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Smith D, Shaw H, Ryder T. Intrapleural tissue plasminogen activator and deoxyribonuclease administered concurrently and once daily for complex parapneumonic pleural effusion and empyema. Intern Med J 2023; 53:2313-2318. [PMID: 37029951 DOI: 10.1111/imj.16084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/06/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Pleural infection is life-threatening and increasingly prevalent. In addition to usual care, twice-daily, separate administration of tissue plasminogen activator and deoxyribonuclease (tPA-DNase) reduces radiological pleural opacity with lower surgical referral rates. AIMS This retrospective cohort study examines the use of once-daily, concurrent administration of tPA-DNase for complex parapneumonic pleural effusion and empyema. METHODS Patients with pleural infection who received intrapleural tPA-DNase between October 2014 and July 2020 at Logan Hospital, where it is given concurrently and once-daily as salvage therapy, were retrospectively identified. Radiographic opacification, inflammatory markers, clinical response and complications were examined. RESULTS Thirty-one patients were identified. Mean age was 48.8 years (standard deviation [SD], 17.2). Median tPA-DNase administration was 3 (interquartile range [IQR], 2-3). Chest x-ray pleural opacity decreased significantly (P = 0.047) from a median of 39.6% (IQR, 28.8-65.7%) to 9.7% (IQR, 2.5-23.2%), a median relative reduction of 75.5% (IQR, 47.7-93.9%). White cell count and C-reactive protein improved significantly (P = 0.002 and P = 0.032, respectively) from a median of 16.3 × 109 /L (IQR, 11.8-20.6 × 109 /L) to 9.9 × 109 /L (IQR, 8.0-12.3 × 109 /L) and 311.0 mg/L (IQR, 218.8-374.0 mg/L) to 69.0 mg/L (IQR, 36.0-118.0 mg/L), respectively. No patients experienced significant bleeding or died. Five patients (16.1%) were referred for surgery. CONCLUSION This is pilot evidence that a practical regimen of concurrent, once-daily intrapleural tPA-DNase improved pleural opacification and inflammatory markers without bleeding or mortality. The surgical referral rate was higher than in studies assessing twice-daily administration, though the validity of this outcome as a measure of treatment success is limited, and further studies are needed to assess the optimal dose and frequency of intrapleural therapy and indications for surgical referral.
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Affiliation(s)
- Dugal Smith
- Respiratory Department, Logan Hospital, Logan City, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Hannah Shaw
- Respiratory Department, Logan Hospital, Logan City, Queensland, Australia
| | - Timothy Ryder
- Respiratory Department, Logan Hospital, Logan City, Queensland, Australia
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Chew C, Bartlett J, Kelly AM. Update on the management of first episode primary spontaneous pneumothorax in an Australian hospital network. Intern Med J 2023; 53:1907-1910. [PMID: 37794773 DOI: 10.1111/imj.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/14/2023] [Indexed: 10/06/2023]
Abstract
International guidelines and recent research favour a less interventional approach to primary spontaneous pneumothorax (PSP). A retrospective clinical audit of 68 first-episode PSP was undertaken at a major tertiary teaching hospital network in Melbourne, Australia, found that most patients presenting with a moderate to large pneumothorax received initial intercostal catheter insertion (56%), though many (81%) would have met criteria for consideration of conservative management. The results suggest continued deviation from clinical guidelines in the management of PSP.
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Affiliation(s)
- Christopher Chew
- Respiratory Fellow, Victorian Respiratory Support Service, Austin Health, Melbourne, Victoria, Australia
| | - James Bartlett
- Respiratory Physician, Western Health, Melbourne, Victoria, Australia
| | - Anne-Maree Kelly
- Professor of Emergency Medicine, Western Health, Melbourne, Victoria, Australia
- Professorial Fellow in Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Weon J, Robson S, Chan R, Ussher S. Development of a risk prediction model of pneumothorax in percutaneous computed tomography guided transthoracic needle lung biopsy. J Med Imaging Radiat Oncol 2021; 65:686-693. [PMID: 33955169 DOI: 10.1111/1754-9485.13187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/10/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION To retrospectively evaluate the incidence of and the risk factors for pneumothorax and intercostal catheter insertion (ICC) after CT-guided lung biopsy and to generate a risk prediction model for developing a pneumothorax and requiring an ICC. METHODS 255 CT-guided lung biopsies performed for 249 lesions in 249 patients from August 2014 to August 2019 were retrospectively analysed using multivariate logistic regression analysis. Risk prediction models were established using backward stepwise variable selection and likelihood ratio tests and were internally validated using split-sample methods. RESULTS The overall incidence of pneumothorax was 30.2% (77/255). ICC insertion was required for 8.32% (21/255) of all procedures. The significant independent risk factors for pneumothorax were lesions not in contact with pleura (P < 0.001), a shorter skin-to-pleura distance (P = 0.01), the needle crossing a fissure (P = 0.004) and emphysema (P = 0.01); those for ICC insertion for pneumothorax were a needle through emphysema (P < 0.001) and lesions in the upper lobe (P = 0.017). AUC of the predictive models for pneumothorax and ICC insertion were 0.800 (95% CI: 0.745-0.856) and 0.859 (95% CI: 0.779-0.939) respectively. Upon internal validation, AUC of the testing sets of pneumothorax and ICC insertion were 0.769 and 0.822 on average respectively. CONCLUSION The complication rates of pneumothorax and ICC insertion after CT-guided lung biopsy at our institution are comparable to results from previously reported studies. This study provides highly accurate risk prediction models of pneumothorax and ICC insertion for patients undergoing CT-guided lung biopsies.
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Affiliation(s)
- JangHo Weon
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiology, Ballarat Base Hospital, Ballarat, Victoria, Australia
| | - Scott Robson
- Department of Radiology, Ballarat Base Hospital, Ballarat, Victoria, Australia
| | - Ronald Chan
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Simon Ussher
- Department of Radiology, Ballarat Base Hospital, Ballarat, Victoria, Australia
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Abstract
Background One of the most frequent complications of coronary artery bypass grafting (CABG) is pleural effusion. Limited previous studies have found post-CABG pleural effusion to be associated with increased length-of-stay and greater morbidity post-CABG. Despite this the associations of this common complication are poorly described. This study sought to identify modifiable risk factors for effusion post-CABG. Methods A retrospective cohort study of prospectively collected data assessed patients who underwent CABG over two-years. Data was collected for risk factors and sequelae related to pleural effusion requiring drainage. Results A total of 409 patients were included. Average age was 64.9±10.2 years, 330 (80.7%) were male. 59 (14.4%) patients underwent drainage of pleural effusion post-CABG. Effusions were drained on average 9.9±8.4 days post-CABG. Earlier removal of drain tubes and removal near time of extubation were associated with development of pleural effusion. Post-CABG pleural effusion was associated with post-operative renal impairment (P<0.01) and pericardial effusion (P<0.01). Patients with pleural effusion were more likely to require readmission to ICU (P<0.01), reintubation (P=0.03) and readmission to hospital (P=0.03). Conclusions Pleural effusion is a common complication of cardiac surgery and is associated with significant morbidity and resource utilization. This study identifies several associated complications that should be considered in the presence of pleural effusion. Modifiable associated factors in the management of drains that may contribute to accumulation of pleural effusion include: early removal of chest drains, higher outputs and removal during or close to mechanical ventilation. Further research is required to assess how adjusting these modifiable factors can decrease rates of effusion post-operatively.
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Affiliation(s)
- John D L Brookes
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Michael Williams
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Manish Mathew
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Tristan Yan
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Sydney Medical School, The University of Sydney, New South Wales, Australia.,Professor of Cardiovascular and Thoracic Surgery, Macquarie University, New South Wales, Australia.,Clinical Professor of Surgery, Faculty of Medicine, The University of Sydney, New South Wales, Australia.,The Baird Institute, Newtown, New South Wales, Australia
| | - Paul Bannon
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Sydney Medical School, The University of Sydney, New South Wales, Australia.,The Baird Institute, Newtown, New South Wales, Australia.,Bosch Professor of Surgery, Faculty of Medicine, The University of Sydney, New South Wales, Australia
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Ponholzer F, Ng C, Maier H, Dejaco H, Schlager A, Lucciarini P, Öfner D, Augustin F. Intercostal Catheters for Postoperative Pain Management in VATS Reduce Opioid Consumption. J Clin Med 2021; 10:jcm10020372. [PMID: 33478098 PMCID: PMC7835787 DOI: 10.3390/jcm10020372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Postoperative pain after video-assisted thoracoscopic surgery (VATS) affects patients’ recovery, postoperative complications, and length of stay (LOS). Despite its relevance, there are no guidelines on optimal perioperative pain management. This study aims to analyse the effects of an additional intercostal catheter (ICC) in comparison to a single shot intraoperative intercostal nerve block (SSINB). Methods: All patients receiving an anatomic VATS resection between June 2019 and May 2020 were analysed retrospectively. The ICC cohort included 51 patients, the SSINB cohort included 44 patients. Results: There was no difference in age, gender, comorbidities, or duration of surgery between cohorts. Pain scores on the first postoperative day, after chest drain removal, and highest pain score measured did not differ between groups. The overall amount of opioids (morphine equivalent: 3.034 mg vs. 7.727 mg; p = 0.002) as well as the duration of opioid usage (0.59 days vs. 1.25 days; p = 0.005) was significantly less in the ICC cohort. There was no difference in chest drain duration, postoperative complications, and postoperative LOS. Conclusions: Pain management with ICC reduces the amount of opioids and number of days with opioids patients require to achieve sufficient analgesia. In conclusion, ICC is an effective regional anaesthesia tool in postoperative pain management in minimally invasive thoracic surgery.
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Affiliation(s)
- Florian Ponholzer
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (F.P.); (C.N.); (H.M.); (P.L.); (D.Ö.)
| | - Caecilia Ng
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (F.P.); (C.N.); (H.M.); (P.L.); (D.Ö.)
| | - Herbert Maier
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (F.P.); (C.N.); (H.M.); (P.L.); (D.Ö.)
| | - Hannes Dejaco
- Department of Anaesthesiology and Critical Care, Medical University of Innsbruck, 6020 Innsbruck, Austria; (H.D.); (A.S.)
| | - Andreas Schlager
- Department of Anaesthesiology and Critical Care, Medical University of Innsbruck, 6020 Innsbruck, Austria; (H.D.); (A.S.)
| | - Paolo Lucciarini
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (F.P.); (C.N.); (H.M.); (P.L.); (D.Ö.)
| | - Dietmar Öfner
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (F.P.); (C.N.); (H.M.); (P.L.); (D.Ö.)
| | - Florian Augustin
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (F.P.); (C.N.); (H.M.); (P.L.); (D.Ö.)
- Correspondence: ; Tel.: +43-512-504-22601
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Carter P, Conroy S, Blakeney J, Sood B. Identifying the site for intercostal catheter insertion in the emergency department: is clinical examination reliable? Emerg Med Australas 2014; 26:450-4. [PMID: 25212066 DOI: 10.1111/1742-6723.12276] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether ED doctors, comprising both consultants and registrars, can accurately identify the 4th or 5th intercostal space (ICS), commonly used for intercostal catheter insertion. METHODS An observational study was designed using a sample of ED doctors applying their clinical skills to a convenience sample of patients reflecting a heterogeneous mix of ED patients. Patients already receiving a CXR in our ED were examined by a registrar or consultant who placed a radiopaque marker on the patients' chest wall over the site they determined to be the 4th or 5th ICS. Consultant radiologists reported the marker's position from postero-anterior projection CXRs, and results were analysed comparing consultants with registrars, right to left hemithoraces and male to female patients. RESULTS ED doctors participating in the present study placed the marker over the 4th or 5th ICS 36.2% of the time, with no significant difference between consultant and registrar groups, nor right or left hemithoraces. Accuracy was improved in female patients compared with male patients. CONCLUSION Emergency registrars and consultants sampled from a regional ED appeared unable to reliably identify the 4th or 5th ICS, as evidenced by marker position, in a heterogeneous patient population.
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Affiliation(s)
- Peter Carter
- Emergency Department, Toowoomba Hospital, Toowoomba, Queensland, Australia
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Salamonsen M, Dobeli K, McGrath D, Readdy C, Ware R, Steinke K, Fielding D. Physician-performed ultrasound can accurately screen for a vulnerable intercostal artery prior to chest drainage procedures. Respirology 2014; 18:942-7. [PMID: 23521021 DOI: 10.1111/resp.12088] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 01/15/2013] [Accepted: 01/22/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Laceration of the intercostal artery during pleural procedures is a rare but serious complication. This study evaluates the utility of thoracic ultrasound (US) to screen for a vulnerable vessel compared with the gold standard computed tomography (CT). METHODS Before undergoing contrast-enhanced CT chest, thoracic US was performed on 50 patients with a high-end and portable machine, and an attempt made to visualize the vessel at three positions across the back to the axilla. These positions were labelled with radio-opaque fiducial markers. On both US and CT images, the location of the vessel at each position, relative to the overlying rib, was calculated and compared. RESULTS The vessel was unshielded by a rib according to CT in 114 of the 133 positions. The sensitivity, specificity and negative predictive value of portable US to image the vessel, when it was within the intercostal space on CT, was 0.86, 0.30 and 0.27 respectively. The performance of a high-end machine was not significantly different. The median time required for a pulmonologist to locate the vessel was 42 s and 18 s for the portable and high-end US respectively. CONCLUSIONS US can be used to screen for a vulnerable vessel prior to pleural procedures, in a time amenable to use in clinical practice. Further, it is achievable by a pulmonologist using a portable US machine. If thoracentesis or chest tube insertion is being performed on a patient at increased risk of bleeding, screening for a vulnerable vessel with US prior to beginning the procedure is recommended.
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Affiliation(s)
- Matthew Salamonsen
- Department of Thoracic Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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