1
|
Kent MS, Mitzman B, Diaz-Gutierrez I, Khullar OV, Fernando HC, Backhus L, Brunelli A, Cassivi SD, Cerfolio RJ, Crabtree TD, Kakuturu J, Martin LW, Raymond DP, Schumacher L, Hayanga JWA. The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains After Pulmonary Lobectomy: Expert Consensus Document. Ann Thorac Surg 2024:S0003-4975(24)00342-4. [PMID: 38723882 DOI: 10.1016/j.athoracsur.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/16/2024] [Accepted: 04/16/2024] [Indexed: 07/04/2024]
Abstract
The Society of Thoracic Surgeons Workforce on Evidence-Based Surgery provides this document on management of pleural drains after pulmonary lobectomy. The goal of this consensus document is to provide guidance regarding pleural drains in 5 specific areas: (1) choice of drain, including size, type, and number; (2) management, including use of suction vs water seal and criteria for removal; (3) imaging recommendations, including the use of daily and postpull chest roentgenograms; (4) use of digital drainage systems; and (5) management of prolonged air leak. To formulate the consensus statements, a task force of 15 general thoracic surgeons was invited to review the existing literature on this topic. Consensus was obtained using a modified Delphi method consisting of 2 rounds of voting until 75% agreement on the statements was reached. A total of 13 consensus statements are provided to encourage standardization and stimulate additional research in this important area.
Collapse
Affiliation(s)
- Michael S Kent
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Brian Mitzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Onkar V Khullar
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Hiran C Fernando
- Division of Thoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Leah Backhus
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St James's University Hospital, Leeds, United Kingdom
| | - Stephen D Cassivi
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Traves D Crabtree
- Division of Thoracic Surgery, Southern Illinois University, Springfield, Illinois
| | - Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Linda W Martin
- Division of Thoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lana Schumacher
- Division of Thoracic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| |
Collapse
|
2
|
Are Routine Chest X-rays Necessary following Thoracic Surgery? A Systematic Literature Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14184361. [PMID: 36139521 PMCID: PMC9496662 DOI: 10.3390/cancers14184361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/03/2022] [Accepted: 09/04/2022] [Indexed: 11/21/2022] Open
Abstract
Simple Summary X-rays of the chest have become part of the clinical routine for patients undergoing surgery of the chest. Each of these X-rays exposes the patient and the medical staff to radiation, increasing the treatment costs and the workload. The scientific evidence for performing X-rays after chest surgery (excluding heart surgery) is limited. The purpose of this study was to gather the evidence and analyze it in order to find out how often these X-rays have consequences or lead to a change in patient care. The results of this study could potentially help reduce the number of X-rays that are routinely performed following surgery of the chest. Abstract (1) Background: The number of chest X-rays that are performed in the perioperative window of thoracic surgery varies. Many clinics X-ray patients daily, while others only perform X-rays if there are clinical concerns. The purpose of this study was to assess the evidence of perioperative X-rays following thoracic surgery and estimate the clinical value with regard to changes in patient care. (2) Methods: A systematic literature research was conducted up until November 2021. Studies reporting X-ray outcomes in adult patients undergoing general thoracic surgery were included. (3) Results: In total, 11 studies (3841 patients/4784 X-rays) were included. The X-ray resulted in changes in patient care in 488 cases (10.74%). In patients undergoing mediastinoscopic lymphadenectomy or thoracoscopic sympathectomy, postoperative X-ray never led to changes in patient care. (4) Conclusions: There are no data to recommend an X-ray before surgery or to recommend daily X-rays. X-rays immediately after surgery seem to rarely have any consequences. It is probably reasonable to keep requesting X-rays after drain removal since they serve multiple purposes and alter patient care in 7.30% of the cases.
Collapse
|
3
|
Kröner A, Beenen L, du Raan M, Meijer P, Spronk PE, Stoker J, Hollmann MW, Schultz MJ. The clinical value of routinely obtained postoperative chest radiographs in post-anaesthesia care unit patients seems poor-a prospective observational study. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:360. [PMID: 30370287 DOI: 10.21037/atm.2018.08.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The clinical value of routinely obtained postoperative chest radiographs (CXRs) in post-anaesthesia care unit (PACU) patients is largely unknown. Methods To determine the diagnostic efficacy and treatment impact of postoperative routinely obtained CXRs in a university hospital PACU. Observational study collecting the expectations of attending physicians, the findings on routinely obtained CXRs and actions based on the findings on these CXRs in postoperative PACU patients. A 22-bed PACU in a university hospital in the Netherlands. Patients admitted to the PACU during a 9-month period. The analysis was restricted to CXRs routinely obtained during the first PACU admission, i.e., CXRs obtained during later admissions were excluded. Diagnostic efficacy, defined as the percentage of CXRs showing any unexpected major abnormality; treatment impact, defined as the percentage of CXRs showing an unexpected major abnormality that triggered a predefined change in therapy. Results The analysis included 294 postoperative CXRs. Of them 94 showed a new and unexpected predefined major abnormality (diagnostic efficacy of 35%). Of these 94 CXRs, only 10 triggered an intervention (treatment impact of 4%). Conclusions The diagnostic efficacy of routinely obtained postoperative CXRs in PACU patients is fair; the treatment impact seems low if we assume that all CXRs that showed an abnormality but were not followed by an intervention and did not require an intervention. Future research should focus on the safety and cost-effectiveness of abrogating routine postoperative CXRs.
Collapse
Affiliation(s)
- Anke Kröner
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Ludo Beenen
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Maretha du Raan
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter Meijer
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter E Spronk
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.,HERMES Critical Care Group, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,HERMES Critical Care Group, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
4
|
Bjerregaard LS, Jensen K, Petersen RH, Hansen HJ. Routinely obtained chest X-rays after elective video-assisted thoracoscopic surgery can be omitted in most patients; a retrospective, observational study. Gen Thorac Cardiovasc Surg 2015; 63:465-71. [PMID: 26007694 DOI: 10.1007/s11748-015-0560-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 05/13/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate whether the use of routinely obtained chest X-rays is necessary after elective VATS. METHODS We retrospectively reviewed 1097 chest X-rays obtained routinely after elective VATS, performed in patients aged over 15 years during an 18-month period. VATS procedures were divided into three groups according to the degree of pulmonary resection. The chest X-rays (obtained anterior-posterior in one plane with the patient in the supine position) were categorized as abnormal if showing pneumothorax >5 cm, possible intra-thoracic bleeding and/or a displaced chest tube. Medical charts were reviewed for all patients with abnormal chest X-rays to see if an intervention was made based on the X-ray. In case of an intervention, detailed clinical data were collected. RESULTS 44 of 1097 chest X-rays (4.0 %) were abnormal and 10 of these X-rays (0.9 %) led to a clinical intervention. Proportions of abnormal chest X-rays were unequally distributed between groups (p < 0.001), whereas the number of interventions was not (p = 0.43). Of the ten chests X-rays that led to an intervention, three showed possible intra-thoracic bleeding, six showed pneumothorax >5 cm and one showed a kinked chest tube. All the patients with possible intra-thoracic bleeding were re-explored in the operating theatre the same day. CONCLUSIONS Only 10 of 1097 chest X-rays (0.9 %) obtained routinely after elective VATS procedures led to a clinical intervention, supporting the abandon of routine chest X rays in favour of a more individualised approach, based on clinical observations.
Collapse
Affiliation(s)
- Lars S Bjerregaard
- Department of Cardiothoracic Anaesthesia and Section for Surgical Pathophysiology, Rigshospitalet Dept. 7621, Copenhagen University Hospital, Copenhagen, Denmark,
| | | | | | | |
Collapse
|
5
|
Kager LM, Kröner A, Binnekade JM, Gratama JW, Spronk PE, Stoker J, Vroom MB, Schultz MJ. Review of a Large Clinical Series: The Value of Routinely Obtained Chest Radiographs on Admission to a Mixed Medical—Surgical Intensive Care Unit. J Intensive Care Med 2010; 25:227-32. [DOI: 10.1177/0885066610366925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and objectives: The efficacy of routinely obtained chest radiographs (CXRs) on admission to the intensive care unit (ICU) is largely unknown. The current study investigated the efficacy of routinely obtained admission CXRs and determined whether the value of this diagnostic test was dependent on patient category. Materials and Methods: Prospective nonrandomized controlled study. including 1081 admission CXRs of 1330 patients admitted to a 28-bed mixed medical—surgical university-affiliated ICU, over a 10-month period. To determine the value of admission CXRs, 2 categories of efficacy were used: diagnostic efficacy (the number of CXRs with a new or progressive major finding divided by the total number of CXRs) and therapeutic efficacy (the number of CXRs resulting in a change in clinical management divided by the total number of CXRs). Efficacy <15% was considered low. Patients were subclassified into subcategories on the basis of type of admission. Results: Of all admission CXRs, 227 were clinically indicated and 854 were routinely obtained to establish a baseline prior to admission to ICU. Diagnostic efficacy of routinely obtained admission CXRs was 11%. The majority of abnormalities were malposition of invasive devices and severe pulmonary congestion. Therapeutic efficacy of routinely obtained admission CXRs was only 5%. Subgroup analysis showed highest efficacy in nonsurgical patients. Conclusions: In our mixed medical—surgical ICU the diagnostic and therapeutic efficacy of routinely obtained admission CXRs is low, though not completely negligible. Highest efficacy of CXRs was found in nonsurgical patients. Prospective studies are needed to determine whether abolishing this diagnostic test is a safe strategy.
Collapse
Affiliation(s)
- Liesbeth Martine Kager
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands,
| | - Anke Kröner
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands, Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jan M. Binnekade
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jan-Willem Gratama
- Department of Radiology, Gelre Hospital, Location Lukas, Apeldoorn, Netherlands
| | - Peter E. Spronk
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands, Department of Intensive Care Medicine, Gelre Hospital, location Lukas, Apeldoorn, Netherlands, HERMES Critical Care Group, Amsterdam, Netherlands
| | - Jaap Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Margreeth B. Vroom
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands, HERMES Critical Care Group, Amsterdam, Netherlands, Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
6
|
Pikwer A, Bååth L, Perstoft I, Davidson B, Akeson J. Routine chest X-ray is not required after a low-risk central venous cannulation. Acta Anaesthesiol Scand 2009; 53:1145-52. [PMID: 19422354 DOI: 10.1111/j.1399-6576.2009.01980.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Knowledge of the radiographic catheter tip position after central venous cannulation is normally not required for short-term catheter use. Detection of a possible iatrogenic pneumothorax may nevertheless justify routine post-procedure chest X-ray. Our aim was to design a clinical decision rule to select patients for radiographic evaluation after central venous cannulation. METHODS A total of 2230 catheterizations performed using external jugular, internal jugular or subclavian venous approaches during a 4-year period were included consecutively. Information on patient data and corresponding procedures was recorded prospectively. A post-procedure chest X-ray was obtained after each cannulation. RESULTS Thirteen cases (0.58%) of cannulation-associated pneumothorax were identified. The risk of pneumothorax after a technically difficult (1.8%) or subclavian (1.6%) cannulation was significantly higher than after cannulation not considered as difficult (0.37%) or performed using other routes (0.33%). Clinical signs of pneumothorax within 8 h of cannulation were found in all seven patients with pneumothorax requiring specific treatment. A new clinical decision rule for radiographic evaluation after central venous cannulation based on the results of the present study shows that 48% of the post-procedure chest X-rays performed in our patients were clinically redundant. CONCLUSION Clinical symptoms were reported in all patients with pneumothorax requiring specific treatment. Approximately half of the post-procedure chest X-ray controls could be avoided using the proposed clinical decision rule to select patients for radiographic evaluation after central venous cannulation. A large prospective multi-centre study should be carried out to further evaluate this decision rule.
Collapse
Affiliation(s)
- A Pikwer
- Department of Anaesthesiology and Intensive Care Medicine, Malmö University Hospital, Lund University, Malmö, Sweden.
| | | | | | | | | |
Collapse
|
7
|
Wang TS, Johnson TM, Cascade PN, Redman BG, Sondak VK, Schwartz JL. Evaluation of staging chest radiographs and serum lactate dehydrogenase for localized melanoma. J Am Acad Dermatol 2004; 51:399-405. [PMID: 15337983 DOI: 10.1016/j.jaad.2004.02.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Radiographic and laboratory evaluations are often routinely used in the initial work-up for melanoma. PURPOSE To examine the yield of a chest radiograph and serum lactate dehydrogenase (LDH), in the work-up for newly diagnosed localized melanoma. METHODS Patients with a new diagnosis of localized invasive melanoma were entered into a prospective database. The status of the chest radiograph, LDH, and sentinel lymph node (SLN) was assessed. RESULTS Two-hundred-twenty-four patients were entered into the study and 210 had chest radiograph data for analysis. The true positive chest radiograph rate, defined as the percent of chest radiographs interpreted as "positive or equivocal possibly melanoma related" with subsequent confirmed melanoma metastases, was 0%. The false positive chest radiograph rate, defined as the percent of chest radiographs interpreted as "positive or equivocal possibly melanoma related" with melanoma metastases excluded based on previous or subsequent studies or other known medical conditions, was 7%. Ninety-six patients (melanoma> or =1 mm) had LDH results for analysis. Elevations in LDH were found in 15% and did not lead to detection of occult disease in any patients. Seventy-seven patients underwent SLN biopsy. A positive SLN did not correlate with abnormal chest radiograph or LDH. CONCLUSION Low yield, high rate of false-positive tests and lack of significant impact of early detection of metastases on survival argue that chest radiographs and serum lactate dehydrogenase should probably not be accepted into routine clinical practice in patients with clinically localized melanoma in the absence of data supporting their use.
Collapse
Affiliation(s)
- Timothy S Wang
- Department of Dermatology, University of Michigan Health System, University of Michigan Comprehensive Cancer Center, USA
| | | | | | | | | | | |
Collapse
|
8
|
Mulhall KJ, Masterson E, Burke TE. Routine recovery room radiographs after total hip arthroplasty: ineffective for screening and unsuitable as baseline for longitudinal follow-up evaluation. J Arthroplasty 2004; 19:313-7. [PMID: 15067643 DOI: 10.1016/j.arth.2003.08.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
To assess the usefulness of traditional recovery room check radiographs after total hip arthroplasty, we retrospectively analysed 2,065 consecutive hip arthroplasty patients. We found a 0.1% rate of radiologic diagnosis of dislocation in the population screened. In 100 patients randomly selected for comparison, the image quality in the recovery room radiographs was significantly inferior to standardized departmental radiographs (P<.001), with further significant differences between cup version (P<.001), and stem alignment assessments (P=.002). We found good agreement between the authors in the assessments of these radiographs with a weighted kappa statistic of 0.8653 (P<.0001). Seven recovery room radiographs needed repetition for poor quality versus none of the departmental films (P=.007). With such poor information and diagnostic yield for follow-up and screening, these investigations should only be performed when clinically indicated.
Collapse
Affiliation(s)
- Kevin J Mulhall
- Department of Orthopaedics, St. Nessans Regional Orthopaedic Hospital, Croom, County Limerick, Ireland
| | | | | |
Collapse
|
9
|
|