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Alcasid NJ, Banks KC, Jiang SF, Susai CJ, Hsu D, Carroway W, Williams K, Patel A, Ashiku S, Velotta JB. Are routine, daily chest radiographs (CXR) necessary following (VATS and RATS) lobectomies? Surg Open Sci 2024; 20:20-26. [PMID: 38873330 PMCID: PMC11169440 DOI: 10.1016/j.sopen.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
Background Consensus guidelines regarding the amount and necessity of post-operative imaging in thoracic surgery are lacking. The efficacy of daily chest radiographs (CXR) following video-assisted (VATS) and robotic-assisted (RATS) thoracoscopic surgery in directing management has not been previously studied. We hypothesize that abnormal clinical findings, rather than abnormal imaging findings, better predict post-operative complications in patients undergoing VATS/RATS lobectomies. Methods A retrospective review of VATS and RATS lobectomy patients were performed at a tertiary referral center from 1/1/2019-12/31/2021. Demographics, hospital course, and imaging were evaluated. Descriptive statistics, Chi-Square test, Fisher's exact, Wilcoxon rank sum, and multivariable logistic regression were performed. Our outcomes were post-operative complications requiring a procedure and extended length of stay (LOS) (>2 days post-operatively). Results Out of 362 VATS/RATS lobectomy patients, 15 patients had post-operative complications requiring a procedure. Almost all patients who required a procedure had abnormal clinical signs and symptoms (14/15; p < 0.001) while 70 % had expected post-operative day (POD) one CXR findings (11/15; p = 0.463). Multivariable logistic regression demonstrated clinical signs and symptoms independently predicted procedural requirement (odds ratio [OR] = 48, 95 % Confidence Interval [CI]:8.5-267) while abnormal POD one imaging did not. For extended LOS, a positive smoking history (OR = 4.4, 95 % CI:1.4-14.1), number of CXRs (OR = 2.4, 95 % CI:1.8-3.2) and thoracostomy tubes (OR = 5.3, 95 % CI:1.0-27.3) were independent predictors while clinical signs and symptoms was not. Conclusion Abnormal clinical findings may guide management more predictably than abnormal CXRs after VATS/RATS. Routine CXR in the post-operative setting may be unnecessary in those without clinical signs or symptoms. Key message There are no consensus guidelines regarding the efficacy of routine, post-operative diagnostic studies after major thoracic lobar resections. The presence of abnormal signs or symptoms after minimally invasive lobectomies may better predict those who will require additional procedures better than the presence of abnormal routine, post-operative chest radiographs.
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Affiliation(s)
- Nathan J. Alcasid
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Kian C. Banks
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Sheng-Fang Jiang
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
| | - Cynthia J. Susai
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Diana Hsu
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - William Carroway
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Kenneth Williams
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Ashish Patel
- Kaiser Permanente Northern California, Division of Thoracic Surgery, Department of Surgery, Oakland, CA, USA
| | - Simon Ashiku
- Kaiser Permanente Northern California, Division of Thoracic Surgery, Department of Surgery, Oakland, CA, USA
| | - Jeffrey B. Velotta
- Kaiser Permanente Northern California, Division of Thoracic Surgery, Department of Surgery, Oakland, CA, USA
- University of California, San Francisco, Department of Surgery, San Francisco, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Clinical Science, Pasadena, CA, USA
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Lobdell KW, Engelman DT. Chest Tube Management: Past, Present, and Future Directions for Developing Evidence-Based Best Practices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:41-48. [PMID: 36803288 DOI: 10.1177/15569845231153623] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
In the field of modern cardiothoracic surgery, chest drainage has become ubiquitous and yet characterized by a wide variation in practice. Meanwhile, the evolution of chest drain technology has created gaps in knowledge that represent opportunities for new research to support the development of best practices in chest drain management. The chest drain is an indispensable tool in the recovery of the cardiac surgery patient. However, decisions about chest drain management-including those about type, material, number, maintenance of patency, and the timing of removal-are largely driven by tradition due to a scarcity of quality evidence. This narrative review surveys the available evidence regarding chest-drain management practices with the objective of highlighting scientific gaps, unmet needs, and opportunities for further research.
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Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC, USA
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
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Esposito R, Conklin M, McGwin G, Gilbert SR. Do We Need Postoperative Chest Radiographs After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis? Spine Deform 2019; 7:571-576.e2. [PMID: 31202373 DOI: 10.1016/j.jspd.2018.09.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 09/19/2018] [Accepted: 09/23/2018] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN The question was addressed in three ways: (1) a query of Kids' Inpatient Database (KID) to obtain nationally representative data; (2) retrospective review of cases at a single institution; (3) survey of Scoliosis Research Society (SRS) spine surgeons. OBJECTIVES Evaluate the rate of immediate postoperative pulmonary complications, risk factors, and relevant surgeon practice patterns, to determine the usefulness of routine postoperative chest radiographs after posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Routine postoperative chest radiography after PSIF for AIS is performed in many institutions to evaluate for acute pulmonary complications, particularly pneumothorax (PTX). The incidence of pneumothorax and its effect on management is unknown. METHODS The frequency of PTX and surgical intervention were recorded. We evaluated associations between PTX and patient demographics or comorbidities, as well as survey respondent demographics and their practice patterns. RESULTS In the KID data sets, the risk of PTX after PSIF for AIS patients was 0.3% (30/9,036), with intervention required in 13.3% (4/30) of PTX-positive patients (0.04% of all cases). Review of cases at our institution revealed a PTX rate of 3.3% (8/244) by radiology report. No surgical intervention was required. Patients with PTX had, on average, an increased number of vertebrae fused (p = .012), a proximal thoracic scoliosis curve location (p = .009), and/or an intraoperative blood transfusion (p = .002). SRS respondents reported a PTX risk of 0.8% (87/11,318), and 32.2% (89/276) of respondents indicated routine use of postoperative chest radiographs. Of those, 46.1% (41/89) specified willingness to change practice patterns if provided evidence of low PTX rates. CONCLUSIONS Pneumothorax is uncommon after PSIF for AIS. The need for intervention is even less common. Routine postoperative chest radiographs are of questionable value after PSIF for AIS. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Robert Esposito
- School of Medicine, University of Alabama at Birmingham, 1720 2nd Ave. South, Birmingham, AL 35294, USA
| | - Michael Conklin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1720 2nd Ave. South, Birmingham, AL 35294, USA; Children's of Alabama, 1600 7th Ave. S., Birmingham, AL 35233, USA
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1720 2nd Ave. South, Birmingham, AL 35294, USA
| | - Shawn R Gilbert
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1720 2nd Ave. South, Birmingham, AL 35294, USA; Children's of Alabama, 1600 7th Ave. S., Birmingham, AL 35233, USA.
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Kröner A, Beenen L, du Raan M, Meijer P, Spronk PE, Stoker J, Hollmann MW, Schultz MJ. The clinical value of routinely obtained postoperative chest radiographs in post-anaesthesia care unit patients seems poor-a prospective observational study. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:360. [PMID: 30370287 DOI: 10.21037/atm.2018.08.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The clinical value of routinely obtained postoperative chest radiographs (CXRs) in post-anaesthesia care unit (PACU) patients is largely unknown. Methods To determine the diagnostic efficacy and treatment impact of postoperative routinely obtained CXRs in a university hospital PACU. Observational study collecting the expectations of attending physicians, the findings on routinely obtained CXRs and actions based on the findings on these CXRs in postoperative PACU patients. A 22-bed PACU in a university hospital in the Netherlands. Patients admitted to the PACU during a 9-month period. The analysis was restricted to CXRs routinely obtained during the first PACU admission, i.e., CXRs obtained during later admissions were excluded. Diagnostic efficacy, defined as the percentage of CXRs showing any unexpected major abnormality; treatment impact, defined as the percentage of CXRs showing an unexpected major abnormality that triggered a predefined change in therapy. Results The analysis included 294 postoperative CXRs. Of them 94 showed a new and unexpected predefined major abnormality (diagnostic efficacy of 35%). Of these 94 CXRs, only 10 triggered an intervention (treatment impact of 4%). Conclusions The diagnostic efficacy of routinely obtained postoperative CXRs in PACU patients is fair; the treatment impact seems low if we assume that all CXRs that showed an abnormality but were not followed by an intervention and did not require an intervention. Future research should focus on the safety and cost-effectiveness of abrogating routine postoperative CXRs.
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Affiliation(s)
- Anke Kröner
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Ludo Beenen
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Maretha du Raan
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter Meijer
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter E Spronk
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.,HERMES Critical Care Group, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,HERMES Critical Care Group, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Tonna JE, Kawamoto K, Presson AP, Zhang C, Mone MC, Glasgow RE, Barton RG, Hoidal JR, Anzai Y. Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes. J Crit Care 2018; 44:18-23. [PMID: 29024879 PMCID: PMC5831480 DOI: 10.1016/j.jcrc.2017.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/25/2017] [Accepted: 10/04/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE Studies suggest that "on-demand" radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied. MATERIALS AND METHODS This was a quasi-experimental, pre-post intervention study. Medical directors of two intervention ICUs requested pCXRs be ordered on an on-demand basis at one time point, without controlling or monitoring behavior or providing follow-up. RESULTS A total of 11,994 patient days over 18months were included. Combined characteristics: Age: 56.7, 66% male, 96% survival, APACHE II 14 (IQR: 11-19), mechanical ventilation (MV) (occurrences)/patient admission: mean 0.7 (SD: 0.6; range: 0-5), duration (hours) of MV: 21.7 (IQR: 9.8-81.4) and ICU LOS (days): 2.8 (IQR: 1.8-5.6). Average pCXR rate/patient/day before was 0.93 (95% CI: 0.89-0.96), and 0.73 (95% CI: 0.69-0.77) after. Controlling for severity, daily pCXR rate decreased by 21.7% (p<0.001), then increased by about 3%/month (p=0.044). There was no change in APACHE II, mortality, and occurrences or duration of MV, unplanned re-intubations, ICU LOS. CONCLUSIONS In critically ill adults, pCXR reduction can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic intervention, without adversely affecting patient care, outside a controlled study.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, United States; Division of Emergency Medicine, Department of Surgery, University of Utah, Salt Lake City, UT, United States.
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States.
| | - Angela P Presson
- Division of Epidemiology, University of Utah, Salt Lake City, UT, United States.
| | - Chong Zhang
- Division of Epidemiology, University of Utah, Salt Lake City, UT, United States.
| | - Mary C Mone
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, United States.
| | - Robert E Glasgow
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, United States.
| | - Richard G Barton
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, United States.
| | - John R Hoidal
- Department of Medicine, University of Utah, Salt Lake City, UT, United States.
| | - Yoshimi Anzai
- Department of Radiology, University of Utah, Salt Lake City, UT, United States.
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Salehi M, Saberi K, Rahmanian M, Bakhshandeh AR, Sharifi S. Assessment of limited chest x-ray technique in postcardiac surgery management. Ann Card Anaesth 2017; 20:38-41. [PMID: 28074793 PMCID: PMC5290692 DOI: 10.4103/0971-9784.197829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: The objective of this study is to investigate the safety of elimination of chest radiography in the postcardiac surgery Intensive Care Unit (ICU). Methods and Design: We compared patients in two different groups of routine CXR (RCXR) and limited CXR (LCXR) and their diagnostic and therapeutic outcome in a University hospital-based single center from 2014 to 2016. 3 CXR in the RCXR group and 1 CXR in the limited group was performed, in addition to on-demand criteria. Measurement and Main Results: A total of 978 samples were acceptable for analysis which 55.21% of RCXR and 59.50% of LCXR were male patients. In total, 523 abnormalities in RCXR group and 154 occasions in LCXR group resulted in 26.73% diagnostic efficacy for RCXRs and 28.57% for LCXR. From 1956 CXR that was taken in RCXR group, 72 occasions required intervention (3.68%) and 84 cases out of 539 (15.58%) LCXR needed an action to therapy. This means a 14.40% in RCXRs’ abnormalities and 56.00% of LCXRs’ abnormalities were accompanied with some interventions. Conclusions: Abolishing routine CXR in the ICUs would not be harmful for the patients, and it can be managed based on their clinical status and other safer imaging techniques.
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Affiliation(s)
- Mehrdad Salehi
- Department of Cardiac Surgery, Imam Khomeini Medical and Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kianoush Saberi
- Department of Anesthesiology, Imam Khomeini Medical and Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrzad Rahmanian
- Department of Cardiac Surgery, Imam Khomeini Medical and Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Reza Bakhshandeh
- Department of Cardiac Surgery, Imam Khomeini Medical and Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahnaz Sharifi
- Nursery Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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