Canadian Society of Plastic Surgeons. ...
... Similarly, the inclusion of ultrasound machine in an outpatient palliative care clinic brings about value addition in rapid diagnosis and may alter treatment trajectories by expediting symptom relief and thereby reducing length of stay in the hospital. [1,[15][16][17][18][19] Ultrasound devices have become compact, portable and easily accessible towards empowering palliative care. ...
Point-of-care diagnosis has become the need of the hour and along with its guided interventions, ultrasound could be utilised bedside in a palliative care patient. Point-of-care ultrasound (POCUS) in palliative care medicine is fast emerging and has varied applications ranging from performing bedside diagnostic evaluation to the performance of interventional paracentesis, thoracocentesis and chronic pain interventions. Handheld ultrasound devices have transformed the application of POCUS and should revolutionise the future of home-based palliative care. Palliative care physicians should be enabled to carry out bedside ultrasounds at home care and hospice setting for achieving rapid symptom relief. The aim of POCUS in palliative care medicine should be adequate training of palliative care physicians, transforming the applicability of this technology to OPD as well as community driven to achieve home outreach. The goal is towards empowering technology by reaching out to the community rather than the terminally ill patient transported for the hospital admission. Palliative care physicians should receive mandatory training in POCUS to enable diagnostic proficiency and early triaging. The inclusion of ultrasound machine in an outpatient palliative care clinic brings about value addition in rapid diagnosis. Limiting POCUS application to certain selected sub-specialities such as emergency medicine, internal medicine and critical care medicine should be overcome. This would need acquiring higher training as well as improvised skill sets to perform bedside interventions. Ultrasonography competency among palliative care providers proposed as palliative medicine point-of-care ultrasound (PM-POCUS) could be achieved by imparting dedicated POCUS training within the core curriculum.
... Proceduralist performed US-guided thoracentesis (USGT) is considered the standard of care as there are substantial data demonstrating reduced complications and improved safety compared with blind techniques, which are performed without US guidance. [3][4][5] Persistent practice of blind techniques is largely a result of the 'radiology gap' between high-resource and low-resource settings, as a large proportion of the global population lack access to even basic diagnostic imaging including CXR. 6 Factors contributing to the 'radiology gap' include the high cost required to procure and maintain most radiology equipment and the specialized expertise of necessary personnel that traditional radiologist performed imaging generally relies on, such as technologists to acquire images, radiologists to interpret the images and technicians to maintain the equipment. 6 In contrast, POCUS, which requires only a clinician and an US, is increasingly more portable and affordable, holding great promise as the ...
Objective
Preprocedure pleural fluid localization using bedside ultrasound has been shown to reduce complications related to thoracentesis and is now considered the standard of care. However, ultrasound-guided thoracentesis (USGT) has not been broadly adopted in many low-resource settings. With increasing affordability and portability of ultrasound equipment, barriers to USGT are changing. The aim of this multisite qualitative study is to understand the current barriers to USGT in two resource-limited settings.
Setting
We studied two geographically diverse settings, Harare, Zimbabwe, and Kathmandu, Nepal.
Participants
19 multilevel stakeholders including clinical trainees, attendings, clinical educators and hospital administrators were interviewed. There were no exclusion criteria.
Primary outcome
To understand the current determinants of USGT adoption in these settings.
Results
Three main themes emerged from these interviews: (1) stakeholders perceived multiple advantages of USGT, (2) access to equipment and training were perceived as limited and (3) while an online training approach is feasible, stakeholders expressed scepticism that this was an appropriate modality for procedural training.
Conclusion
Our data suggests that USGT implementation is desired by local stakeholders and that the development of an educational intervention, cocreated with local stakeholders, should be explored to ensure optimal contextual fit.
... Transthoracic ultrasonography (TUS) has consistently been shown to be more accurate than physical examination in the selection of pleural puncture site [16], thus is effective in reducing the risks of procedure related complications [17][18][19]. International guidelines recommend all pleural procedures (for fluid) should be performed under TUS guidance [20]. ...
Background
Major advances in management of common pleural diseases have taken place in the past decade. However, pleural diseases are often managed by physicians of diverse training background and research on implementation of new knowledge is scanty. We aim to evaluate the practice pattern in pleural medicine among physicians in Hong Kong, for identification of possible gaps for clinical service improvement.
Methods
The Hong Kong Thoracic Society undertook a cross-sectional questionnaire survey in 2019, targeting clinicians of various subspecialties in internal medicine and levels of experience (basic and higher trainees, specialists) from twelve regional hospitals of diverse service scopes throughout Hong Kong. Respondents were selected by non-probability quota sampling. The questionnaire tool consisted of 46 questions covering diagnostic and therapeutic aspects of common pleural diseases. The responses were anonymous, and analysed independently using SPSS statistics software.
Results
The survey collected 129 responses, 47(36%) were from clinicians specialized in respiratory medicine. Majority of the respondents (98%) managed pleural diseases, including performing pleural procedures in their practice. Fifty-five percent of all the respondents had not received any formal training in transthoracic ultrasonography. A significant proportion of clinicians were unaware of pleuroscopy for investigation of exudative pleural effusion, indwelling pleural catheter for recurrent malignant pleural effusion, and combined intra-pleural Alteplase plus DNase for treatment of pleural infection (30%, 15% and 70% of non-respiratory clinicians respectively). Significant heterogeneity was found in the management of pleural infection, malignant pleural effusion and pneumothorax among respiratory versus non-respiratory clinicians. Contributing factors to the observed heterogeneity included lack of awareness or training, limited accessibility of drugs, devices, or dedicated service support.
Conclusion
Significant heterogeneity in management of pleural diseases was observed among medical clinicians in Hong Kong. Continuous medical education and training provision for both specialists and non-specialists has to be strengthened to enhance the implementation of advances, improve quality and equity of healthcare provision in pleural medicine.
... 10,[14][15][16][17] These smaller studies report on successful assessments using POCUS in hospice settings, as well as preventing unnecessary procedures and trips to the hospital. [18][19][20] One retrospective chart review reported on patients with ascites in nonhospital settings such as hospice, residential care, and patient homes. 10 The most prevalent pathology in the cohort was ovarian (Table 1). ...
Background:
Technological advancements have rapidly increased the use of point-of-care ultrasound (POCUS) across various medical disciplines, leading to real-time information for clinicians at the bed side. However, literature reveals scant evidence of POCUS use in palliative care. The objective of this study 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 in Brampton, Canada, to evaluate characteristics of patients for whom POCUS was utilized. Patients were identified through pre-existing logs and descriptive information was collected from electronic health records, including 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. Sixty-two patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from gastrointestinal, lung, and breast pathologies. Sixty-one POCUS cases (48.4%) were in the outpatient setting. Eighty-one 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 and caregiver satisfaction, and health care utilization in palliative care patients receiving POCUS.
... Position statements by the Society of Hospital Medicine (SHM) [2] and British Thoracic Society [3] highlight the importance of point of care ultrasound (POCUS) guided pre-procedural planning for thoracentesis. In one study, POCUS conducted pre-procedural planning decreased the rate of pneumothorax from 18% to 3% [4], in another analysis it reduced the cost of in-patient care, when compared to a landmark only based approach [5]. A less frequent complication associated with thoracentesis is intercostal artery (ICA) laceration and secondary hemothorax, estimated to occur in 0.2-2% of thoracenteses [6,7]. ...
Ultrasound-guided pre-procedural planning decreases complications from bedside thoracentesis. Although rare, intercostal artery (ICA) laceration is a serious complication that occurs when vulnerable intercostal arteries (VICA) are no longer protected by the superior rib. We sought to determine if increasing patient age is associated with greater odds of encountering a VICA. Randomly selected in-patients underwent pre-procedural planning for a mock posterior bedside thoracentesis. ICAs were categorized as vulnerable if they were visible within the corresponding intercostal space (ICS). We recorded where the VICA entered and exited the ICS as well as its unshielded length. A total of 40 patients (20 male) were enrolled and 240 ICS (6 ICS per patient) were scanned. Within this cohort, 25% of patients were noted to have at least one VICA. We could not demonstrate any relationship between the patient’s age or location of the ICS, with the odds of encountering a VICA (odds ratio (OR) = 1.0, p = 0.76; OR = 0.85, p = 0.27, respectively). Given the haphazard nature of VICA distribution and poor outcomes associated with inadvertent laceration, we recommend that ICA screening at the site of needle insertion be routinely performed prior to thoracentesis.
... The most basic of these procedures are US-guided paracentesis and thoracentesis, which both have low complication rates. 42 The complication rates for thoracentesis have been reported as lower for those who have undergone simulation training than not, 19 though that study did not use US guidance. For our simulation training, we use customized phantoms for both ascites and pleural effusions ( Figure 4). ...
Medical simulation training can be used to improve clinician performance, teach communication and professionalism skills, and enhance team training. Radiology residents can benefit from simulation training in diagnostic ultrasound, procedural ultrasound, and communication skills prior to direct patient care experiences. This paper details a weeklong ultrasound simulation training curriculum for radiology residents during the PGY‐1 clinical internship. The organization of established teaching methods into a dedicated course early in radiology residency training with the benefit of a multi‐disciplinary approach makes this method unique. This framework can be adapted to fit learners at different skill levels or with specific procedural needs.
... 2a) reduces complications such as hemothorax, pneumothorax, and accidental penetration into the abdominal cavity. [68][69][70][71] The target location of entry should be free of wounds or other infection. In relation to the ribs, the needle should enter lateral to the angle of the rib, along the posterior axillary line, and traverse the top of the rib to avoid hitting the intercostal neurovascular bundle at the 6-7 th intercostal space. ...
Pleural space diseases such as recurrent pleural effusion and pneumothorax inflict a significant symptomatic burden on patients. Guidelines and studies are available to guide best practices in the setting of refractory effusions, mostly in the setting of malignancy, and recurrent pneumothorax. Less data is available to guide management of refractory transudative effusions. Recurrent pleural effusions can be treated with tunneled pleural catheters or catheter-based pleurodesis. While refractory transudative effusions can benefit from tunneled pleural catheter, this is an area of ongoing research. Regarding recurrent pneumothorax, video-assisted thoracoscopic surgery (VATS) pleurodesis using mechanical or laser/argon beam coagulation is the most effective means of preventing recurrence. Catheter based pleurodesis, a less invasive means of administering chemical sclerosant via percutaneous thoracostomy tube, is only used when surgery is not an option. However, both approaches induce inflammation of the pleural space, resulting in adherence of the parietal and visceral pleura to prevent fluid or air re-accumulation. This article will discuss catheter based chemical pleurodesis geared toward the interventional radiologist, including a review of disease processes and indications, technique, and strategies to mitigate complications as well as a literature review comparing percutaneous chemical pleurodesis to other therapies.
... 8 LUS has been increasingly used to safely perform bedside thoracentesis. 7,[9][10][11] In our case, the possibility of identifying the corpuscular nature of the pleural fluid has contributed to the diagnostic suspicion, 5,12 and the US quantification of the fluid was fundamental to guide the therapeutic intervention. 13 We did not perform a complete US evaluation of the abdomen since we focused on the immediate evaluation of the lung parenchyma to diagnose the possible lifethreatening condition given the Emergency setting and the need to evaluate the respiratory status of our patient who presented with a respiratory failure. ...
We present a case in which lung ultrasound (LUS) was relevant to reach an early diagnosis of lung tuberculosis and to manage the patient in the right setting. Moreover, ultrasound allowed to detect and treat massive pleural effusion through an ultrasound‐guided thoracentesis. A 36‐year‐old Caucasian policeman was referred to our Emergency Department for dyspnea. He reported persistent cough and fever with night sweats for about 2 weeks, for which antibiotic therapy for 5 days without clinical benefit. Laboratory investigations revealed a C‐reactive protein of 15.10 mg/dl (n.v. 0.00–0.50). We performed a bedside lung ultrasound (LUS) that showed a massive finely corpuscular anechoic pleural effusion with thin branches of fibrin on the left, with a consolidated lung parenchyma collapsing to the hilum as for complete atelectasis; in the context of the consolidated lung parenchyma, multiple round hypo‐anechoic formations were seen, with finely irregular margins, not assuming colordoppler signal suspicious for cavitations.
... 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. ...
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. ...
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.
... Experts believe it to be a low-risk and typically safe procedure. Pneumothorax during thoracentesis is associated with increased morbidity, mortality, and length of stay 4,5 . Around 50 percent of patients with pneumothorax are forced to have chest tubes placed into their lungs, which adds to their length of stay and costs. ...
Objective: To determine the frequency of pneumothorax in patients undergoing large volume thoracocentesis. Study Deign: Prospective study Place and Duration of Study: Methodology: One hundred and twenty patients of both genders were presented in this study. Patients were aged between 18 to 75 years of age. Patients details demographics age, sex and body mass index were recorded after taking informed written consent. Ultrasound was performed among all patients to diagnosed pleural effusion >1000 ml. Patients were underwent for thoracocentesis in large volume. Outcomes were prevalence of pneumothorax and amount of fluid aspirated were assessed. Results: Seventy (58.3%) patients were males and 50 (41.7%) were female patients. Mean age of the patients was 36.9±13.65 years with mean BMI 25.7±6.26 kg/m2. Frequency of pneumothorax was 22 (18.3%) and was increases with a number of multiple attempts by passing needle. Among 22 cases, 4 (18.2%) patients had pneumothorax by passing single needle for fluid aspirated. Conclusion: Frequency of pneumothorax was high in patients with thoracentesis. In these instances, the risk of pneumothorax was mostly determined by the quantity of pleural fluid that was removed. Keywords: Pneumothorax, Thoracentesis, Pleural fluid
... 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]. ...
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.
... 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]. ...
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]. ...
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.
... While significant morbidity and mortality is rare, it can be easily avoided. In general, ultrasound-guided paracentesis can reduce bleeding complications by 68% [5]. ...
... 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. ...
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.
... LUS is increasingly employed to safely perform bedside thoracentesis 7,[9][10][11] . In our case, the possibility of identifying the corpuscular nature of the pleural fluid has contributed to the diagnostic suspicion 5,12 , and the US quantification of the fluid was fundamental to guide the therapeutic intervention 13 . ...
We present a case in which lung Ultrasound was relevant to reach an early diagnosis of lung tuberculosis and to manage the patient in the right setting. Moreover, ultrasound allowed to detect and treat massive pleural effusion through an ultrasound-guided thoracentesis.
... 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]. ...
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.
Ultrasound-guided vascular access procedures have emerged as the standard of practice across many clinical settings. Ultrasound use by pediatric acute care providers now extends to many other commonly performed bedside procedures. Growing literature supports improved procedural success as well as reduced failure rates, need for multiple attempts, and overall lower complications rate when ultrasound technology is utilized in nonvascular access procedural applications. This chapter explores many nonvascular access procedural applications in which ultrasound is utilized in the acute care setting and describes methods by which to optimize clinical performance.KeywordsVascular accessLumbar punctureThoracentesisParacentesisPericardiocentesis
Introduction:
Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites and is associated with significant risk of mortality. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this condition.
Objective:
This paper evaluates key evidence-based updates concerning SBP for the emergency clinician.
Discussion:
SBP is commonly due to Gram-negative bacteria, but infections due to Gram-positive bacteria and multidrug resistant bacteria are increasing. The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease; however, some patients may be asymptomatic or present with only mild symptoms. Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis. Ultrasound should be used to optimize the procedure. An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm3 is diagnostic of SBP. Ascitic fluid should be placed in blood culture bottles to improve the culture yield. Leukocyte esterase reagent strips can be used for rapid diagnosis if available. While many patients will demonstrate coagulation panel abnormalities, routine transfusion is not recommended. Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam. Albumin infusion is associated with reduced risk of renal impairment and mortality.
Conclusions:
An understanding of literature updates can improve the care of patients with suspected SBP.
Background:
Ultrasound guidance has become standard of care in hospital medicine for invasive bedside procedures, especially central venous catheter placement. Despite ultrasound-guided bedside procedures having a high degree of success, only a few hospitalists perform them. This is because these are usually performed by radiologists or in the setting of trainee-run procedure teams.
Objective:
To determine the impact of a non-trainee driven, hospitalist-run procedure service relative to time from consult to procedure.
Methods:
The University of Alabama at Birmingham Hospital (UAB), Department of Hospital Medicine, trained 8 non-trainee hospitalist physicians (from existing staff) to implement the ultrasound-guided procedure service. This study examines consult to procedure completion time since the implementation of the procedure service (2014 to 2020). Univariate analyses are used to analyze pre-implementation (2012-2014), pilot (2014 -2016), and post-implementation data (2016-2018 initial, and 2018-2020 sustained).
Results:
Results suggest a 50% reduction in time from consult to procedure completion when compared with the period before implementation of the nontrainee hospitalist procedure service.
Conclusions:
A hospitalist procedure service, which does not include trainees, results in less time lag from consult to procedure completion time, which could increase patient satisfaction and improve throughput. As such, this study has wide generalizability to community hospitals and other nonacademic medical centers that may not have trainees.
Onco-Nephrology is an emerging subspecialty of Nephrology that focuses on a broad spectrum of renal disorders that can arise in patients with cancer. It encompasses acute kidney injury (AKI), complex fluid, electrolyte, and acid-base disorders, as well as chronic kidney disease caused or exacerbated by cancer and/or its treatment. In many such scenarios including AKI and hyponatremia, objective evaluation of hemodynamics is vital for appropriate management. Point of care ultrasonography (POCUS) is a limited ultrasound exam performed at the bedside and interpreted by the treating physician intended to answer focused clinical questions and guide therapy. Compared to conventional physical examination, POCUS offers substantially higher diagnostic accuracy for various structural and hemodynamic derangements. In this narrative review, we provide an overview of the utility of POCUS enhanced physical examination for the Onconephrologist supported by the current evidence and our experience-based opinion.
With the increasing number of the elderly population, the number of people with respiratory diseases along with other comorbidities is also increasing. With the good number of available evidence, the use of interventional pulmonary procedures is also increasing.
However, the studies on the safety and therapeutic benefit of these procedures in the elderly population are limited. Because of the paucity of data, we decided to do a systematic review of the scientific literature that is currently available, to boost confidence to do these procedures by clinicians.
This review deals with the procedures that are commonly performed in elderly respiratory patients, their indications, safety and the diagnostic and therapeutic yield, and compares them with the results in the younger population. It also focuses on the safety of anaesthetic techniques used for these procedures in the elderly.
The bottom line of this review is that there is no significant difference between the older and younger age groups with regard to the above parameters and that age alone is not a criterion to decide whether the patients may undergo interventional pulmonary procedures.
Objective:
The aim of the study is to evaluate a novel point-of-care ultrasound (POCUS) educational curriculum for pediatric residents.
Methods:
The cohort study in graduate medical education was completed from January 2017 to March 2019. Postgraduate year 1 (PGY1) pediatric residents attended the educational curriculum that consisted of 3 half-day sessions over a 3-month period. Each session consisted of a lecture (introduction, extended focused assessment with sonography for trauma, soft tissue/musculoskeletal, cardiac, and resuscitative applications) followed by supervised hands-on scanning sessions. Group ratio was 3 learners to 1 machine/expert instructor. Main outcome measures included pre- and post-written test scores, as well as objective structured clinical examination (OSCE) scores.
Results:
Forty-nine PGY1 residents (78% women) completed the curriculum. The mean (SD) pretest score was 68% (8.5), and the mean posttest score was 83% (8.3) with a difference of 15 (95% confidence interval, 12.5-17.6; P < 0.001). Mean (SD) focused assessment with sonography for trauma OSCE score after the curriculum was 88.7% (11.9). The number of PGY1 pediatric residents that were comfortable performing POCUS examinations increased from pretraining to posttraining for soft tissue/musculoskeletal (14%-61%, P < 0.001), extended focused assessment with sonography for trauma (24%-90%, P < 0.001), and cardiac (18%-86%, P < 0.001). All participants found the curriculum useful, and 42 of 49 (86%) stated the curriculum increased their ability to acquire and interpret images.
Conclusions:
Postgraduate year 1 pediatric residents learned the basics of POCUS through 3 brief educational sessions. The increase in posttest scores demonstrated improved POCUS knowledge, and the high OSCE score demonstrated their ability to acquire ultrasound images. Point-of-care ultrasound guidelines are needed for pediatric residency programs.
Résumé
Un épanchement pleural lié à une cause maligne survient chez 20 % de tous les patients atteints de cancer et laisse généralement présager un mauvais pronostic, tout en limitant la qualité de vie du patient. Le diagnostic et la palliation des symptômes est le but de la prise en charge de ces épanchements, tout en minimisant la durée de son hospitalisation pour améliorer sa qualité de vie. Traditionnellement, cela était réalisé par une ponction et/ou une biopsie pleurale suivi d’un drainage thoracique avec l’instillation d’agents sclérosants dans l’espace pleural, en cas de récidive de l’épanchement. Récemment, l’émergence des nouvelles méthodes telles que la biopsie échoguidée, la réalisation de plus en plus courante de la thoracoscopie médicale, ainsi que les cathéters pleureux à demeure ont modifié la prise en charge des pleurésies malignes. L’objectif de cette revue de la littérature est de préciser le rôle du pneumologue interventionnel dans la gestion des pleurésies malignes en se référant aux divers moyens diagnostiques et thérapeutiques qu’il doit posséder actuellement.
Ein maligner Pleuraerguss (MPE) ist eine häufige Komplikation von thorakalen und extrathorakalen Malignomen und geht mit einer hohen Sterblichkeit einher. Die Behandlung ist hauptsächlich palliativ, wobei die Symptome durch Ergussdrainage und Pleurodese gelindert werden. Die Pleurodese kann durch die Verabreichung eines Sklerosierungsmittels über eine Thorakostomie-Sonde, eine Thorakoskopie oder einen Pleuraverweilkatheter (IPC) beschleunigt werden. In den letzten zehn Jahren haben mehrere randomisierte, kontrollierte Studien das derzeitige Management von MPE zugunsten eines ambulanten Ansatzes geprägt, wobei der Einsatz von IPC deutlich zugenommen hat. Die Präferenzen der Patienten sind nach wie vor entscheidend für die Wahl der optimalen Therapie, insbesondere wenn die Lunge erweiterbar ist. In dieser Übersichtsarbeit haben wir die MPE-Literatur der letzten 10 bis 15 Jahre durchgesehen und uns dabei besonders auf die Diagnose und das sich entwickelnde Management konzentriert.
要旨
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。
During the last five decades, lung sonography has developed into a core competency of intensive care medicine. It is a highly accurate bedside tool, with clear diagnostic criteria for most causes of respiratory failure (pneumothorax, pulmonary edema, pneumonia, pulmonary embolism, chronic obstructive pulmonary disease, asthma, and pleural effusion). It helps in distinguishing a hypovolemic from a cardiogenic, obstructive, or distributive shock. In addition to diagnostics, it can also be used to guide ventilator settings, fluid administration, and even antimicrobial therapy, as well as to assess diaphragmatic function. Moreover, it provides risk-reducing guidance during invasive procedures, e.g., intubation, thoracocentesis, or percutaneous dilatational tracheostomy. The recent pandemic has further increased its scope of clinical applications in the management of COVID-19 patients, from their initial presentation at the emergency department, during their hospitalization, and after their discharge into the community. Despite its increasing use, a consensus on education, assessment of competencies, and certification is still missing. Deep learning and artificial intelligence are constantly developing in medical imaging, and contrast-enhanced ultrasound enables new diagnostic perspectives. This review summarizes the clinical aspects of lung sonography in intensive care medicine and provides an overview about current training modalities, diagnostic limitations, and future developments.
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.
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.
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.
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.
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.
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.
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.
In this chapter we discuss pulmonary, pleural and mediastinal TB. We review the common presenting clinical and radiological features of these. Diagnostic approaches for each are explored and incorporate currently available interventional and molecular tools.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
