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Fong T, Heverling H, Rhyne R. Common Ultrasound-Guided Procedures. Emerg Med Clin North Am 2024; 42:927-945. [PMID: 39326995 DOI: 10.1016/j.emc.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
Ultrasound guidance is fundamental to procedural safety and success. For many emergency department (ED) procedures, the use of ultrasound improves first-pass success rate, time-to-completion, and complication rate when compared with traditional landmark-based techniques. Once learned, the general principles of ultrasound guidance may be adapted across a broad range of bedside procedures.
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Affiliation(s)
- Tiffany Fong
- Division of Emergency Ultrasound, Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287, USA.
| | - Harry Heverling
- Division of Emergency Ultrasound, Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287, USA
| | - Randall Rhyne
- Division of Emergency Ultrasound, Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287, USA
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2
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Dumas C, Getten P, Flamarion E. [An unexpected pulmonary edema]. Rev Med Interne 2024:S0248-8663(24)00756-2. [PMID: 39227285 DOI: 10.1016/j.revmed.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 08/25/2024] [Indexed: 09/05/2024]
Affiliation(s)
- Charlotte Dumas
- Service de médecine interne, hôpital européen Georges-Pompidou, AP-HP-Centre, université de Paris, 20, rue Leblanc, 75015 Paris, France
| | - Prunelle Getten
- Service de médecine interne, hôpital européen Georges-Pompidou, AP-HP-Centre, université de Paris, 20, rue Leblanc, 75015 Paris, France
| | - Edouard Flamarion
- Service de médecine interne, hôpital européen Georges-Pompidou, AP-HP-Centre, université de Paris, 20, rue Leblanc, 75015 Paris, France.
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3
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Tajarernmuang P, Valenti D, Gonzalez AV, Artho G, Tsatoumas M, Beaudoin S. Reduction of Chest Drain Overuse Through Implementation of a Pleural Drainage Order Set. Qual Manag Health Care 2024; 33:206-212. [PMID: 37651595 DOI: 10.1097/qmh.0000000000000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Small chest drains are used in many centers as the default drainage strategy for various pleural effusions. This can lead to drain overuse, which may be harmful. This study aimed to reduce chest drain overuse. METHODS We studied consecutive pleural procedures performed in the radiology department before (August 1, 2015, to July 31, 2016) and after intervention (September 1, 2019, to January 31, 2020). Chest drains were deemed indicated or not based on criteria established by a local interdisciplinary work group. The intervention consisted of a pleural drainage order set embedded in electronic medical records. It included indications for chest drain insertion, prespecified drain sizes for each indication, fluid analyses, and postprocedure radiography orders. Overall chest drain use and proportion of nonindicated drains were the outcomes of interest. RESULTS We reviewed a total of 288 procedures (pre-intervention) and 155 procedures (post-intervention) (thoracentesis and drains). Order-set implementation led to a reduction in drain use (86.5% vs 54.8% of all procedures, P < .001) and reduction in drain insertions in the absence of an indication (from 45.4% to 29.4% of drains, P = .01). The need for repeat procedures did not increase after order-set implementation (22.0% pre vs 17.7% post, P = .40). Complication rates and length of hospital stay did not differ significantly after the intervention. More pleural infections were treated with drain sizes of 12Fr and greater (31 vs 70%, P < .001) after order-set deployment, and direct procedural costs were reduced by 27 CAN$ per procedure. CONCLUSION Implementation of a pleural drainage order-set reduced chest drain use, improved procedure selection according to clinical needs, and reduced direct procedural costs. In institutions where small chest drains are used as the default drainage strategy for pleural effusions, this order set can reduce chest drain overuse.
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Affiliation(s)
- Pattraporn Tajarernmuang
- Author Affiliations: Respiratory Division, Department of Medicine (Drs Tajarernmuang, Gonzalez, and Beaudoin) and Department of Radiology (Drs Valenti, Artho, and Tsatoumas), McGill University Health Centre, Montreal, Quebec, Canada; and Division of Pulmonary, Critical Care, and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (Dr Tajarernmuang)
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Scott S, Morrison B, Young K, Clark L, Li Y, Walter C, Rohr A, Alli A. Re-expansion Pulmonary Edema (REPE) Following Thoracentesis: Is Large-Volume Thoracentesis Associated with Increased Incidence of REPE? Cardiovasc Intervent Radiol 2024; 47:912-917. [PMID: 38858252 DOI: 10.1007/s00270-024-03773-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/23/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE To determine the safety and efficacy associated with drainage volumes greater than 1,500 mL in a single, unilateral thoracentesis without pleural manometry measurements. MATERIALS AND METHODS This retrospective, single-institution study included 872 patients (18 years and older) who underwent ultrasound-guided thoracentesis. Patient and procedures data were collected including demographics, number of and laterality of thoracenteses, volume and consistency of fluid removed, and whether clinical or radiologic evidence of re-expansion pulmonary edema (REPE) developed within 24 h of thoracentesis. Fisher's exact test was used to test the significance of the relationship between volume of fluid removed and evidence of REPE. RESULTS A total of 1376 thoracenteses were performed among the patients included in the study. The mean volume of fluid removed among all procedures was 901.1 mL (SD = 641.7 mL), with 194 (14.1%) procedures involving the removal of ≥ 1,500 mL of fluid. In total, six (0.7%) patients developed signs of REPE following thoracentesis, five of which were a first-time thoracentesis. No statistically significant difference in incidence of REPE was observed between those with ≥ 1,500 mL of fluid removed compared to those with < 1,500 mL of fluid removed (p-value = 0.599). CONCLUSIONS Large-volume thoracentesis may safely improve patients' symptoms while preventing the need for repeat procedures.
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Affiliation(s)
- Sandon Scott
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA.
| | - Brennan Morrison
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Kate Young
- Department of Biostatistics & Data Science, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Lauren Clark
- Department of Biostatistics & Data Science, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Yanming Li
- Department of Biostatistics & Data Science, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Carissa Walter
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Aaron Rohr
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Adam Alli
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
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5
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Tiwari N, Shlomovitz E, Capel J, Wong F. Innovative Management of a Difficult Case of Hepatic Hydrothorax. ACG Case Rep J 2024; 11:e01372. [PMID: 38854808 PMCID: PMC11161277 DOI: 10.14309/crj.0000000000001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 04/22/2024] [Indexed: 06/11/2024] Open
Abstract
Hepatic hydrothorax affects 5%-15% of decompensated cirrhosis patients, with up to 26% being refractory to standard treatments. For those ineligible for transjugular intrahepatic systemic shunts or liver transplants, alternatives to repeated thoracentesis are limited but can include the insertion of an indwelling pleural catheter. We present the first case of the use of an automatic low-flow ascites pump (alfapump) to manage nonmalignant pleural effusion in an elderly patient with cirrhosis.
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Affiliation(s)
- Neha Tiwari
- Department of Medicine, Division of Gastroenterology & Hepatology, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Eran Shlomovitz
- Joint Medical Imaging Department, Toronto General Hospital, University of Toronto, Toronto, Canada
| | | | - Florence Wong
- Department of Medicine, Division of Gastroenterology & Hepatology, Toronto General Hospital, University of Toronto, Toronto, Canada
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6
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Lester W, Bent C, Alikhan R, Roberts L, Gordon-Walker T, Trenfield S, White R, Forde C, Arachchillage DJ. A British Society for Haematology guideline on the assessment and management of bleeding risk prior to invasive procedures. Br J Haematol 2024; 204:1697-1713. [PMID: 38517351 DOI: 10.1111/bjh.19360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Will Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Clare Bent
- Department of Radiology, University Hospitals Dorset, Dorset, UK
| | - Raza Alikhan
- Department of Haematology, University Hospitals of Cardiff, Cardiff, UK
| | - Lara Roberts
- Department of Haematology, King College London, London, UK
| | - Tim Gordon-Walker
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sarah Trenfield
- Department of Anaesthesia and Critical Care, Royal Brompton Hospital, London, UK
| | - Richard White
- Department of Radiology, Cardiff and Vale UHB, Cardiff, UK
| | - Colm Forde
- Department of Radiology, University Hospitals Birmingham, Birmingham, UK
| | - Deepa J Arachchillage
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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Christopher DJ, Gupta R, Thangakunam B, Daniel J, Jindal SK, Kant S, Chhajed PN, Gupta KB, Dhooria S, Chaudhri S, Chaudhry D, Patel D, Mehta R, Chawla RK, Srinivasan A, Kumar A, Bal SK, James P, Roger SJ, Nair AA, Katiyar SK, Agarwal R, Dhar R, Aggarwal AN, Samaria JK, Behera D, Madan K, Singh RB, Luhadia SK, Sarangdhar N, Souza GD, Nene A, Paul A, Varghese V, Rajagopal TV, Arun M, Nair S, Roy AD, Williams BE, Christopher SA, Subodh DV, Sinha N, Isaac B, Oliver AA, Priya N, Deva J, Chandy ST, Kurien RB. Pleural effusion guidelines from ICS and NCCP Section 1: Basic principles, laboratory tests and pleural procedures. Lung India 2024; 41:230-248. [PMID: 38704658 PMCID: PMC11093145 DOI: 10.4103/lungindia.lungindia_33_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 05/06/2024] Open
Abstract
Pleural effusion is a common problem in our country, and most of these patients need invasive tests as they can't be evaluated by blood tests alone. The simplest of them is diagnostic pleural aspiration, and diagnostic techniques such as medical thoracoscopy are being performed more frequently than ever before. However, most physicians in India treat pleural effusion empirically, leading to delays in diagnosis, misdiagnosis and complications from wrong treatments. This situation must change, and the adoption of evidence-based protocols is urgently needed. Furthermore, the spectrum of pleural disease in India is different from that in the West, and yet Western guidelines and algorithms are used by Indian physicians. Therefore, India-specific consensus guidelines are needed. To fulfil this need, the Indian Chest Society and the National College of Chest Physicians; the premier societies for pulmonary physicians came together to create this National guideline. This document aims to provide evidence based recommendations on basic principles, initial assessment, diagnostic modalities and management of pleural effusions.
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Affiliation(s)
| | - Richa Gupta
- Department of Respiratory Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Jefferson Daniel
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Surya Kant
- Department of Respiratory Medicine, King George’s Medical University, Lucknow, UP, India
| | - Prashant N. Chhajed
- Centre for Chest and Respiratory Diseases, Nanavati Max Super Specialty Hospital, Mumbai, Maharashtra, India
| | - K B Gupta
- Department of Respiratory Medicine, Eras Medical College, Lucknow, Uttar Pradesh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sudhir Chaudhri
- Department of Respiratory Medicine, Rama Medical College, Kanpur, Uttar Pradesh, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences Rohtak, Haryana, India
| | - Dharmesh Patel
- City Clinic and Bhailal Amin General Hospital, Vadodara, Gujarat, India
| | - Ravindra Mehta
- VAAYU Chest and Sleep Services and VAAYU Pulmonary Wellness and Rehabilitation Center, Bengaluru, Karnataka, India
| | - Rakesh K. Chawla
- Department of Respiratory Medicine Critical Care and Sleep Disorders, Jaipur Golden Hospital and Saroj Super Specialty Hospital, Delhi, India
| | - Arjun Srinivasan
- Centre for Advanced Pulmonary Interventions, Royal Care Hospital, Coimbatore, Tamil Nadu, India
| | - Arvind Kumar
- Institute of Chest Surgery, Chest Onco Surgery and Lung Transplantation and Medanta Robotic Institute, Medanta-the Medicity, Gurugram, Haranya, India
| | - Shakti K. Bal
- Department of Pulmonary Medicine, AIIMS Bhubaneswar, Odisha, India
| | - Prince James
- Interventional Pulmonology and Respiratory Medicine, Naruvi Hospital, Vellore, Tamil Nadu, India
| | - S Jebin Roger
- Department of Respiratory Medicine, Apollo Hospital, Chennai, Tamil Nadu, India
| | | | - S K Katiyar
- Department of Tuberculosis and Respiratory Diseases, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Dhar
- Department of Pulmonology, C K Birla Hospitals, Kolkata, West Bengal, India
| | - Ashutosh N. Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Department of Chest Diseases, IMS, B.H.U., Varanasi, Uttar Pradesh, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
| | - Raj B Singh
- Department of Respiratory Medicine, Apollo Hospital, Chennai, Tamil Nadu, India
| | - S K Luhadia
- Department of Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | | | - George D’ Souza
- Department of Pulmonary Medicine, St. John’s Medical College, Bangalore, Karnataka, India
| | - Amita Nene
- Department of Respiratory Medicine, Bombay Hospital India, Mumbai, Maharashtra, India
| | - Akhil Paul
- Department of Pulmonary Medicine, MOSC Medical Mission Hospital, Thrissur, Kerala, India
| | - Vimi Varghese
- Department of Heart and Lung Transplant, Yashoda Hospitals, Hyderabad, Telangana, India
| | - T V Rajagopal
- SKS Hospital and Post Graduate Medical Institute, Salem, Tamil Nadu, India
| | - M Arun
- Department of Respiratory Medicine, Meenakshi Hospital, Thanjavur, Tamil Nadu, India
| | - Shraddha Nair
- Department of Respiratory Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - A Dhivya Roy
- Kanyakumari Medical Mission, CSI Mission Hospital, Neyyoor, Tamil Nadu, India
| | - Benjamin E. Williams
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shona A. Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dhanawade V. Subodh
- Division of Critical Care Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nishant Sinha
- Department of Pulmonary Medicine, Continental Hospitals, Financial District, Hyderabad, Telangana, India
| | - Barney Isaac
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - A Ashwin Oliver
- Department of Respiratory Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - N Priya
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Sujith T. Chandy
- Department of Respiratory Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Richu Bob Kurien
- Department of Respiratory Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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Wen KZ, Brereton CJ, Douglas EM, Samuel SRN, Jones AC. Pleural procedures: an audit of practice and complications in a regional Australian teaching hospital. Intern Med J 2024; 54:172-177. [PMID: 37255366 DOI: 10.1111/imj.16147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/13/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Pleural procedures are essential for the investigation and management of pleural disease and can be associated with significant morbidity and mortality. There is a lack of pleural procedure complication data in the Australian and New Zealand region. AIMS To review pleural procedure practices at Wollongong Hospital with an emphasis on the assessment of complications, use of thoracic ultrasound (TUS), pathology results and comparison of findings with international data. METHODS Retrospective analysis of medical records was performed on pleural procedures identified through respiratory specialist trainee logbooks at Wollongong Hospital from January 2018 to December 2021. Comparison of complication rates was made to the British Thoracic Society 2011 a national pleural audit. RESULTS One hundred and twenty-one pleural procedures were identified. There were 71 chest drains, 49 thoracocentesis and one indwelling pleural catheter (IPC) insertion. Ninety-seven per cent of procedures were performed for pleural effusions and 3% for pneumothorax. This audit demonstrated a complication rate (excluding pain) of 16.9% for chest drains and 4.1% for thoracocentesis. This gave an overall complication event rate of 10.8% (excluding pain) for pleural procedures. There was no major bleeding, organ puncture, pleural space infection or death. Bedside TUS was used in 99% of procedures. CONCLUSION Complication rates for pleural procedures performed by respiratory specialist trainees at Wollongong Hospital are comparable with international outcomes. This audit provides data for comparison on pleural procedure complication rates in Australia. Future studies are required to determine complication rates with IPCs.
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Affiliation(s)
- Kevin Z Wen
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
| | - Christopher J Brereton
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Sydney, New South Wales, Australia
| | - Eric M Douglas
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
| | - Sameh R N Samuel
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Sydney, New South Wales, Australia
| | - Andrew C Jones
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Sydney, New South Wales, Australia
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Piggott LM, Hayes C, Greene J, Fitzgerald DB. Malignant pleural disease. Breathe (Sheff) 2023; 19:230145. [PMID: 38351947 PMCID: PMC10862126 DOI: 10.1183/20734735.0145-2023] [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: 08/15/2023] [Accepted: 01/02/2024] [Indexed: 02/16/2024] Open
Abstract
Malignant pleural disease represents a growing healthcare burden. Malignant pleural effusion affects approximately 1 million people globally per year, causes disabling breathlessness and indicates a shortened life expectancy. Timely diagnosis is imperative to relieve symptoms and optimise quality of life, and should give consideration to individual patient factors. This review aims to provide an overview of epidemiology, pathogenesis and suggested diagnostic pathways in malignant pleural disease, to outline management options for malignant pleural effusion and malignant pleural mesothelioma, highlighting the need for a holistic approach, and to discuss potential challenges including non-expandable lung and septated effusions.
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Affiliation(s)
- Laura M. Piggott
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Department of Respiratory Medicine, St. James's Hospital, Dublin, Ireland
- These authors contributed equally
| | - Conor Hayes
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Department of Respiratory Medicine, St. James's Hospital, Dublin, Ireland
- These authors contributed equally
| | - John Greene
- Department of Oncology, Tallaght University Hospital, Dublin, Ireland
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Zaghba N, Laklaai Z, Chaanoun K, Benjelloune H, Yassine N. Pulmonary edema ex vacuo after drainage of pyo-pneumothorax. BMC Pulm Med 2023; 23:444. [PMID: 37974106 PMCID: PMC10652472 DOI: 10.1186/s12890-023-02739-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/29/2023] [Indexed: 11/19/2023] Open
Abstract
This case presents a rare occurrence of re-expansion pulmonary edema following a drainage of pyo-pneumothorax in a 33-year-old patient. The diagnosis was established through a thoracic radiography, and the treatment consisted of symptomatic management, showing positive progress. Later on, the patient was diagnosed with pleural tuberculosis via GeneXpert testing and subsequently initiated on anti-bacterial therapy.This case report aims to shed light on the infrequent pulmonary edema ex vacuo as a complication of pleural drainage. It explores its causes, risk factors, diagnostic approaches, and treatment options. this study highlights the necessity of effective prevention and management strategies.
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Affiliation(s)
- Nahid Zaghba
- Department of Respiratory Diseases Ibn Rochd Casablanca, Casablanca, Morocco
| | - Zakaria Laklaai
- Department of Respiratory Diseases Ibn Rochd Casablanca, Casablanca, Morocco.
| | - Khadija Chaanoun
- Department of Respiratory Diseases Ibn Rochd Casablanca, Casablanca, Morocco
| | - Hanane Benjelloune
- Department of Respiratory Diseases Ibn Rochd Casablanca, Casablanca, Morocco
| | - Najiba Yassine
- Department of Respiratory Diseases Ibn Rochd Casablanca, Casablanca, Morocco
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Nathanson R, Baher H, Phillips J, Freeman M, Sehgal R, O'Rorke J, Soni NJ. Development of a Chief Resident Medical Procedure Service: a 10-Year Experience. J Gen Intern Med 2023; 38:3077-3081. [PMID: 37237120 PMCID: PMC10593632 DOI: 10.1007/s11606-023-08234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Lack of experienced faculty to supervise internal medicine (IM) residents is a significant barrier to establishing a medical procedure service (MPS). AIM Describe the development and 10-year outcomes of an MPS led by IM chief residents. SETTING University-based IM residency program affiliated with a county and Veterans Affairs hospital. PARTICIPANTS Categorical IM interns (n=320) and 4th-year IM chief residents (n=48) from 2011 to 2022. PROGRAM DESCRIPTION The MPS operated on weekdays, 8 am-5 pm. After training and sign-off by the MPS director, chief residents trained and supervised interns in ultrasound-guided procedures during a 4-week rotation. PROGRAM EVALUATION From 2011 to 2022, our MPS received 5967 consults and 4465 (75%) procedures were attempted. Overall procedure success, complication, and major complication rates were 94%, 2.6%, and 0.6%, respectively. Success and complication rates for paracentesis (n=2285) were 99% and 1.1%, respectively; 99% and 4.2% for thoracentesis (n=1167); 76% and 4.5% for lumbar puncture (n=883); 83% and 1.2% for knee arthrocentesis (n=85); and 76% and 0% for central venous catheterization (n=45). The rotation was rated 4.6 out of 5 for overall learning quality. DISCUSSION A chief resident-led MPS is a practical and safe approach for IM residency programs to establish an MPS when experienced attending physicians are unavailable.
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Affiliation(s)
- Robert Nathanson
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA.
- Division of Hospital Medicine, Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.
| | - Hasan Baher
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jason Phillips
- Division of Cardiology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Megan Freeman
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of Hospital Medicine, Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Raj Sehgal
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of Hospital Medicine, Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jane O'Rorke
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of General Internal Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Nilam J Soni
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of Hospital Medicine, Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
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12
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Dos Santos GMF, Gupta A, Souza CA, Bayanati H. Review of Image-Guided Pleural Interventions. Semin Roentgenol 2023; 58:454-462. [PMID: 37973274 DOI: 10.1053/j.ro.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/19/2023] [Indexed: 11/19/2023]
Affiliation(s)
| | - Ashish Gupta
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Carolina A Souza
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Hamid Bayanati
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
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13
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Cruz JC, Edelstein M. Ultrasonography-Guided Procedures in the Intensive Care Setting. AACN Adv Crit Care 2023; 34:201-206. [PMID: 37644633 DOI: 10.4037/aacnacc2023551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Ultrasonography guidance can help make procedures safer and more effective, particularly in the intensive care setting. This article discusses techniques to optimize periprocedural ultrasonography and reviews common intensive care procedures for which ultrasonography can be used: vascular access procedures, paracentesis, thoracentesis, and pericardiocentesis.
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Affiliation(s)
- Jeffrey C Cruz
- Jeffrey C. Cruz is Assistant Professor of Clinical Radiology, Division of Interventional Radiology, Department of Radiology, Temple University Hospital, Temple University Health System, 3401 N Broad Street, Philadelphia, PA 19140
| | - Mark Edelstein
- Mark Edelstein is Intergrated Interventional Radiology Resident, Division of Interventional Radiology, Department of Radiology, Temple University Hospital, Temple University Health System
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14
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Asciak R, Bedawi EO, Bhatnagar R, Clive AO, Hassan M, Lloyd H, Reddy R, Roberts H, Rahman NM. British Thoracic Society Clinical Statement on pleural procedures. Thorax 2023; 78:s43-s68. [PMID: 37433579 DOI: 10.1136/thorax-2022-219371] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Affiliation(s)
- Rachelle Asciak
- Respiratory Medicine, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eihab O Bedawi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Maged Hassan
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Heather Lloyd
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Raja Reddy
- Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Helen Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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15
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Maughan KS, Romain M, Brown DB. Use of Ethylene Vinyl Copolymer for Embolization Outside the Central Nervous System: A Case Review. Semin Intervent Radiol 2023; 40:221-230. [PMID: 37333750 PMCID: PMC10275679 DOI: 10.1055/s-0043-1768611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Affiliation(s)
- Kyle S. Maughan
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mike Romain
- Meharry Medical College, Nashville, Tennessee
| | - Daniel B. Brown
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Biolato M, Vitale F, Galasso T, Gasbarrini A, Grieco A. Minimum platelet count threshold before invasive procedures in cirrhosis: Evolution of the guidelines. World J Gastrointest Surg 2023; 15:127-141. [PMID: 36896308 PMCID: PMC9988645 DOI: 10.4240/wjgs.v15.i2.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
Cirrhotic patients with severe thrombocytopenia are at increased risk of bleeding during invasive procedures. The need for preprocedural prophylaxis aimed at reducing the risk of bleeding in cirrhotic patients with thrombocytopenia who undergo scheduled procedures is assessed via the platelet count; however, establishing a minimum threshold considered safe is challenging. A platelet count ≥ 50000/μL is a frequent target, but levels vary by provider, procedure, and specific patient. Over the years, this value has changed several times according to the different guidelines proposed in the literature. According to the latest guidelines, many procedures can be performed at any level of platelet count, which should not necessarily be checked before the procedure. In this review, we aim to investigate and describe how the guidelines have evolved in recent years in the evaluation of the minimum platelet count threshold required to perform different invasive procedures, according to their bleeding risk.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Federica Vitale
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Tiziano Galasso
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
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17
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Shriki J, Dave SB. Minor Procedures in Trauma. Emerg Med Clin North Am 2023; 41:143-159. [DOI: 10.1016/j.emc.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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18
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Cao XS, Zheng WQ, Hu ZD. Diagnostic value of soluble biomarkers for parapneumonic pleural effusion. Crit Rev Clin Lab Sci 2023; 60:233-247. [PMID: 36593742 DOI: 10.1080/10408363.2022.2158779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Parapneumonic pleural effusion (PPE) is a common complication in patients with pneumonia. Timely and accurate diagnosis of PPE is of great value for its management. Measurement of biomarkers in circulating and pleural fluid have the advantages of easy accessibility, short turn-around time, objectiveness and low cost and thus have utility for PPE diagnosis and stratification. To date, many biomarkers have been reported to be of value for the management of PPE. Here, we review the values of pleural fluid and circulating biomarkers for the diagnosis and stratification PPE. The biomarkers discussed are C-reactive protein, procalcitonin, presepsin, soluble triggering receptor expressed on myeloid cells 1, lipopolysaccharide-binding protein, inflammatory markers, serum amyloid A, soluble urokinase plasminogen activator receptor, matrix metalloproteinases, pentraxin-3 and cell-free DNA. We found that none of the available biomarkers has adequate performance for diagnosing and stratifying PPE. Therefore, further work is needed to identify and validate novel biomarkers, and their combinations, for the management of PPE.
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Affiliation(s)
- Xi-Shan Cao
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Wen-Qi Zheng
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
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19
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Outcome of Intermittent Thoracentesis versus Pigtail Catheter Drainage for Hepatic Hydrothorax. J Clin Med 2022; 11:jcm11237221. [PMID: 36498795 PMCID: PMC9735472 DOI: 10.3390/jcm11237221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/21/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Background/Aims: The management of hepatic hydrothorax (HH) remains a challenging clinical scenario with suboptimal options. We investigated the effect and safety of pigtail catheter drainage compared to intermittent thoracentesis. Methods: This multicenter, retrospective study included 164 cirrhotic patients with recurrent pleural effusion from March 2012 to June 2017. Patients with neoplasms, cardiopulmonary disease, and infectious conditions were excluded. We compared the clinical outcomes of pigtail catheter drainage versus thoracentesis for variables including complications related to procedures, overall survival, and re-admission rates. Results: A total of 164 patients were divided into pigtail catheter (n = 115) and thoracentesis (n = 49) groups. During the follow-up period of 6.93 months after discharge, 98 patients died (pigtail; n = 47 vs. thoracentesis; n = 51). The overall survival (p = 0.61) and 30-day mortality (p = 0.77) rates were similar between the pigtail catheter and thoracentesis groups. Only MELD scores were associated with overall survival (adjusted HR, 1.08; p < 0.01) in patients with HH. Spontaneous pleurodesis occurred in 59 patients (51.3%) in the pigtail catheter group. Re-admission rates did not differ between the pigtail catheter and thoracentesis groups (13.2% vs 19.6% p = 0.7). A total of five complications occurred, including four total cases of bleeding (one patient in the pigtail catheter group and three in the thoracentesis group) and one case of empyema in the pigtail catheter group. Conclusions: Pigtail catheter drainage is not inferior to that of intermittent thoracentesis for the management of HH, proving it may be an effective and safe clinical option.
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20
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Langsted ST, Lauridsen KG, Weile JB, Skaarup SH, Kirkegaard H, Løfgren B. Lack of Thoracentesis Competencies and Training in Danish Emergency Departments: A Danish Nationwide Study. Open Access Emerg Med 2022; 14:609-614. [PMID: 36411796 PMCID: PMC9675400 DOI: 10.2147/oaem.s384608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/20/2022] [Indexed: 09/08/2024] Open
Abstract
Background Dyspnea caused by pleural effusion is a common reason for admission to the emergency department (ED). In such cases, thoracentesis performed in the ED may allow for swift symptom relief, diagnostics, and early patient discharge. However, the competence level of thoracentesis and training in the ED are currently unclear. This study aimed to describe the current competencies and training in thoracentesis in Danish EDs. Methods We performed a nationwide cross-sectional study in Denmark. A questionnaire was distributed to all EDs in March 2022 including questions on competencies and thoracentesis training methods. Descriptive statistics were used. Results In total, 21 EDs replied (response rate 100%) between March and May 2022. Overall, 50% of consultant and 77% of physicians in emergency medicine specialist training were unable to perform thoracentesis independently. Only 2 of 21 EDs (10%) had a formalized training program. In these 2 EDs, there were no requirements of maintaining these competences. Informal training was reported by 14 out 21 (66%) EDs and consisted of ad-hoc bedside procedural demonstration and/or guidance. Among the 19 EDs without formalized training, 9 (47%) had no intention of establishing a formalized training program. Conclusion We found a major lack of thoracentesis competencies in Danish EDs among both consultant and physicians in emergency medicine specialist training. Moreover, the vast majority of EDs had no formalized thoracentesis training program.
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Affiliation(s)
- Sandra Thun Langsted
- Department of Emergency Medicine, Randers Regional Hospital, Randers, Denmark
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kasper Glerup Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Jesper Bo Weile
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Emergency Medicine, Horsens Regional Hospital, Horsens, Denmark
| | - Søren Helbo Skaarup
- Department of Respiratory Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bo Løfgren
- Department of Emergency Medicine, Randers Regional Hospital, Randers, Denmark
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
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21
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Nguyen ET, Bayanati H, Hurrell C, Aitken M, Cheung EM, Gupta A, Harris S, Sedlic T, Taylor JL, Gahide G, Dennie C. Canadian Association of Radiologists/Canadian Association of Interventional Radiologists/Canadian Society of Thoracic Radiology Guidelines on Thoracic Interventions. Can Assoc Radiol J 2022; 74:272-287. [PMID: 36154303 DOI: 10.1177/08465371221122807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thoracic interventions are frequently performed by radiologists, but guidelines on appropriateness criteria and technical considerations to ensure patient safety regarding such interventions is lacking. These guidelines, developed by the Canadian Association of Radiologists, Canadian Association of Interventional Radiologists and Canadian Society of Thoracic Radiology focus on the interventions commonly performed by thoracic radiologists. They provide evidence-based recommendations and expert consensus informed best practices for patient preparation; biopsies of the lung, mediastinum, pleura and chest wall; thoracentesis; pre-operative lung nodule localization; and potential complications and their management.
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Affiliation(s)
- Elsie T Nguyen
- Joint Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Hamid Bayanati
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Casey Hurrell
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Matthew Aitken
- Joint Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada,St. Michael's Hospital, University of Toronto, ON, Canada
| | - Edward M Cheung
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Ashish Gupta
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Scott Harris
- Health Sciences Centre, Memorial University of Newfoundland, St. John’s, NL, Canada
| | - Tony Sedlic
- Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jana Lyn Taylor
- Department of Diagnostic Radiology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Gerald Gahide
- Service de radiologie interventionelle, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Carole Dennie
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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22
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Rosmini S, Seraphim A, Knott K, Brown JT, Knight DS, Zaman S, Cole G, Sado D, Captur G, Gomes AC, Zemrak F, Treibel TA, Cash L, Culotta V, O’Mahony C, Kellman P, Moon JC, Manisty C. Non-invasive characterization of pleural and pericardial effusions using T1 mapping by magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 2022; 23:1117-1126. [PMID: 34331054 PMCID: PMC9612798 DOI: 10.1093/ehjci/jeab128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Indexed: 12/20/2022] Open
Abstract
AIMS Differentiating exudative from transudative effusions is clinically important and is currently performed via biochemical analysis of invasively obtained samples using Light's criteria. Diagnostic performance is however limited. Biochemical composition can be measured with T1 mapping using cardiovascular magnetic resonance (CMR) and hence may offer diagnostic utility for assessment of effusions. METHODS AND RESULTS A phantom consisting of serially diluted human albumin solutions (25-200 g/L) was constructed and scanned at 1.5 T to derive the relationship between fluid T1 values and fluid albumin concentration. Native T1 values of pleural and pericardial effusions from 86 patients undergoing clinical CMR studies retrospectively analysed at four tertiary centres. Effusions were classified using Light's criteria where biochemical data was available (n = 55) or clinically in decompensated heart failure patients with presumed transudative effusions (n = 31). Fluid T1 and protein values were inversely correlated both in the phantom (r = -0.992) and clinical samples (r = -0.663, P < 0.0001). T1 values were lower in exudative compared to transudative pleural (3252 ± 207 ms vs. 3596 ± 213 ms, P < 0.0001) and pericardial (2749 ± 373 ms vs. 3337 ± 245 ms, P < 0.0001) effusions. The diagnostic accuracy of T1 mapping for detecting transudates was very good for pleural and excellent for pericardial effusions, respectively [area under the curve 0.88, (95% CI 0.764-0.996), P = 0.001, 79% sensitivity, 89% specificity, and 0.93, (95% CI 0.855-1.000), P < 0.0001, 95% sensitivity; 81% specificity]. CONCLUSION Native T1 values of effusions measured using CMR correlate well with protein concentrations and may be helpful for discriminating between transudates and exudates. This may help focus the requirement for invasive diagnostic sampling, avoiding unnecessary intervention in patients with unequivocal transudative effusions.
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Affiliation(s)
- Stefania Rosmini
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
- King’s College Hospital NHS Trust Foundation, Denmark Hill, London SE5 9RS, UK
| | - Andreas Seraphim
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Kristopher Knott
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - James T Brown
- Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Daniel S Knight
- Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Sameer Zaman
- Imperial College London, Imperial College, Healthcare NHS Trust, South Kensington, London SW7 2BX, UK
| | - Graham Cole
- Imperial College London, Imperial College, Healthcare NHS Trust, South Kensington, London SW7 2BX, UK
| | - Daniel Sado
- King’s College Hospital NHS Trust Foundation, Denmark Hill, London SE5 9RS, UK
| | - Gabriella Captur
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
- Institute for Cardiovascular Sciences, University College London, 62 Huntley St, London WC1E 6DD, UK
| | - Ana Caterina Gomes
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Filip Zemrak
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Thomas A Treibel
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Lizette Cash
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Veronica Culotta
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Constantinos O’Mahony
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Medical Signal and Imaging Processing Program, 10 Center Dr, Bethesda, MD 20814, USA
| | - James C Moon
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
- Institute for Cardiovascular Sciences, University College London, 62 Huntley St, London WC1E 6DD, UK
| | - Charlotte Manisty
- Department of Cardiac Imaging, Barts Heart Centre, St Bartholomew’s Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
- Institute for Cardiovascular Sciences, University College London, 62 Huntley St, London WC1E 6DD, UK
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23
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Heinemann A. Death at Hospital and Medical Liability: Investigation of Medical Interventions with Fatal Outcome by Post-mortem Computed Tomography. FORENSIC IMAGING 2022. [DOI: 10.1007/978-3-030-83352-7_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Sundaralingam A, Bedawi EO, Harriss EK, Munnavar M, Rahman NM. The Frequency, Risk Factors and Management of Complications from Pleural Procedures. Chest 2021; 161:1407-1425. [PMID: 34896096 DOI: 10.1016/j.chest.2021.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022] Open
Abstract
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.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital.
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital
| | | | | | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital; University of Oxford, NIHR Oxford Biomedical Research Centre
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25
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Weinstein D, Guay R, Sacks D. Pulmonary Artery Hemorrhage Post Thoracentesis. Cardiovasc Intervent Radiol 2021; 45:382-383. [PMID: 34796376 DOI: 10.1007/s00270-021-03004-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022]
Affiliation(s)
- David Weinstein
- Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA, 19129, USA.
| | - Robert Guay
- Section of Interventional Radiology, Department of Diagnostic Radiology, Reading Hospital, 420 S 5th Ave, West Reading, PA, 19611, USA
| | - David Sacks
- Section of Interventional Radiology, Department of Diagnostic Radiology, Reading Hospital, 420 S 5th Ave, West Reading, PA, 19611, USA
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26
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Abstract
Malignant pleural effusions have a significant burden on patients and the health care system. Diagnosis is typically via thoracentesis, although other times more invasive procedures are required. Management centers around relief of dyspnea and patient quality of life and can be done via serial thoracentesis, indwelling pleural catheter, or pleurodesis. This article focuses on the diagnosis and management of malignant pleural effusion.
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Affiliation(s)
- Christopher M Kapp
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Illinois at Chicago, 840 South Wood Street, Room 920-N, Chicago, IL 60612, USA.
| | - Hans J Lee
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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27
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DeBiasi EM, Feller-Kopman D. Anatomy and Applied Physiology of the Pleural Space. Clin Chest Med 2021; 42:567-576. [PMID: 34774165 DOI: 10.1016/j.ccm.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The unique anatomy and physiology of the pleural space provides tight regulation of liquid within the space under normal physiologic conditions. When this balance is disrupted and pleural effusions develop, there can be significant impacts on the respiratory system. Drainage of effusions can lead to meaningful improvement in symptoms, primarily owing to improvement in the length-tension relationship of the respiratory muscles. Ultrasound examination to evaluate the movement and function of the diaphragm, as well as pleural manometry, have provided a greater understanding of the impact of pleural effusion and thoracentesis.
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Affiliation(s)
- Erin M DeBiasi
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT 06510, USA.
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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28
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Husnain SMN, Shojaee S. Hepatic Hydrothorax and Congestive Heart Failure Induced Pleural Effusion. Clin Chest Med 2021; 42:625-635. [PMID: 34774170 DOI: 10.1016/j.ccm.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Pleural effusions (PEs) are frequently encountered in routine clinical practice, affecting more than 3000 people per million population every year. Heart and liver failures are two of the most common causes of transudative PE. Because these effusions have nonmalignant etiologies, they are commonly referred to as benign effusions despite of the poor prognosis they foretell in their refractory stages. Like malignant effusions, symptom management is important and plays a significant role in palliation when these effusions become refractory to medical therapy.
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Affiliation(s)
| | - Samira Shojaee
- Department of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Virginia Commonwealth University Health System, 1200 East Broad Street, PO Box 980050, Richmond, VA 23298, USA.
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29
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Godfrey M, Puchalski J. Pleural Effusions in the Critically Ill and "At-Bleeding-Risk" Population. Clin Chest Med 2021; 42:677-686. [PMID: 34774174 DOI: 10.1016/j.ccm.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Thoracentesis is a common bedside procedure, which has a low risk of complications when performed with thoracic ultrasound and by experienced operators. In critically ill or mechanically ventilated patients, or in patients with bleeding risks due to medications or other coagulopathies, the complication rate remains low. Drainage of pleural effusion in the intensive care unit has diagnostic and therapeutic utility, and perceived bleeding risks should be one part of an individualized and comprehensive risk-benefit analysis.
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Affiliation(s)
- Mark Godfrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, 15 York Street, LCI 100, New Haven, CT 06510, USA
| | - Jonathan Puchalski
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, 15 York Street, LCI 100, New Haven, CT 06510, USA.
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Smith TA, Gage D, Quencer KB. Narrative review of vascular iatrogenic trauma and endovascular treatment. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1199. [PMID: 34430640 PMCID: PMC8350708 DOI: 10.21037/atm-20-4332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/12/2020] [Indexed: 11/29/2022]
Abstract
Iatrogenic injury is unfortunately a leading cause of morbidity and mortality for patients worldwide. The etiology of iatrogenic injury is broad, and can be seen with both diagnostic and therapeutic interventions. While steps can be taken to reduce the occurrence of iatrogenic injury, it is often not completely avoidable. Once iatrogenic injury has occurred, prompt recognition and appropriate management can help reduce further harm. The objective of this narrative review it to help reader better understand the risk factors associated with, and treatment options for a broad range of potential iatrogenic injuries by presenting a series of iatrogenic injury cases. This review also discusses rates, risk factors, as well as imaging and clinical signs of iatrogenic injury with an emphasis on endovascular and minimally invasive treatments. While iatrogenic vascular injury once required surgical intervention, now minimally invasive endovascular treatment is a potential option for certain patients. Further research is needed to help identify patients that are at the highest risk for iatrogenic injury, allowing patients and providers to reconsider or avoid interventions where the risk of iatrogenic injury may outweigh the benefit. Further research is also needed to better define outcomes for patients with iatrogenic vascular injury treated with minimally invasive endovascular techniques verses conservative management or surgical intervention.
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Affiliation(s)
- Tyler Andrew Smith
- Department of Interventional Radiology, University of Utah, Salt Lake City, UT, USA
| | - David Gage
- Department of Medicine, Intermountain Healthcare, Murray, UT, USA
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Hale C, Crocker J, Vanka A, Ricotta DN, McSparron JI, Huang GC. Cohort study of hospitalists' procedural skills: baseline competence and durability after simulation-based training. BMJ Open 2021; 11:e045600. [PMID: 34400443 PMCID: PMC8370503 DOI: 10.1136/bmjopen-2020-045600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Hospitalists are expected to be competent in performing bedside procedures, which are associated with significant morbidity and mortality. A national decline in procedures performed by hospitalists has prompted questions about their procedural competency. Additionally, though simulation-based mastery learning (SBML) has been shown to be effective among trainees whether this approach has enduring benefits for independent practitioners who already have experience is unknown. We aimed to assess the baseline procedural skill of hospitalists already credentialed to perform procedures. We hypothesised that simulation-based training of hospitalists would result in durable skill gains after several months. DESIGN Prospective cohort study with pretraining and post-training measurements. SETTING Single, large, urban academic medical centre in the USA. PARTICIPANTS Twenty-two out of 38 eligible participants defined as hospitalists working on teaching services where they would supervise trainees performing procedures. INTERVENTIONS One-on-one, 60 min SBML of lumbar puncture (LP) and abdominal paracentesis (AP). PRIMARY AND SECONDARY OUTCOME MEASURES Our primary outcome was the percentage of hospitalists obtaining minimum passing scores (MPS) on LP and AP checklists; our secondary outcomes were average checklist scores and self-reported confidence. RESULTS At baseline, only 16% hospitalists met or exceeded the MPS for LP and 32% for AP. Immediately after SBML, 100% of hospitalists reached this threshold. Reassessment an average of 7 months later revealed that only 40% of hospitalists achieved the MPS. Confidence increased initially after training but declined over time. CONCLUSIONS Hospitalists may be performing invasive bedside procedures without demonstration of adequate skill. A single evidence-based training intervention was insufficient to sustain skills for the majority of hospitalists over a short period of time. More stringent practices for certifying hospitalists who perform risky procedures are warranted, as well as mechanisms to support skill maintenance, such as periodic simulation-based training and assessment.
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Affiliation(s)
- Caleb Hale
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Crocker
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Anita Vanka
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel N Ricotta
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jakob I McSparron
- Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Grace C Huang
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Shimoda M, Morimoto K, Tanaka Y, Yoshimori K, Ohta K. Evaluation of the position of the needle tip during thoracentesis: Experimental study. Medicine (Baltimore) 2021; 100:e26600. [PMID: 34260543 PMCID: PMC8284708 DOI: 10.1097/md.0000000000026600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Thoracentesis is performed to both diagnose and/or treat pleural effusion, and several important complications of thoracentesis are occasionally observed. To assess precise thoracentesis procedures, we evaluated the position of the needle tip during thoracentesis by using a thoracentesis unit, comparing experienced and inexperienced groups. METHODS Twenty eight physicians (19 board-certified pulmonologists as an experienced group and the remaining 9 as an inexperienced group) participated at Fukujuji Hospital in January 2021. All participants performed 2 punctures with a handmade thoracentesis unit and measured the needle's angle to the midline. RESULTS The median distance from the needle tip to the midline when the needle was inserted 5 cm (D5) was 0.47 cm (range 0.06-1.05), and the median difference between D5 on the 1st puncture (D51st) and D5 on the 2nd puncture (D52nd) was 0.22 cm (range 0.00-0.69). D5 was shorter in the experienced group than in the inexperienced group (median 0.40 cm (range 0.06-0.66) vs 0.58 cm (range 0.44-1.05), P < .001). There were no significant differences in the D51st and D52nd distances between the experienced and inexperienced groups (median 0.22 cm (range 0.00-0.40) vs 0.41 cm (range 0.04-0.69), P = .094). When 4 areas were divided by the x-axis and y-axis, 32 punctures (55.2%) deviated to the right-upper quadrant, and 25 (86.2%) of participants made the 1st puncture and 2nd puncture in the same direction. CONCLUSIONS All doctors should know that the needle direction might shift by approximately 1 cm, and more than half of the practitioners punctured towards the upper right.
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Limited Clinical Utility of Chest Radiography in Asymptomatic Patients after Interventional Radiology-Performed Ultrasound-Guided Thoracentesis: Analysis of 3,022 Consecutive Patients. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1723096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Purpose The aim of this study was to report the utility of chest radiography following interventional radiology-performed ultrasound-guided thoracentesis.
Materials and Methods A total of 3,998 patients underwent thoracentesis between 2003 and 2018 at two institutions. A total of 3,022 (75.6%) patients were older than 18 years old, underwent interventional radiology-performed ultrasound-guided thoracentesis, and had same-day post-procedure chest radiograph evaluation. Patient age (years), laterality of thoracentesis, procedural technical success, volume of fluid removed (mL), method of post-procedure chest imaging, absence or presence of pneumothorax, pneumothorax size (mm), pneumothorax management measures, and clinical outcomes were recorded. Technical success was defined as successful aspiration of pleural fluid. Post-procedure clinical outcomes included new patient-perceived dyspnea and hypoxia (oxygen saturations < 90% on room air). Costs associated with radiographs were estimated using Medicare and Medicaid fee schedules.
Results Mean age was 56.7 ± 15.5 years. Interventional radiology-performed ultrasound-guided thoracentesis was performed on the left (n = 1,531; 50.7%), right (n = 1,477; 48.9%), and bilaterally (n = 14; 0.5%) using 5-French catheters. Technical success was 100% (n = 3,022). Mean volume of 940 ± 550 mL of fluid was removed. Post-procedure imaging was performed in the form of posteroanterior (PA) (2.6%; 78/3,022), anteroposterior (AP) (17.0%; 513/3,022), PA and lateral (77.9%; 2,355/3,022), or PA, lateral, and left lateral decubitus (2.5%; 76/3,022) chest radiographs. Post-procedural pneumothorax was identified in 21 (0.69%) patients. Mean pneumothorax size, measured on chest radiograph as the longest distance from the chest wall to the lung, was 18.8 ± 10.2 mm (range: 5.0–35.0 mm). Of the 21 pneumothoraces, 7 (33.3%) were asymptomatic, resolved spontaneously, and had a mean size of 6.4 ± 2.4 mm. Fourteen pneumothoraces, of mean size 25.0 ± 5.8 mm, required management with a pleural drainage catheter (66.6%). The overall incidence of pneumothorax requiring pleural drainage catheter placement following interventional radiology-performed ultrasound-guided thoracentesis was 0.46% (14/3,022). Of the patients requiring drainage catheter placement, 12/14 (85.7%) and 13/14 (92.9%) had dyspnea and hypoxia, respectively. Potential costs to Medicare and Medicaid, for chest radiographs, in this study, were $27,547 and $10,581, respectively.
Conclusion The incidence of clinically significant pneumothorax requiring catheter drainage following interventional radiology-operated ultrasound-guided thoracentesis is exceedingly low (0.46%), and routine post-procedure chest radiographs in asymptomatic patients provide little value. Reserving post-procedure chest radiographs for patients with post-procedure dyspnea or hypoxia will result in more efficient resource utilization and health care cost savings.
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Reason for Consult: Still on Oxygen, Discharge Pending, Requesting Thoracentesis. J Bronchology Interv Pulmonol 2021; 28:172-173. [PMID: 34151898 DOI: 10.1097/lbr.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Small Drainage Volumes of Pleural Effusions Are Associated with Complications in Critically Ill Patients: A Retrospective Analysis. J Clin Med 2021; 10:jcm10112453. [PMID: 34205925 PMCID: PMC8197788 DOI: 10.3390/jcm10112453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 11/29/2022] Open
Abstract
Pleural effusions are a common finding in critically ill patients and small bore chest drains (SBCD) are proven to be efficient for pleural drainage. The data on the potential benefits and risks of drainage remains controversial. We aimed to determine the cut-off volume for complications, to investigate the impact of pleural drainage and drained volume on clinically relevant outcomes. Medical records of all critically ill patients undergoing insertion of SBCD were retrospectively examined. We screened 13,003 chest radiographs and included 396 SBCD cases in the final analysis. SBCD drained on average 900 mL, with less amount in patients with complications (p = 0.003). A drainage volume of 975 mL in 24 h represented the optimal threshold for complications. Pneumothorax was the most frequent complication (4.5%), followed by bleeding (0.8%). Female and lighter-weighted patients experienced a higher risk for any complication. We observed an improvement in the arterial partial pressure of oxygen and respiratory quotient (p < 0.001). We conclude that the small drainage volumes are associated with complications in critically ill patients—the more you drain, the safer the procedure gets. The use of SBCD is a safe and efficient procedure, further investigations regarding the higher rate of complications in female and lighter-weighted patients are desirable.
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Tajarernmuang P, Gonzalez AV, Valenti D, Beaudoin S. Overuse of small chest drains for pleural effusions: a retrospective practice review. Int J Health Care Qual Assur 2021; ahead-of-print. [PMID: 33909374 DOI: 10.1108/ijhcqa-11-2020-0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place. DESIGN/METHODOLOGY/APPROACH We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015-July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable. FINDINGS A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03). ORIGINALITY/VALUE Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.
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Affiliation(s)
- Pattraporn Tajarernmuang
- Division of Pulmonary, Critical Care, and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Anne V Gonzalez
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - David Valenti
- Radiology Department, McGill University Health Centre, Montreal, Canada
| | - Stéphane Beaudoin
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Canada
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Fong C, Chang Tan CW, Yan Tan DK, See KC. Safety of Thoracentesis and Tube Thoracostomy in Patients With Uncorrected Coagulopathy: A Systematic Review and Meta-analysis. Chest 2021; 160:1875-1889. [PMID: 33905681 DOI: 10.1016/j.chest.2021.04.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/04/2021] [Accepted: 04/17/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Thoracentesis and tube thoracostomy are common procedures with bleeding risks, but existing guidelines may be overly conservative. We reviewed the evidence on the safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy. RESEARCH QUESTION Is it safe to perform thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy? STUDY DESIGN AND METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. PubMed and Embase were searched from inception through December 31, 2019. Included studies involved patients with uncorrected coagulopathy because of disease (eg, thrombocytopenia, liver cirrhosis, kidney failure) or drugs (eg, antiplatelets, anticoagulants). Relevant outcomes were major bleeding and mortality. RESULTS Eighteen studies (5,134 procedures) were included. Using random-effects meta-analysis, the pooled major bleeding and mortality rate was 0 (95% CI, 0%-1%). No publication bias was found. Excluding six studies that were in abstract form, meta-analysis of the remaining 12 full articles showed that the pooled major bleeding and mortality rate also was 0 (95% CI, 0%-2%). Subgroup analysis performed for patients with uncorrected coagulopathy resulting from disease or drugs showed similar results. INTERPRETATION Among patients with uncorrected coagulopathy who underwent thoracentesis or tube thoracostomy, major bleeding and mortality complications were uncommon. Our results suggest that in appropriately selected patients, thoracentesis or tube thoracostomy can be performed safely. TRIAL REGISTRY PROSPERO; No.: CRD42020152226; URL: www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Clare Fong
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University of Singapore, Singapore, Republic of Singapore.
| | - Colin Wei Chang Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore
| | - Drusilla Kai Yan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University of Singapore, Singapore, Republic of Singapore; Department of Medicine, National University of Singapore, Singapore, Republic of Singapore
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CIRSE Standards of Practice on Peri-operative Anticoagulation Management During Interventional Radiology Procedures. Cardiovasc Intervent Radiol 2021; 44:523-536. [PMID: 33474606 DOI: 10.1007/s00270-020-02763-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Abstract
This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for peri-operative anticoagulation management during interventional radiology procedures.
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Kamio T, Iizuka Y, Koyama H, Fukaguchi K. Adverse events related to thoracentesis and chest tube insertion: evaluation of the national collection of subject safety incidents in Japan. Eur J Trauma Emerg Surg 2021; 48:981-988. [PMID: 33386863 PMCID: PMC7775838 DOI: 10.1007/s00068-020-01575-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/07/2020] [Indexed: 10/31/2022]
Abstract
PURPOSE Thoracentesis and chest tube insertion are procedures commonly performed in routine clinical practice and are considered mandatory skills for all physicians. Adverse events secondary to these procedures have been widely reported; however, epidemiology data concerning life-threatening events associated with these procedures are lacking. METHODS We retrospectively analyzed data from the Japan Council for Quality Health Care open database regarding subject safety incidents involving thoracentesis and chest tube insertion. The adverse events extracted from the database included only events associated with thoracentesis and chest tube insertion reported between January 2010 and April 2020. RESULTS We identified 137 adverse events due to thoracentesis or chest tube insertion. Our analysis also revealed at least 15 fatal adverse events and 17 cases of left/right misalignment. Not only resident doctors but also physicians with 10 years or more of clinical experience had been mentioned in these reports. The most common complications due to adverse events were lung injury (55%), thoracic vascular injury (21%), and liver injury (10%). Surgical treatment was required for 43 (31%) of the 137 cases, and the mortality risk was significantly higher for thoracic vascular injury than for other complications (p = 0.02). CONCLUSION We identified at least 15 fatal adverse events and 17 cases of left/right misalignment over a 10-year period in the Japan Council for Quality Health Care open database. Our findings also suggest that care should be taken to avoid thoracic vascular injury during chest tube insertion and that immediate intervention is required should such an injury occur.
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Affiliation(s)
- Tadashi Kamio
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Hiroshi Koyama
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Kiyomitsu Fukaguchi
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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Mytinger A, Taylor T, Gershman E, Shojaee S. Pleural Disease Management: Manometry-guided Thoracentesis, Optimal Drainage Regimen of Indwelling Pleural Catheters, and Talc Poudrage versus Slurry for Malignant Pleural Effusion. Am J Respir Crit Care Med 2020; 202:448-450. [PMID: 32421351 DOI: 10.1164/rccm.202003-0599rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrea Mytinger
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Trevor Taylor
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Evgeni Gershman
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
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Jackson K, Johnston R, Mackay L, Aujayeb A. A difficult pleural effusion in a cirrhotic patient. Breathe (Sheff) 2020; 16:200049. [PMID: 33304406 PMCID: PMC7714551 DOI: 10.1183/20734735.0049-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Failure of medical management of hepatic hydrothoraces will require pleural interventions. Indwelling pleural catheters and medical thoracoscopy can help. Careful liaison with liver transplantation teams is required. https://bit.ly/2XO1naG.
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Affiliation(s)
- Karl Jackson
- Respiratory Dept, Northumbria HealthCare NHS Trust, North Shields, UK.,These authors contributed equally
| | - Robert Johnston
- Respiratory Dept, Northumbria HealthCare NHS Trust, North Shields, UK.,These authors contributed equally
| | - Laura Mackay
- Respiratory Dept, Northumbria HealthCare NHS Trust, North Shields, UK.,These authors contributed equally
| | - Avinash Aujayeb
- Respiratory Dept, Northumbria HealthCare NHS Trust, North Shields, UK.,These authors contributed equally
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Caldwell KB. A Novel Ventilatory Technique in Refractory Hypoxemic Respiratory Failure Secondary to Therapeutic Thoracentesis and Paracentesis. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e924862. [PMID: 32841226 PMCID: PMC7476739 DOI: 10.12659/ajcr.924862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 61-year-old Final Diagnosis: Hypoxemic respiratory failure • reperfusion pulmonary edema Symptoms: Respiratory deterioration Medication: — Clinical Procedure: — Specialty: Critical Care Medicine
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Sá Mendes G, De Araújo Gonçalves P, Madeira S, Oliveira P. Percutaneous closure of accidental left atrium puncture: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 33426441 PMCID: PMC7780441 DOI: 10.1093/ehjcr/ytaa194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/13/2020] [Accepted: 06/05/2020] [Indexed: 12/01/2022]
Abstract
Background Minimally invasive alternatives to surgical closure of cardiac perforations are a recognized need, especially in critically ill patients in whom predicted surgical mortality is prohibitive. To the best of our knowledge, this is the first reported case of an iatrogenic left atrium (LA) puncture closed with a plug-based vascular closure device (VCD). Case summary During a palliative right-sided thoracentesis on a 73-year-old woman, with end-stage heart failure due to rheumatic valvular heart disease, an accidental puncture and insertion of a central venous catheter into an aneurysmatic LA occurred. This complication was successfully managed percutaneously, under transthoracic echocardiographic guidance, after cardiac computed tomography planning, using a plug-based VCD. Discussion This case demonstrates the possible utility of plug-based devices for iatrogenic LA perforation closure, when surgical risk is deemed prohibitive.
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Affiliation(s)
- Gustavo Sá Mendes
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Av. Prof. Dr Reinaldo dos Santos, Carnaxide 2790-134, Portugal
| | - Pedro De Araújo Gonçalves
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Av. Prof. Dr Reinaldo dos Santos, Carnaxide 2790-134, Portugal
| | - Sérgio Madeira
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Av. Prof. Dr Reinaldo dos Santos, Carnaxide 2790-134, Portugal
| | - Paulo Oliveira
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Av. Prof. Dr Reinaldo dos Santos, Carnaxide 2790-134, Portugal
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Pattison A, Jeagal L, Yasufuku K, Pierre A, Donahoe L, Yeung J, Darling G, Cypel M, De Perrot M, Waddell T, Keshavjee S, Czarnecka-Kujawa K. The impact of concordance with a lung cancer diagnosis pathway guideline on treatment access in patients with stage IV lung cancer. J Thorac Dis 2020; 12:4327-4337. [PMID: 32944345 PMCID: PMC7475595 DOI: 10.21037/jtd-20-157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Timely access to treatment of lung cancer is dependent on efficient and appropriate patient assessment and early referral for diagnostic workup. This study assesses the impact of Cancer Care Ontario (CCO) Lung Cancer Diagnostic Pathway Guideline (LCDPG) concordance on access to treatment of stage IV lung cancer patients referred to the Diagnostic Assessment Program (DAP) at a Canadian tertiary cancer centre. Methods This retrospective cohort study includes patients diagnosed with clinical stage IV lung cancer referred to the DAP at a Canadian tertiary cancer centre between November 1, 2015 and May 31, 2017. Referral concordance was determined based on CCO LCDPG. The primary outcome; time to treatment from initial healthcare presentation; was compared between the concordant and discordant referrals. Results Two hundred patients were referred for clinical stage IV lung cancer during the study period. Of these referrals, 151 (75.5%) were assessed and referred in concordance with LCDPG. Guideline concordant referrals were associated with reduced time to treatment from first healthcare presentation compared with guideline discordant referrals (55.3 vs. 108.8 days, P<0.001). Time to diagnostic procedure (32.2 vs. 86.7 days, P<0.001) and decision to treat (38.5 vs. 93.8 days, P<0.001) were also reduced with guideline concordance. The most common reason for discordant assessment and referral was delayed or inadequate investigation of symptoms in a high risk patient (32.7% of discordant referrals). Conclusions Guideline concordant assessment and referral of stage IV lung cancer patients results in reduced time to diagnosis and treatment. Future research and education should focus on improving factors that delay DAP referral.
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Affiliation(s)
- Andrew Pattison
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Luke Jeagal
- Division of Respirology, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Andrew Pierre
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Jonathan Yeung
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Gail Darling
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Marc De Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Tom Waddell
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Kasia Czarnecka-Kujawa
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.,Division of Respirology, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
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Congedo MT, Ferretti GM, Nachira D, Pennisi MA. Management of Pleural Effusions in the Emergency Department. Rev Recent Clin Trials 2020; 15:258-268. [PMID: 32579507 DOI: 10.2174/1574887115666200624194457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/02/2020] [Accepted: 04/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND In symptomatic patients, admitted in emergency department for acute chest pain and dyspnea, who require an urgent treatment, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving. AIM The aim of this review was to summarize the current diagnostic and therapeutic approaches for the management of the main types of pleural effusions that physicians can have in an emergency department setting. METHODS Current literature about the topic was reviewed and critically reported, adding the experience of the authors in the management of pleural effusions in emergency settings. RESULTS The paper analyzed the main types of pleural effusions that physicians can have to treat. It illustrated the diagnostic steps by the principal radiological instruments, with a particular emphasis to the role of ultrasonography, in facilitating diagnosis and guiding invasive procedures. Then, the principal procedures, like thoracentesis and insertion of small and large bore chest drains, are indicated and illustrated according to the characteristics and the amount of the effusion and patient clinical conditions. CONCLUSION The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions.
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Affiliation(s)
- Maria Teresa Congedo
- Department of Thoracic Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gian Maria Ferretti
- Department of Thoracic Surgery, Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Dania Nachira
- Department of Thoracic Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Anesthesiology and Intensive Care, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Universita Cattolica del Sacro Cuore, Rome, Italy
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Physician Practice Patterns for Performing Thoracentesis in Patients Taking Anticoagulant Medications. J Bronchology Interv Pulmonol 2020; 27:42-49. [PMID: 31436608 DOI: 10.1097/lbr.0000000000000614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients undergoing thoracentesis often have comorbid conditions or take medications that potentially put them at higher bleeding risk. Direct oral anticoagulant (DOAC) use has also increased significantly. There are no published guidelines or consensus on when to perform thoracentesis in patients on anticoagulants. Recent studies support the safety of a more liberal approach for thoracentesis among patients with coagulopathy. METHODS We conducted a survey to ascertain the practices of physicians regarding thoracentesis in patients with increased bleeding risk. The survey was administered to the email distribution lists of the American Association of Bronchology and Interventional Pulmonology and of the American Thoracic Society. RESULTS The survey was completed by 256 attending physicians. Most of them were general pulmonologists practicing at academic medical centers. Most of them would perform a thoracentesis in patients receiving acetylsalicylic acid or prophylactic doses of unfractionated heparin or low molecular weight heparin (96%, 89%, and 88%, respectively). Half of the respondents would perform a thoracentesis in patients on antiplatelet medications (clopidogrel and ticagrelor, 51%; ticlopidine, 53%). A minority would perform thoracentesis in patients on direct oral anticoagulants or infused thrombin inhibitors (19% and 12%, respectively). The only subgroup that had a higher proclivity for performing thoracentesis without holding medications were attending physicians practicing for under 10 years. Relative to noninterventional pulmonologists, there were no significant differences in the responses of interventional pulmonologists. CONCLUSION There was variation in the practice patterns of attending physicians in performing thoracentesis in patients with elevated bleeding risk. Further data and guidelines regarding the safety of thoracentesis in these patients are needed.
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Life Is Really Simple, but We Insist on Making It Complicated-Lessons From Confucius on Ultrasound Use in the ICU. Crit Care Med 2020; 48:e81. [PMID: 31833995 DOI: 10.1097/ccm.0000000000004019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sagar AES, Landaeta MF, Adrianza AM, Aldana GL, Pozo L, Armas-Villalba A, Toquica CC, Larson AJ, Vial MR, Grosu HB, Ost DE, Eapen GA, Sheshadri A, Morice RC, Shannon VR, Bashoura L, Balachandran DD, Almeida FA, Uzbeck MH, Casal RF, Faiz SA, Jimenez CA. Complications following symptom-limited thoracentesis using suction. Eur Respir J 2020; 56:13993003.02356-2019. [DOI: 10.1183/13993003.02356-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/27/2020] [Indexed: 11/05/2022]
Abstract
BackgroundThoracentesis using suction is perceived to have increased risk of complications, including pneumothorax and re-expansion pulmonary oedema (REPO). Current guidelines recommend limiting drainage to 1.5 L to avoid REPO. Our purpose was to examine the incidence of complications with symptom-limited drainage of pleural fluid using suction and identify risk factors for REPO.MethodsA retrospective cohort study of all adult patients who underwent symptom-limited thoracentesis using suction at our institution between January 1, 2004 and August 31, 2018 was performed, and a total of 10 344 thoracenteses were included.ResultsPleural fluid ≥1.5 L was removed in 19% of the procedures. Thoracentesis was stopped due to chest discomfort (39%), complete drainage of fluid (37%) and persistent cough (13%). Pneumothorax based on chest radiography was detected in 3.98%, but only 0.28% required intervention. The incidence of REPO was 0.08%. The incidence of REPO increased with Eastern Cooperative Oncology Group performance status (ECOG PS) ≥3 compounded with ≥1.5 L (0.04–0.54%; 95% CI 0.13–2.06 L). Thoracentesis in those with ipsilateral mediastinal shift did not increase complications, but less fluid was removed (p<0.01).ConclusionsSymptom-limited thoracentesis using suction is safe even with large volumes. Pneumothorax requiring intervention and REPO are both rare. There were no increased procedural complications in those with ipsilateral mediastinal shift. REPO increased with poor ECOG PS and drainage ≥1.5 L. Symptom-limited drainage using suction without pleural manometry is safe.
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Zheng M, Kang Y, Wang T, Wei J. Cardiac tamponade complicating thoracentesis in a patient after left pneumonectomy: A case report. Medicine (Baltimore) 2020; 99:e19778. [PMID: 32282740 PMCID: PMC7220478 DOI: 10.1097/md.0000000000019778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Therapeutic or diagnostic thoracentesis is widely used in different clinical settings. Cardiac injury, a rare complication, could lead to fatal consequences. We describe a case of cardiac tamponade complicating thoracentesis that was recognized and rescued in a timely manner. PATIENT CONCERNS A 42-year-old woman underwent blind thoracentesis due to excessive left pleural effusion after left pneumonectomy surgery. She suddenly lost consciousness and was in a state of shock a few minutes after needle insertion and fluid drainage. DIAGNOSIS Bedside transthoracic echocardiography revealed pericardial effusion at a depth of 20 mm, and cardiac tamponade complicating thoracentesis was diagnosed. INTERVENTIONS After draining 250 mL of non-coagulated blood by pericardiocentesis under transthoracic echocardiography guidance, a tube was placed for continuous drainage over the subsequent 36 hours. OUTCOMES The patient's hemodynamic condition was stabilized hours after pericardiocentesis. The patient was discharged in good condition a few days later. LESSONS Imaging assessment and guidance in the process of thoracentesis was indispensable, especially in a patient with altered intra-thoracic anatomy. Cardiac damage, as a life-threatening complication, should be considered once hemodynamic instability occurs during the procedure.
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Reducing Iatrogenic Pneumothoraces: Using Real-Time Ultrasound Guidance for Pleural Procedures. Crit Care Med 2020; 47:903-909. [PMID: 30985389 DOI: 10.1097/ccm.0000000000003761] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Awareness of the impact of bedside ultrasound to reduce iatrogenic pneumothoraces while performing bedside pleural procedures has increased but with little understanding in how ultrasound is used for these procedures. DESIGN AND SETTING We conducted a retrospective chart review at a tertiary referral center in the United States from January 1, 2014, to March 31, 2017. Our study assessed adverse effect rates between real-time ultrasound-guided and ultrasound-marked thoracenteses and thoracostomy tube placements. PATIENTS Three-hundred ninety-four ICU patients were included in this study. MEASUREMENTS AND MAIN RESULTS There was a significant difference in the rate of adverse effects between real-time ultrasound-guided (0.63% [95% CI, 0.11-3.4%]) and ultrasound-marked (6.89% [95% CI, 4.15-11.24%]; p ≤ 0.01) procedures. More specifically, the rate of pneumothoraces was different between the two procedures (0.63% [95% CI, 0.11-3.4%] vs 4.43% [95% CI, 2.35-8.21%]; p = 0.02). In patients mechanically ventilated, there was a significant difference in overall adverse effect rates between groups of ultrasound use (p = 0.01). CONCLUSIONS The use of real-time ultrasound guidance was associated with a lower rate of iatrogenic pneumothoraces.
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