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Sekimoto Y, Kohmaru M, Okuma T, Tajima M, Sekiya M. Subcutaneous and muscle layer seroma complicated with thoracentesis. Respirol Case Rep 2023; 11:e01100. [PMID: 36844791 PMCID: PMC9947521 DOI: 10.1002/rcr2.1100] [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: 12/02/2022] [Accepted: 01/29/2023] [Indexed: 02/25/2023] Open
Abstract
Diagnostic thoracentesis is a basic and relatively safe diagnostic method for patients with pleural effusion. However, complications of thoracentesis are rare and not well known because of the low incidence. Herein, we report a case of subcutaneous and muscle layer seroma following thoracentesis.
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Affiliation(s)
- Yasuhito Sekimoto
- Department of Respiratory MedicineSaitama Saiseikai Kawaguchi General HospitalKawaguchiJapan
| | - Makiko Kohmaru
- Department of Respiratory MedicineSaitama Saiseikai Kawaguchi General HospitalKawaguchiJapan
| | - Tomoko Okuma
- Department of Respiratory MedicineSaitama Saiseikai Kawaguchi General HospitalKawaguchiJapan
| | - Manabu Tajima
- Department of Respiratory MedicineSaitama Saiseikai Kawaguchi General HospitalKawaguchiJapan
| | - Mitsuaki Sekiya
- Department of Respiratory MedicineSaitama Saiseikai Kawaguchi General HospitalKawaguchiJapan
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2
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Park BC, Mallemat H. Special Procedures for Pulmonary Disease in the Emergency Department. Emerg Med Clin North Am 2022; 40:583-602. [PMID: 35953218 DOI: 10.1016/j.emc.2022.05.009] [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: 11/29/2022]
Abstract
In the emergency department, there are infrequent but essential procedures related to pulmonary diseases that emergency physicians must be able to perform. These include thoracentesis, chest tube thoracostomy, tracheostomy manipulation, and fiberoptic intubation.
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Affiliation(s)
- Brian C Park
- Critical Care Medicine Program, Cooper Medical School of Rowan University, Cooper University Hospital, 1 Cooper Plaza, Dorrance 4th Floor, Suite D427, Camden, NJ 08103, USA.
| | - Haney Mallemat
- Emergency Medicine/Critical Care Medicine Program, Cooper Medical School of Rowan University, Cooper University Hospital, 1 Cooper Plaza, Dorrance 4th Floor, Suite D427, Camden, NJ 08103, USA. https://twitter.com/CritCareNow
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3
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Misura T, Drakopoulos D, Mitrakovic M, Loennfors T, Primetis E, Hoppe H, Obmann VC, Huber AT, Ebner L, Christe A. Avoiding the Intercostal Arteries in Percutaneous Thoracic Interventions. J Vasc Interv Radiol 2022; 33:416-419.e2. [DOI: 10.1016/j.jvir.2021.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022] Open
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Williams JG, Lerner AD. Managing complications of pleural procedures. J Thorac Dis 2021; 13:5242-5250. [PMID: 34527363 PMCID: PMC8411187 DOI: 10.21037/jtd-2019-ipicu-04] [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: 01/18/2020] [Accepted: 04/29/2020] [Indexed: 11/06/2022]
Abstract
Pleural disease is common and often requires procedural intervention. Given this prevalence, pleural procedures are performed by a wide range of providers with varying skill level in both medical and surgical specialties. Even though the overall complication rate of pleural procedures is low, the proximity to vital organs and blood vessels can lead to serious complications which if left unrecognized can be life threatening. As a result, it is of the utmost importance for the provider to have a firm grasp of the local anatomy both conceptually when preparing for the procedure and physically, via physical exam and the use of a real time imaging modality such as ultrasound, when performing the procedure. With this in mind, anyone who wishes to safely perform pleural procedures should be able to appropriately anticipate, quickly identify, and efficiently manage any potential complication including not only those seen with many procedures such as pain, bleeding, and infection but also those specific to procedures performed in the thorax such as pneumothorax, re-expansional pulmonary edema, and regional organ injury. In this article, we will review the basic approach to most pleural procedures along with essential local anatomy most often encountered during these procedures. This will lay the foundation for the remainder of the article where we will discuss clinical manifestations and management of various pleural procedure complications.
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Affiliation(s)
- John G Williams
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew D Lerner
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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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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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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7
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An 87-Year-Old Man With Progressive Breathlessness and a Complex Chest CT Scan. Chest 2020; 158:e51-e54. [PMID: 32654741 DOI: 10.1016/j.chest.2019.08.2212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/29/2019] [Indexed: 11/22/2022] Open
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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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Rodriguez Lima DR, Yepes AF, Birchenall Jiménez CI, Mercado Díaz MA, Pinilla Rojas DI. Real-time ultrasound-guided thoracentesis in the intensive care unit: prevalence of mechanical complications. Ultrasound J 2020; 12:25. [PMID: 32337606 PMCID: PMC7184066 DOI: 10.1186/s13089-020-00172-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/16/2020] [Indexed: 12/29/2022] Open
Abstract
Background The use of thoracic ultrasound during thoracentesis reduces complications. The aim of this study was to determine the prevalence of complications for real-time ultrasound-guided thoracentesis performed by intensivists. As a secondary objective, the change in oxygenation before and after the procedure was evaluated. Patients and methods An observational prospective study was conducted. A total of 81 cases of real-time ultrasound-guided thoracentesis performed by intensivists in the intensive care unit (ICU) of Méderi Major University Hospital, Bogotá, Colombia, between August 2018 and August 2019 were analyzed. Thoracentesis performed by interventional radiologists and using techniques different from the focus of this study were excluded from the analysis. Results There was one pneumothorax, for a prevalence rate of mechanical complications in this population of 1.2%. The mean partial oxygen pressure to inspired oxygen fraction ratio (PaO2/FiO2) prior to the procedure was 198.1 (95% CI 184.75–211.45), with a PaO2/FiO2 after the procedure of 224.6 (95% CI 213.08–226.12) (p < 0.05). Conclusions Real-time ultrasound-guided thoracentesis performed by intensivists is a safe procedure and leads to a significant improvement in oxygenation rates. Future studies are required to determine the impact of these results on other outcomes, such as mortality, ICU stay, and days of mechanical ventilation.
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Affiliation(s)
- David Rene Rodriguez Lima
- Emergency Medicine and Critical and Intensive Care Medicine, Hospital Universitario Mayor Méderi-Universidad del Rosario, Bogotá, Colombia.
| | - Andrés Felipe Yepes
- Critical and Intensive Care Medicine, Hospital Universitario Mayor Méderi-Universidad del Rosario, Bogotá, Colombia
| | | | - Mario Andrés Mercado Díaz
- Critical and Intensive Care Medicine, Hospital Universitario Mayor Méderi-Universidad del Rosario, Bogotá, Colombia
| | - Darío Isaías Pinilla Rojas
- Critical and Intensive Care Medicine, Hospital Universitario Mayor Méderi-Universidad del Rosario, Bogotá, Colombia
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Shechtman L, Shrem M, Kleinbaum Y, Bornstein G, Gilad L, Grossman C. Incidence and risk factors of pneumothorax following pre-procedural ultrasound-guided thoracentesis. J Thorac Dis 2020; 12:942-948. [PMID: 32274162 PMCID: PMC7138967 DOI: 10.21037/jtd.2019.12.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Data regarding the incidence and risk factors of pneumothorax following pre-procedural ultrasound (US)-guided thoracentesis is scarce. We aimed to evaluate the incidence and risk factors of pneumothorax following pre-procedural US-guided thoracentesis in a tertiary medical center. Methods Retrospective analysis of patients who underwent pre-procedural US-guided thoracentesis in Sheba Medical Center between January 2016 and December 2018. Data collected included incidence of pneumothorax following thoracentesis, baseline clinical and demographic characteristics, and thoracentesis-associated factors. Outcomes evaluated included length of hospital stay, mortality, chest tube insertion and intensive care unit admission. Results A total of 550 patients with pleural effusions underwent pre-procedural US-guided thoracentesis. Sixty-six (12%) of them developed pneumothorax. Compared to patients who did not develop pneumothorax, those who developed pneumothorax had a higher rate of congestive heart failure (32.2% vs. 47%, P=0.026), a smaller depth of pleural fluid marking (3.4 vs. 3.2 cm, P=0.024), a larger amount of pleural fluid drained (1,093 vs. 903.5 mL, P=0.01), and were more likely to undergo bilateral procedures (7.6% vs. 2.3%, P=0.044). In the multivariate regression analysis, volume of pleural fluid drained was significantly associated with the development of pneumothorax (OR, 1.001, 95% CI, 1–1.001; P=0.042). Conclusions The incidence of pneumothorax following pre-procedural US-guided thoracentesis was relatively high in the present study. The amount of pleural fluid drained was the main factor associated with the risk of developing pneumothorax in these cases.
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Affiliation(s)
- Liran Shechtman
- Department of Internal Medicine F, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Maayan Shrem
- Department of Internal Medicine F, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yeruham Kleinbaum
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Gil Bornstein
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Lee Gilad
- Department of Internal Medicine F, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Chagai Grossman
- Department of Internal Medicine F, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Safety and Tolerability of Vacuum Versus Manual Drainage During Thoracentesis: A Randomized Trial. J Bronchology Interv Pulmonol 2020; 26:166-171. [PMID: 30433893 DOI: 10.1097/lbr.0000000000000556] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pleural effusions may be aspirated manually or via vacuum during thoracentesis. This study compares the safety, pain level, and time involved in these techniques. METHODS We randomized 100 patients receiving ultrasound-guided unilateral thoracentesis in an academic medical center from December 2015 through September 2017 to either vacuum or manual drainage. Without using pleural manometry, the effusion was drained completely or until the development of refractory symptoms. Measurements included self-reported pain before and during the procedure (from 0 to 10), time for completion of drainage, and volume removed. Primary outcomes were rates of all-cause complications and of early termination of the procedure with secondary outcomes of change in pain score, drainage time, volume removed, and inverse rate of removal. RESULTS Patient characteristics in the manual (n=49) and vacuum (n=51) groups were similar. Rate of all-cause complications was higher in the vacuum group (5 vs. 0; P=0.03): pneumothorax (n=3), surgically treated hemothorax with subsequent death (n=1) and reexpansion pulmonary edema causing respiratory failure (n=1), as was rate of early termination (8 vs. 1; P=0.018). The vacuum group exhibited greater pain during drainage (P<0.05), shorter drainage time (P<0.01), no association with volume removed (P>0.05), and lower inverse rate of removal (P≤0.01). CONCLUSION Despite requiring less time, vacuum aspiration during thoracentesis was associated with higher rates of complication and of early termination of the procedure and greater pain. Although larger studies are needed, this pilot study suggests that manual aspiration provides greater safety and patient comfort.
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Farinas Lugo D, Chalasani P, Del Calvo V. Left ventricular puncture during thoracentesis. BMJ Case Rep 2019; 12:12/4/e227613. [PMID: 30967447 DOI: 10.1136/bcr-2018-227613] [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: 11/04/2022] Open
Abstract
Left ventricular puncture during a thoracentesis is a rare and unusual complication that has yet to be reported. We report a case in which a 74-year-old woman with dilated ischaemic heart disease suffered from puncture of the left ventricle during a routine ultrasound-guided thoracentesis despite following the recommended protocol and procedures. She became haemodynamically unstable and underwent an emergent thoracotomy for removal of the catheter and repair of the left ventricular wall.
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Affiliation(s)
- Daniel Farinas Lugo
- Department of Cardiology, College of Medicine, Florida State University, Tallahassee, Florida, USA
| | - Prasad Chalasani
- Department of Cardiology, College of Medicine, Florida State University, Tallahassee, Florida, USA
| | - Veronica Del Calvo
- Department of Cardiology, College of Medicine, Florida State University, Tallahassee, Florida, USA
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Vetrugno L, Bignami E, Orso D, Vargas M, Guadagnin GM, Saglietti F, Servillo G, Volpicelli G, Navalesi P, Bove T. Utility of pleural effusion drainage in the ICU: An updated systematic review and META-analysis. J Crit Care 2019; 52:22-32. [PMID: 30951925 DOI: 10.1016/j.jcrc.2019.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE The effects on the respiratory or hemodynamic function of drainage of pleural effusion on critically ill patients are not completely understood. First outcome was to evaluate the PiO2/FiO2 (P/F) ratio before and after pleural drainage. SECONDARY OUTCOMES evaluation of A-a gradient, End-Expiratory lung volume (EELV), heart rate (HR), mean arterial pressure (mAP), left ventricular end-diastolic volume (LVEDV), stroke volume (SV), cardiac output (CO), ejection fraction (EF), and E/A waves ratio (E/A). A tertiary outcome: evaluation of pneumothorax and hemothorax complications. MATERIALS AND METHODS Searches were performed on MEDLINE, EMBASE, COCHRANE LIBRARY, SCOPUS and WEB OF SCIENCE databases from inception to June 2018 (PROSPERO CRD42018105794). RESULTS We included 31 studies (2265 patients). Pleural drainage improved the P/F ratio (SMD: -0.668; CI: -0.947-0.389; p < .001), EELV (SMD: -0.615; CI: -1.102-0.219; p = .013), but not A-a gradient (SMD: 0.218; CI: -0.273-0.710; p = .384). HR, mAP, LVEDV, SV, CO, E/A and EF were not affected. The risks of pneumothorax (proportion: 0.008; CI: 0.002-0.014; p = .138) and hemothorax (proportion: 0.006; CI: 0.001-0.011; p = .962) were negligible. CONCLUSIONS Pleural effusion drainage improves oxygenation of critically ill patients. It is a safe procedure. Further studies are needed to assess the hemodynamic effects of pleural drainage.
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Affiliation(s)
- Luigi Vetrugno
- Division of Anesthesia and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100 Udine, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126 Parma, Italy
| | - Daniele Orso
- Division of Anesthesia and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100 Udine, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Giovanni M Guadagnin
- Division of Anesthesia and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100 Udine, Italy
| | - Francesco Saglietti
- University of Milan-Bicocca, School of Medicine and Surgery, Via Cadore 48, 20900 Monza, MB, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Orbassano, Torino, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Tiziana Bove
- Division of Anesthesia and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100 Udine, Italy
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Affiliation(s)
- Michael J Lenaeus
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA.
| | - Amanda Shepard
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Andrew A White
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
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15
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Sabath B, Hakim R, Yung R. An 87-Year-Old Woman With Pleural Effusion and Tortuous Aorta. Chest 2018; 151:e21-e24. [PMID: 28183499 DOI: 10.1016/j.chest.2016.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/20/2016] [Accepted: 05/07/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- Bruce Sabath
- Pulmonary and Critical Care Division, Greater Baltimore Medical Center, Baltimore, MD.
| | - Rimoun Hakim
- Pulmonary and Critical Care Division, Greater Baltimore Medical Center, Baltimore, MD
| | - Rex Yung
- Pulmonary and Critical Care Division, Greater Baltimore Medical Center, Baltimore, MD
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Abstract
Over the last decade there has been increasing interest and enthusiasm in point-of-care ultrasound (POCUS) as an aide to traditional examination techniques in assessing acutely unwell adult patients. However, it currently remains the domain of a relatively small handful of physicians within the UK. There are numerous reasons for this, notably a lack of training pathways and supervisors but also a lack of understanding of the evidence base behind this imaging modality. This review article aims to explore some of the evidence base behind POCUS for a number of medical pathologies, and where possible compare it to evidenced traditional examination techniques. We discuss the issues around training in bedside ultrasound and recommend a push to integrate POCUS training into internal medicine curricula and support trainers to comprehensively deliver this.
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Thiam K, Berbis J, Laroumagne S, Guinde J, Chollet B, Dutau H, Touré NO, Astoul P. Diagnostic Accuracy of Lateral Decubitus Chest Radiography before Pleural Maneuvers for the Management of Pleurisies in the Era of Chest Ultrasound. Respiration 2018; 95:449-453. [PMID: 29723854 DOI: 10.1159/000487999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 02/26/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Chest ultrasound (CUS) is the gold standard to detect pleural adhesions before pleural maneuvers. However, the CUS technique is not available in all countries where the assessment is only based on clinical examination and chest radiography. OBJECTIVE To assess the value of lateral decubitus chest radiography (LDCR) to detect pleural adhesions. METHODS Consecutive patients with pleural effusions undergoing LCDR followed by medical thoracoscopy the day after were identified from an institutional database. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for LDCR were calculated. RESULTS Eighty-six patients were included in the study. The sensitivity, specificity, PPV, and NPV of LDCR for the presence of adhesions taking into account the shape of the horizontal level were 71.2% (56.7-82.5), 44.1% (27.6-61.9), 66.1% (52.1-77.8), and 50% (31.7-68.3), respectively. The accuracy to predict pleural adhesions for the sign "incomplete horizontal level" was 60.5 (49.3-70.7). The accuracy to predict pleural adhesions in case of irregular aspect of the horizontal level was 53.5 (42.5-64.2). CONCLUSIONS The accuracy of LDCR for the detection of pleural adhesions is low in patients with pleural effusion and LDCR is not sufficient before pleural maneuvers. This has to be taken into account in countries with a high prevalence of pleural tuberculosis which usually lead to loculated pleural effusions. CUS has to be urgently included in dedicated educational programs in these areas in order to decrease the complications related to unexpected pleural adhesions and achieve better planning for the management of pleural effusions.
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Affiliation(s)
- Khady Thiam
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Marseille, France.,Department of Pulmonology and Phthisiology, CHNU Fann, Dakar, Senegal
| | - Julie Berbis
- Aix-Marseille University, EA 3279, Public Health, Chronic Diseases and Quality of Life, Research Unit, Marseille, France
| | - Sophie Laroumagne
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Marseille, France.,G-Echo, French National Group for Chest Ultrasonography, Paris, France
| | - Julien Guinde
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Marseille, France
| | - Bertrand Chollet
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Marseille, France
| | - Hervé Dutau
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Marseille, France
| | | | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Marseille, France.,G-Echo, French National Group for Chest Ultrasonography, Paris, France.,Aix-Marseille University, Marseille, France
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Orlandi E, Citterio C, Seghini P, Di Nunzio C, Mordenti P, Cavanna L. Thoracentesis in advanced cancer patients with severe thrombocytopenia: Ultrasound guide improves safety and reduces bleeding risk. THE CLINICAL RESPIRATORY JOURNAL 2018; 12:1747-1752. [DOI: 10.1111/crj.12739] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Elena Orlandi
- Oncology‐Hematology DepartmentPiacenza Hospitalvia Taverna 49, 29121 Piacenza Italy
| | - Chiara Citterio
- Oncology‐Hematology DepartmentPiacenza Hospitalvia Taverna 49, 29121 Piacenza Italy
| | - Pietro Seghini
- Unit of Biostatistics and EpidemiologyPiacenza Hospitalvia Taverna 49, 29121 Piacenza Italy
| | - Camilla Di Nunzio
- Oncology‐Hematology DepartmentPiacenza Hospitalvia Taverna 49, 29121 Piacenza Italy
| | - Patrizia Mordenti
- Oncology‐Hematology DepartmentPiacenza Hospitalvia Taverna 49, 29121 Piacenza Italy
| | - Luigi Cavanna
- Oncology‐Hematology DepartmentPiacenza Hospitalvia Taverna 49, 29121 Piacenza Italy
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Abstract
Promoting patient safety and increasing health care quality have dominated the health care landscape during the last 15 years. Health care regulators and payers are now tying patient safety outcomes and best practices to hospital reimbursement. Many health care leaders are searching for new technologies that not only make health care for patients safer but also reduce overall health care costs. New advances in ultrasonography have made this technology available to health care providers at the patient's bedside. Point-of-care ultrasound assistance now aids providers with real-time diagnosis and with visualization for procedural guidance. This is especially true for common deep needle procedures such as central venous catheter insertion, thoracentesis, and paracentesis.There is now mounting evidence that clinician-performed point-of-care ultrasound improves patient safety, enhances health care quality, and reduces health care cost for deep needle procedures. Furthermore, the miniaturization, ease of use, and the evolving affordability of ultrasound have now made this technology widely available. The adoption of point-of-care ultrasonography has reached a tipping point and should be seriously considered the safety standard for all hospital-based deep needle procedures.
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20
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Complications of thoracentesis: incidence, risk factors, and strategies for prevention. Curr Opin Pulm Med 2017; 22:378-85. [PMID: 27093476 DOI: 10.1097/mcp.0000000000000285] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema. RECENT FINDINGS Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study. SUMMARY Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.
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21
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Wall suction-assisted image-guided thoracentesis: a safe alternative to evacuated bottles. Clin Radiol 2017; 72:898.e1-898.e5. [DOI: 10.1016/j.crad.2017.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/13/2017] [Accepted: 05/02/2017] [Indexed: 11/21/2022]
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22
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Cho HY, Ko BS, Choi HJ, Koh CY, Sohn CH, Seo DW, Lee YS, Lee JH, Oh BJ, Lim KS, Kim WY. Incidence and risk factors of iatrogenic pneumothorax after thoracentesis in emergency department settings. J Thorac Dis 2017; 9:3728-3734. [PMID: 29268380 DOI: 10.21037/jtd.2017.08.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background There is a lack of data regarding the incidence and associated factors of pneumothorax following thoracentesis conducted in emergency department (ED) settings. The present study aims to determine the incidence of pneumothorax following thoracentesis in ED settings and evaluate the association of specific demographics, clinical, and procedure factors with thoracentesis-related pneumothorax. Methods We retrospectively reviewed the medical records of 3,067 thoracentesis cases in the ED of a tertiary care, university-affiliated hospital between January 2009 and December 2014. To evaluate the factors associated with the occurrence of pneumothorax following thoracentesis, matched controls were used with a case to control ratio of 1:5. Results Of the 3,067 cases that received thoracentesis, 19 cases of pneumothorax were observed (0.62%). Patients with pneumothorax had significantly lower weight and body mass index (BMI) than those without pneumothorax (51.0 vs. 61.2 kg, 20.0 vs. 22.6; P<0.001, respectively). In the multivariate logistic regression analysis, being underweight, defined as a BMI of <18.5 [OR, 5.2 (95% CI, 1.3-21.2); P=0.021] was significantly associated with the occurrence of pneumothorax. Conclusions The incidence of pneumothorax following thoracentesis was very low in the present study. However, clinicians should be aware of the risk of pneumothorax in underweight patients during thoracentesis. Further prospective studies are required to clarify the results of the present study.
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Affiliation(s)
- Hyun Young Cho
- Department of Emergency Medicine, College of Medicine, Dankook University, Chungcheongnam-do, Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Han Joo Choi
- Department of Emergency Medicine, College of Medicine, Dankook University, Chungcheongnam-do, Korea
| | - Chan Young Koh
- Department of Emergency Medicine, College of Medicine, Dankook University, Chungcheongnam-do, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Woo Seo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yoon-Seon Lee
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Ho Lee
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Bum Jin Oh
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, College of Medicine, Dankook University, Chungcheongnam-do, Korea
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23
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Better With Ultrasound: Pleural Procedures in Critically Ill Patients. Chest 2017; 153:224-232. [PMID: 28736305 DOI: 10.1016/j.chest.2017.06.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/07/2017] [Accepted: 06/30/2017] [Indexed: 12/21/2022] Open
Abstract
Procedures designed to drain fluid or air from the pleural spaces can be technically challenging in patients who are critically ill, and are associated with significant complications. Many individual ultrasound techniques have been described, each with the goal of making pleural drainage procedures safer. This article presents a systemic approach for incorporating many of these tools into procedures such as diagnostic thoracentesis, therapeutic drainage, and pleural catheter insertion. A series of illustrative figures and narrated video presentations are included to demonstrate many of the described techniques.
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24
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Corcoran JP, Tazi-Mezalek R, Maldonado F, Yarmus LB, Annema JT, Koegelenberg CFN, St Noble V, Rahman NM. State of the art thoracic ultrasound: intervention and therapeutics. Thorax 2017; 72:840-849. [PMID: 28411248 DOI: 10.1136/thoraxjnl-2016-209340] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 03/14/2017] [Accepted: 03/23/2017] [Indexed: 12/25/2022]
Abstract
The use of thoracic ultrasound outside the radiology department and in everyday clinical practice is becoming increasingly common, having been incorporated into standards of care for many specialties. For the majority of practitioners, their experience of, and exposure to, thoracic ultrasound will be in its use as an adjunct to pleural and thoracic interventions, owing to the widely recognised benefits for patient safety and risk reduction. However, as clinicians become increasingly familiar with the capabilities of thoracic ultrasound, new directions for its use are being sought which might enhance practice and patient care. This article reviews the ways in which the advent of thoracic ultrasound is changing the approach to the investigation and treatment of respiratory disease from an interventional perspective. This will include the impact of thoracic ultrasound on areas including patient safety, diagnostic and therapeutic procedures, and outcome prediction; and will also consider potential future research and clinical directions.
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Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - Rachid Tazi-Mezalek
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care Medicine, John Hopkins University, Baltimore, Maryland, USA
| | - Jouke T Annema
- Department of Pulmonology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa.,Tygerberg Academic Hospital, Cape Town, South Africa
| | - Victoria St Noble
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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25
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Wilson MM, Irwin RS. Thoracentesis in Medical ICU Patients: When is “Safe” Really “Safe Enough”? J Intensive Care Med 2016. [DOI: 10.1177/088506669801300302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Mark M. Wilson
- University of Massachusetts Medical School, Worcester, MA
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26
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Abstract
The objective of this study was to determine the safety and value of thoracentesis in an ICU, Thoracentesis is a safe procedure for critically ill patients, even those on mechanical ventilators, and usually confirms the suspected diagnosis. However, thoracentesis revealed an unexpected diagnosis that changed management in 12% of patients. Repeat or contralateral thoracentesis is indicated when either the clinical course is inconsistent or may represent a complication of the original diagnosis.
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Affiliation(s)
- Gregory P. Le Mense
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Steven A. Sahn
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
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27
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Abstract
Pleural effusions are common and account for high morbidity and mortality in a range of patients. Thoracentesis can provide significant symptom relief and improvement in physiologic parameters including dyspnea, exercise, and sleep. Recent advances, including the use of ultrasound and dedicated procedural teams, have improved the safety of thoracentesis. This has allowed thoracentesis to be performed on higher-risk individuals including those with elevated bleeding risk and bilateral pleural effusions. This review will summarize recent advances in thoracentesis procedural safety, symptom relief following thoracentesis, and understanding of the physiologic basis for such improvements.
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Affiliation(s)
- Erin M. DeBiasi
- Department of Pulmonary and Critical Care Medicine, Yale University, New Haven, CT, USA
| | - Jonathan Puchalski
- Department of Pulmonary and Critical Care Medicine, Yale University, New Haven, CT, USA
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28
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Dangers L, Similowski T, Chenivesse C. Gestes pleuraux sous antiagrégants plaquettaires : une enquête d’opinion. Rev Mal Respir 2016; 33:41-6. [DOI: 10.1016/j.rmr.2015.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/20/2015] [Indexed: 11/17/2022]
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29
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Corcoran JP, Psallidas I, Wrightson JM, Hallifax RJ, Rahman NM. Pleural procedural complications: prevention and management. J Thorac Dis 2015; 7:1058-67. [PMID: 26150919 PMCID: PMC4466427 DOI: 10.3978/j.issn.2072-1439.2015.04.42] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/08/2015] [Indexed: 12/11/2022]
Abstract
Pleural disease is common with a rising case frequency. Many of these patients will be symptomatic and require diagnostic and/or therapeutic procedures. Patients with pleural disease present to a number of different medical specialties, and an equally broad range of clinicians are therefore required to have practical knowledge of these procedures. There is often underestimation of the morbidity and mortality associated with pleural interventions, even those regarded as being relatively straightforward, with potentially significant implications for processes relating to patient safety and informed consent. The advent of thoracic ultrasound (TUS) has had a major influence on patient safety and the number of physicians with the necessary skill set to perform pleural procedures. As the variety and complexity of pleural interventions increases, there is increasing recognition that early specialist input can reduce the risk of complications and number of procedures a patient requires. This review looks at the means by which complications of pleural procedures arise, along with how they can be managed or ideally prevented.
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30
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Embolización de arterias intercostales en un hemotórax iatrogénico. Cir Esp 2015; 93:340-1. [DOI: 10.1016/j.ciresp.2014.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 01/09/2014] [Accepted: 01/25/2014] [Indexed: 01/13/2023]
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31
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Anjum S, Tahir R, Pathan SA. Nontuberculous mycobacterial infection presenting as empyema and life threatening pneumothorax: A challenging situation in the emergency department. Qatar Med J 2015; 2015:8. [PMID: 26535176 PMCID: PMC4614334 DOI: 10.5339/qmj.2015.8] [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: 02/11/2015] [Accepted: 05/07/2015] [Indexed: 11/23/2022] Open
Abstract
Nontuberculous mycobacterial infection in an immunocompetent young patient complicated with empyema and pneumothorax is rarely reported. A 36-year-old man presented to the emergency department with a history of worsening dyspnea and pleuritic chest pain. The patient had unstable vital signs on presentation, and was referred to the resuscitation area on a monitored bed. The patient had a chest x-ray (CXR) performed on a prior occasion at a primary health clinic, revealing pneumothorax and some fluid at the left costophrenic angle. On arrival at the hospital, bedside ultrasound was performed which confirmed the diagnosis of pneumothorax. His vital signs were pulse 153, BP 88/62, RR 50 breaths per minute and his oxygen saturation on air was 92%. Tension pneumothorax was diagnosed based on clinical presentation and given vital signs. It was managed immediately with needle decompression followed by chest tube insertion. The patient improved dramatically after needle decompression with stabilization of vital signs. A CXR was repeated post-needle decompression which showed an incompletely resolved pneumothorax with an increase in the size of the effusion. Iatrogenic haemothorax was a possible explanation for this increase in effusion size. Chest tube was successfully inserted in the fourth intercostal space just anterior to the midaxillary line under full aseptic precautions. The chest tube drained 1.4 liters of blood, which on analysis showed a low pH and elevated adenosine deaminase level. Two out of three sputum samples sent from the medical ward were positive for mycobacteria other than tuberculosis as confirmed on culture. The patient's symptoms improved with percutaneous tube drainage of hemopneumothorax and antituberculous medications.
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Affiliation(s)
- Shahzad Anjum
- Accident and Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ramsha Tahir
- Accident and Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Sameer A. Pathan
- Accident and Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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32
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Abstract
PURPOSE OF REVIEW Thoracentesis is a commonly performed procedure throughout the world. Convention dictates that patients should have laboratory values such as international normalized ratio (INR) and platelets corrected or medications that affect bleeding withheld prior to performing this procedure. By transfusing blood products or withholding medications, patients are exposed to risks that are different than but equally if not more significant than the risk of hemothorax from thoracentesis. This review highlights recent studies that suggest the parameters of performing thoracentesis should be less stringent than traditionally thought. RECENT FINDINGS Although the safety of thoracentesis has improved with the use of ultrasound and other advancements, the number of patients on new medications that exert an influence on bleeding and those who have physiologic coagulation abnormalities continues to grow. Despite a 1991 study demonstrating the safety of thoracentesis in patients with an abnormal INR or low platelet count, transfusion of blood products to normalize laboratory values is commonplace. A number of studies within the past year address the safety of thoracentesis amidst INR and platelet abnormalities and in patients taking antiplatelet or other medications that affect a patient's bleeding potential. SUMMARY Although large randomized studies do not exist, recent literature suggests that it is time to reevaluate the need to correct INR and platelet counts or to transfuse blood products or withhold medications prior to thoracentesis in patients felt to have a risk of possible bleeding.
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33
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Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax. J Trauma Acute Care Surg 2014; 76:1029-34. [PMID: 24662868 DOI: 10.1097/ta.0000000000000158] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Five-centimeter needles at the second intercostal space midclavicular line (2MCL) have high failure rates for decompression of tension pneumothorax. This study evaluates 8-cm needles directed at the fourth intercostal space anterior axillary line (4AAL). METHODS Retrospective radiographic analysis of 100 consecutive trauma patients 18 years or older from January to September 2011. Measurements of chest wall thickness (CWT) and depth to vital structure (DVS) were obtained at 2MCL and 4AAL. 4AAL measurements were taken based on two angles: closest vital structure and perpendicular to the chest wall. Primary outcome measures were radiographic decompression (RD) (defined as CWT < 80 mm) and radiographic noninjury (RNI) (DVS > 80 mm) of 8-cm needles at 4AAL. Secondary outcome measures are effect of angle of entry on RNI at 4AAL, RD and RNI of 8-cm needles at 2MCL, and comparison of 5-cm needles with 8-cm needles at both locations. RESULTS Eighty-four percent of the patients were male, with mean Injury Severity Score (ISS) of 17.7 (range, 1.0-66.0) and body mass index of 26.8 (16.5-48.4). Mean CWT at 4AAL ranged from 37.6 mm to 39.9 mm, significantly thinner than mean CWT at 2MCL (43.3-46.7 mm). Eight-centimeter needle RD was more than 96% at both 4AAL and 2MCL. Five-centimeter RD ranged from 66% to 81% at all sites. Mean DVS at 4AAL ranged from 91.8 mm to 128.0 mm. RNI at all sites was more than 91% except at left 4AAL, when taken to the closest vital structure (mean DVS, 91.8 mm), with 68% RNI. Perpendicular entry increased DVS to 109.4 mm and subsequent RNI to 91%. Five-centimeter RNI at all sites was more than 99%. CONCLUSION CWT at 4AAL is significantly thinner than 2MCL. Based on radiographic measurements, 8-cm catheters have a higher chance of pleural decompression when compared with 5-cm catheters. Steeper angle of entry at 4AAL improves 8-cm noninjury rates to more than 91%. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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34
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Corbett RW, Ashby DR. Complication of diagnostic pleural aspiration: is it of value in hemodialysis patients? Hemodial Int 2014; 18:546-50. [PMID: 24393436 DOI: 10.1111/hdi.12130] [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: 11/30/2022]
Abstract
Pleural effusions are common in hemodialysis patients and are associated with significant morbidity. Diagnostic pleural aspiration and subsequent biochemical analysis can be used to differentiate exudates and transudates. In particular, Light's criteria have been validated in the general population although their efficacy in hemodialysis patients is unclear. Furthermore, aspiration is not without risk; we report the case of a life-threatening thoracic bleed as a complication of diagnostic thoracocentesis in a hemodialysis patient, in whom a transudative effusion was misclassified according to Light's criteria. Retrospective examination of a further 22 aspirations in hemodialysis patients suggests that biochemical analysis of pleural fluid in this group is of limited value. Careful clinical and radiological assessment may be of greater value in determining individuals who may benefit from formal drainage, rather than diagnostic aspiration with its attendant risks.
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Affiliation(s)
- Richard W Corbett
- Imperial College and Renal Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
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35
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Letheulle J, Tattevin P, Saunders L, Kerjouan M, Léna H, Desrues B, Le Tulzo Y, Jouneau S. Iterative thoracentesis as first-line treatment of complicated parapneumonic effusion. PLoS One 2014; 9:e84788. [PMID: 24400113 PMCID: PMC3882258 DOI: 10.1371/journal.pone.0084788] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 11/26/2013] [Indexed: 11/19/2022] Open
Abstract
Rationale Optimal management of complicated parapneumonic effusions (CPPE) remains controversial. Objectives to assess safety and efficacy of iterative therapeutic thoracentesis (ITTC), the first-line treatment of CPPE in Rennes University Hospital. Methods Patients with CPPE were identified through our computerized database. We retrospectively studied all cases of CPPE initially managed with ITTC in our institution between 2001 and 2010. ITTC failure was defined by the need for additional treatment (i.e. surgery or percutaneous drainage), or death. Results Seventy-nine consecutive patients were included. The success rate was 81% (n = 64). Only 3 patients (4%) were referred to thoracic surgery. The one-year survival rate was 88%. On multivariate analysis, microorganisms observed in pleural fluid after Gram staining and first thoracentesis volume ≥450 mL were associated with ITTC failure with adjusted odds-ratios of 7.65 [95% CI, 1.44–40.67] and 6.97 [95% CI, 1.86–26.07], respectively. The main complications of ITTC were iatrogenic pneumothorax (n = 5, 6%) and vasovagal reactions (n = 3, 4%). None of the pneumothoraces required chest tube drainage, and no hemothorax or re-expansion pulmonary edema was observed. Conclusions Although not indicated in international recommendations, ITTC is safe and effective as first-line treatment of CPPE, with limited invasiveness.
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Affiliation(s)
- Julien Letheulle
- Respiratory medicine department, Pontchaillou Hospital, Rennes 1 University, Rennes, France
- Infectious diseases and intensive care unit, Pontchaillou Hospital, Rennes 1 University, Rennes, France
| | - Pierre Tattevin
- Infectious diseases and intensive care unit, Pontchaillou Hospital, Rennes 1 University, Rennes, France
- INSERM U835, Rennes 1 University, Rennes, France
| | - Lauren Saunders
- Department of medical information, Pontchaillou Hospital, Rennes 1 University, Rennes, France
| | - Mallorie Kerjouan
- Respiratory medicine department, Pontchaillou Hospital, Rennes 1 University, Rennes, France
| | - Hervé Léna
- Respiratory medicine department, Pontchaillou Hospital, Rennes 1 University, Rennes, France
| | - Benoit Desrues
- Respiratory medicine department, Pontchaillou Hospital, Rennes 1 University, Rennes, France
| | - Yves Le Tulzo
- Infectious diseases and intensive care unit, Pontchaillou Hospital, Rennes 1 University, Rennes, France
- CIC –INSERM 0203Rennes 1 University, Rennes, France
| | - Stéphane Jouneau
- Respiratory medicine department, Pontchaillou Hospital, Rennes 1 University, Rennes, France
- IRSET U1085, Rennes 1 University, Rennes, France
- * E-mail:
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36
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Hemorrhagic Complications of Thoracentesis and Small-Bore Chest Tube Placement in Patients Taking Clopidogrel. Ann Am Thorac Soc 2014; 11:73-9. [DOI: 10.1513/annalsats.201303-050oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Hibbert RM, Atwell TD, Lekah A, Patel MD, Carter RE, McDonald JS, Rabatin JT. Safety of Ultrasound-Guided Thoracentesis in Patients With Abnormal Preprocedural Coagulation Parameters. Chest 2013; 144:456-463. [DOI: 10.1378/chest.12-2374] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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38
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Soldati G, Smargiassi A, Inchingolo R, Sher S, Valente S, Corbo GM. Ultrasound-guided pleural puncture in supine or recumbent lateral position - feasibility study. Multidiscip Respir Med 2013; 8:18. [PMID: 23497643 PMCID: PMC3605139 DOI: 10.1186/2049-6958-8-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 02/01/2013] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study is to evaluate feasibility, safety and efficacy of accessing the pleural space with the patient supine or in lateral recumbent position, under constant ultrasonic guidance along the costophrenic sinus. Methods All patients with pleural effusion, referred to thoracentesis or pleural drainage from February 2010 to January 2011 in two institutions, were drained either supine or in lateral recumbent position through an echomonitored cannulation of the costophrenic sinus. The technique is described in detail and an analysis of safety and feasibility is carried out. Results One hundred and one thoracenteses were performed on 76 patients and 30 pigtail catheters were inserted in 30 patients (for a total of 131 pleural procedures in 106 patients enrolled). The feasibility of the procedures was 100% and in every case it was possible to follow real time needle tip passage in the pleural space. Ninety eight thoracenteses (97%) and all catheter drainages were successfully completed. Four thoracenteses were stopped because of the appearance of complications while no pigtail drainage procedure was stopped. After 24 hour follow up, one chest pain syndrome (1.3% of completed thoracenteses) and two pneumothoraces (1.4%) occurred. The mean acquisition time of pleural space was 76 ± 9 seconds for thoracentesis and 185 ± 46 seconds for drainage insertion (p < 0.05). Conclusions This study highlights the safety and efficacy of this technique of real time echo-monitored pleural space puncture, that offers a more comfortable patient position, an easier approach for the operator, a very low rate of complications with short acquisition time of pleural space.
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Affiliation(s)
- Gino Soldati
- Pulmonary Medicine Department, University Hospital A, Gemelli, Rome, Italy.
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Berg D, Berg K, Riesenberg LA, Weber D, King D, Mealey K, Justice EM, Geffe K, Tinkoff G. The Development of a Validated Checklist for Thoracentesis. Am J Med Qual 2012; 28:220-6. [DOI: 10.1177/1062860612459881] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dale Berg
- Thomas Jefferson University, Philadelphia, PA
| | | | | | - Danielle Weber
- University of Cincinnati and Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Daniel King
- Ross University School of Medicine, Dominica
| | | | | | | | - Glen Tinkoff
- Thomas Jefferson University, Philadelphia, PA
- Christiana Care Health System, Newark, DE
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Abnormal preprocedural international normalized ratio and platelet counts are not associated with increased bleeding complications after ultrasound-guided thoracentesis. AJR Am J Roentgenol 2011; 197:W164-8. [PMID: 21700980 DOI: 10.2214/ajr.10.5589] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to identify differences in hemorrhagic complications after ultrasound-guided thoracentesis on the basis of patient coagulation parameters. MATERIALS AND METHODS The records of consecutive patients who underwent ultrasound-guided thoracentesis between January 1, 2008 and April 30, 2010 were reviewed to document the international normalized ratio (INR) and platelet count obtained within 72 hours before thoracentesis and to identify bleeding complications that occurred after the procedure. The observed complication rates and 95% CIs for differences in complication rates were calculated. RESULTS There were 1076 procedures performed during the study period with no hemorrhagic complications identified (0% complication rate; 95% CI, 0.00-0.34%). INR values before thoracentesis were available for 822 procedures: INR exceeded 2.0 in 139 cases (17%), 2.5 in 59 cases (7%), and 3.0 in 32 cases (4%). The 95% CI for the 0% difference in complications observed between two groups of patients determined by specific INR values was -0.008 to 0.014 (INR, 1.5), -0.007 to 0.026 (INR, 2.0), -0.007 to 0.061 (INR, 2.5), and -0.009 to 0.11 (INR, 3.0). Platelet values before thoracentesis were available for 953 procedures; the platelet count was less than 100,000/μL for 148 procedures (16%), less than 50,000/μL for 58 procedures (6%), and less than 25,000/μL for 12 procedures (1%). The 95% CI for the 0% difference in complications between two groups of patients determined by a platelet count threshold of 50,000/μL was -0.007 to 0.062. CONCLUSION The risk of bleeding after ultrasound-guided thoracentesis performed by radiologists is low even if the preprocedural INR and platelet count are abnormal. An approach in which no coagulation testing or correction is performed before thoracentesis may be justified.
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Affiliation(s)
- Chia-Hung Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.
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Yoneyama H, Arahata M, Temaru R, Ishizaka S, Minami S. Evaluation of the risk of intercostal artery laceration during thoracentesis in elderly patients by using 3D-CT angiography. Intern Med 2010; 49:289-92. [PMID: 20154433 DOI: 10.2169/internalmedicine.49.2618] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Our study was undertaken to determine the location of the tortuous intercostal artery in elderly patients by using 3D-CT angiography in order to prevent laceration during thoracentesis. METHODS We evaluated the data of 3D-CT angiography of the intercostal artery in consecutive patients who had undergone contrast chest CT scan in our hospital from December 2007 to April 2008. We considered the "percent safe space" (the shortest lower rib-to-intercostal artery distance/the upper rib-to-lower rib distance) to be an index of safety that can be used to prevent laceration of the intercostal artery during thoracentesis. We measured this index at 3 points: the total site (5-10 cm lateral to the spine), the lateral site (9-10 cm lateral to the spine), and the medial site (5-6 cm lateral to the spine). RESULTS We evaluated 33 cases (25 males and 8 females; mean age, 74.2 years). The mean percent safe space at the total site was 58.6%. The percent safe space at the total site tended to decrease with advancing age, but the correlation was low (p=0.0378, r=-0.3631). The percent safe space at the lateral site (mean, 79.8%) was significantly higher than that at the medial site (61.2%, p<0.0001). CONCLUSION We showed that the intercostal artery is tortuous and does not always lie along the inferior edge of the rib and that the percent safe space at the lateral site is significantly higher than that at the medial site in elderly patients.
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Affiliation(s)
- Hiroshi Yoneyama
- Department of Internal Medicine, Nanto Municipal Hospital, Toyama.
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[Massive iatrogenic haemothorax treated by lidocaïne-adrenaline intercostal injection]. Rev Mal Respir 2009; 26:985-8. [PMID: 19953045 DOI: 10.1016/s0761-8425(09)73334-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Massive haemothorax is a relatively rare complication of thoracocentesis or the placement of tube thoracostomy. It is principally caused by intercostal vessel injury. The therapeutic approach consists in pleural drainage and sometimes thoracotomy for haemostasis. CASE REPORT We describe a frail 72 year old patient, who developed a massive haemothorax occurring after a tube thoracostomy placing, persisting despite second pleural drainage, and complicated by deep haemodynamic shock. He was considered to have a very high risk of mortality if surgery was undertaken. Haemorrhage was totally stopped after intercostal instillation of lidocaïne-adrenaline. CONCLUSION This case report suggests a role for pleural vasoconstrictor injection as initial treatment in case of persistent pleural haemorrhage caused by intercostal vessel injury.
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Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE. Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment. Chest 2008; 135:1315-1320. [PMID: 19017865 DOI: 10.1378/chest.08-1227] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We studied the reasons why patients undergoing thoracenteses performed in our outpatient pulmonary clinic had a higher frequency of iatrogenic pneumothorax compared to that in the concurrent radiology practice in our institution, which utilizes ultrasound guidance. We reviewed our practice model and implemented a unique experiential training paradigm in a zero-risk simulation environment to improve efficacy, timeliness, service orientation, and safety. METHODS We retrospectively determined the rate of clinically significant pneumothoraces in our practice (phase I, July 1, 2001, to June 30, 2002). The training system redesign included the following: (1) a designated group of pulmonologist instructors dedicated to treating pleural disease and reducing the number of iatrogenic complications; (2) the use of ultrasound image guidance for all thoracenteses; and (3) structured proficiency and competency standards for proceduralists. Postintervention (phase II) data were prospectively collected (January 2005 to December 2006) and compared with our baseline data. RESULTS The baseline rate of pneumothorax was 8.6% (5 of 58 patients) in our pulmonary practice. Following intervention (phase II), the rate of pneumothorax declined to 1.1% (p = 0.0034). During phase II, the number of thoracenteses performed increased (186 vs 58 per year, respectively; p < 0.05). The iatrogenic pneumothorax rate was stable in the 2 years following intervention (2005, 0.7% [1 of 137 pneumothoraces]; 2006, 1.3% [3 of 226 pneumothoraces]; p > 0.9). Postintervention complications included procedure-related pain (n = 19), cough (n = 4), and hypotension (n = 10). CONCLUSIONS An improvement program that included simulation, ultrasound guidance, competency testing, and performance feedback reduced iatrogenic risk to patients. We recommend application of this process to procedural practices.
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Affiliation(s)
| | | | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Craig E Daniels
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Faruqi S, Raychaudhuri C, Thirumaran M, Blaxill P. Winging of the scapula: An unusual complication of needle thoracocentesis. Eur J Intern Med 2008; 19:381-2. [PMID: 18549948 DOI: 10.1016/j.ejim.2007.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Revised: 07/23/2007] [Accepted: 10/08/2007] [Indexed: 10/22/2022]
Abstract
Needle thoracocentesis is a common interventional procedure and is generally considered to be safe. Major complications associated with this procedure are uncommon. Here we describe a rare instance of winging of the scapula following needle thoracocentesis.
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Affiliation(s)
- S Faruqi
- Department of Respiratory Medicine, Pinderfields General Hospital, Aberford Road, Wakefield, West Yorkshire, WF1 4DG, UK.
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Lee YY, Choi WJ, Yu CM, Suh SO, Kim ES, Ahn SJ, Chung JO, Park SJ, Kim YK, Kim S, Kim YJ, Lee SH, Heo H. Diagnostic Approach to a Patient with a Pleural Effusion Including Ultrasound-guided Paracentesis Performed by a Medical Resident. Tuberc Respir Dis (Seoul) 2008. [DOI: 10.4046/trd.2008.64.6.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yun Young Lee
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Won Je Choi
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Chang Min Yu
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Seong O Suh
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Eun Sil Kim
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Seok Jin Ahn
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Jun-Oh Chung
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Sang Joon Park
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Yun Kwon Kim
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Soyon Kim
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Young Jung Kim
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Se Han Lee
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Heon Heo
- Department of Radiology, National Police Hospital, Seoul, Korea
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