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Thoracentesis Outcomes: a 12-Year Experience Mark J Ault,1 Bradley T Rosen,1 Jordan Scher,2 Joe Feinglass,2 Jeffrey H Barsuk2

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Thoracentesis Outcomes: a 12-Year Experience Mark J Ault,1 Bradley T Rosen,1 Jordan Scher,2 Joe Feinglass,2 Jeffrey H Barsuk2 Critical care Thorax: first published as 10.1136/thoraxjnl-2014-206114 on 5 November 2014. Downloaded from ORIGINAL ARTICLE Thoracentesis outcomes: a 12-year experience Mark J Ault,1 Bradley T Rosen,1 Jordan Scher,2 Joe Feinglass,2 Jeffrey H Barsuk2 ▸ Additional material is ABSTRACT published online only. To view Background Despite a lack of evidence in the Key messages please visit the journal online (http://dx.doi.org/10.1136/ literature, several assumptions exist about the safety of thoraxjnl-2014-206114). thoracentesis in clinical guidelines and practice patterns. We aimed to evaluate specific demographic and clinical 1Division of General Internal What is the key question? Medicine, Cedars-Sinai Medical factors that have been commonly associated with ▸ Are common assumptions regarding Center, Los Angeles, California, complications such as iatrogenic pneumothorax, re- thoracentesis safety guidelines accurate USA expansion pulmonary oedema (REPE) and bleeding. 2 including: Department of Medicine, Methods We performed a cohort study of inpatients – Avoiding bilateral procedures or procedures Northwestern University Feinberg School of Medicine, who underwent thoracenteses at Cedars-Sinai Medical on patients receiving positive pressure Chicago, Illinois, USA Center (CSMC) from August 2001 to October 2013. ventilation due to increased risk of Data were collected prospectively including information catastrophic complications; Correspondence to on volume of fluid removed, procedure side, whether the – Limiting fluid removal to less than 1500 mL to Dr Jeffrey H Barsuk, Division of patient was on positive pressure ventilation, number of Hospital Medicine, Department avoid re-expansion pulmonary oedema; and of Medicine, Northwestern needle passes and supine positioning. Iatrogenic – Not performing procedures on patients with University Feinberg School of pneumothorax, REPE and bleeding were tracked for 24 h coagulopathy or low platelets without first Medicine, 211 E. Ontario St, after the procedure or until a clinical question was administering blood products? Suite 717, Chicago, IL 60611, reconciled. Demographic and clinical characteristics were USA; [email protected] obtained through query of electronic medical records. What is the bottom line? ▸ Received 31 July 2014 Results CSMC performed 9320 inpatient thoracenteses The common assumptions about the safety of Revised 6 October 2014 on 4618 patients during the study period. There were 57 thoracentesis procedures are based on weak Accepted 16 October 2014 (0.61%) iatrogenic pneumothoraces, 10 (0.01%) evidence and may adversely affect patient care. Published Online First incidents of REPE and 17 (0.18%) bleeding episodes. 5 November 2014 Why read on? Iatrogenic pneumothorax was significantly associated ▸ fl We report a large series of over 9300 with removal of >1500 mL uid (p<0.0001), unilateral thoracentesis procedures and their procedures (p=0.001) and more than one needle pass fl complications that refute several commonly through the skin (p=0.001). For every 1 mL of uid held assumptions. removed there was a 0.18% increased risk of REPE http://thorax.bmj.com/ (95% CI 0.09% to 0.26%). There were no significant associations between bleeding and demographic or clinical variables including International Normalised Thoracenteses have been a core procedure per- Ratio, partial thromboplastin time and platelet counts. formed by dedicated proceduralists at Cedars-Sinai Conclusions Our series of thoracenteses had a very Medical Center (CSMC) in Los Angeles for over low complication rate. Current clinical guidelines and 12 years. As a standard part of quality assurance, practice patterns may not reflect evidence-based best CSMC documents complications from thoracent- practices. on September 24, 2021 by guest. Protected copyright. eses performed in their procedure centre. Northwestern University investigators ( JS, JF, JHB) evaluated these data independently to look for associations between procedure complications and Pleural effusions are commonly encountered in patient characteristics. This study reports findings hospitalised patients and up to 173 000 thoracent- of this collaboration and had three major aims: (1) esis procedures are performed annually in the to evaluate whether specific demographics, clinical USA.12Complications from thoracentesis include factors or procedure techniques were associated pneumothorax, re-expansion pulmonary oedema with complications including pneumothorax; (2) to (REPE) and bleeding. These complications increase evaluate whether REPE was associated with volume morbidity, prolong length of stay and escalate of effusion removed; and (3) to evaluate whether healthcare costs.34Despite a lack of supporting coagulopathy or thrombocytopenia increased the evidence in the literature, common assumptions risk of thoracentesis-related bleeding. regarding thoracentesis safety guidelines include: (1) avoiding bilateral procedures or procedures on MATERIALS AND METHODS patients receiving positive pressure ventilation due Design – to increased risk of catastrophic complications;157 We performed a cohort study of inpatients who (2) limiting fluid removal to <1500 mL to avoid underwent thoracenteses at CSMC from August To cite: Ault MJ, Rosen BT, REPE;8 and (3) not performing procedures on 2001 to October 2013. CSMC is a tertiary care Scher J, et al. Thorax patients with coagulopathy or low platelets without academic medical centre with 896 inpatient beds. – 2015;70:127 132. first administering blood products.89 The procedure service prospectively followed Ault MJ, et al. Thorax 2015;70:127–132. doi:10.1136/thoraxjnl-2014-206114 127 Critical care Thorax: first published as 10.1136/thoraxjnl-2014-206114 on 5 November 2014. Downloaded from patients for complications up to 24 h after the procedure was splenic laceration and vasovagal reactions were combined into an completed, and we evaluated these cases for factors associated ‘any complications’ category for further analysis. with these complications. The CSMC and Northwestern We also performed a query of the electronic medical record University Institutional Review Boards approved this study. on patient demographic and clinical information for the admis- sion during which the thoracentesis was performed including: Procedure protocol and registry complication data age, sex, body mass index (BMI), International Normalised Inpatients at CSMC were referred to the procedure service for Ratio (INR), partial thromboplastin time (PTT), platelet counts thoracenteses by physicians directly involved in each patient’s (103/mL) and International Classification of Diseases, 9th care. The thoracenteses in this study were all performed or Revision (ICD-9) codes. Our query for laboratory data retrieved supervised by a single clinician/author (MJA) who is the medical the closest laboratory entry up to 48 h before the procedure. If director of the procedure service. Procedures were performed in no laboratory data were available before the procedure, the a dedicated suite or at the patients’ bedside. Portable ultrasound query searched for laboratory data up to 24 h after the proced- was routinely used for fluid localisation through site marking ure. We used ICD-9 diagnosis codes to calculate patients’ (not real-time) and a safety-tipped needle/catheter was used in Charlson scores (a severity of illness indicator based on 19 all cases. Fluid was removed by manual hand pumping. chronic disease comorbidities which predicts 1-year mortality Aspirations were done with a 10 mL syringe to optimise the for hospitalised medical patients).10 11 ability to detect resistance changes. Ultrasound was used to monitor the progress of fluid removal by intermittently interro- Statistical analysis gating the pleural space throughout the procedure. Attempts We used random effects Poisson regression to model the likeli- were made in all cases to remove all of the fluid present in the hood of either iatrogenic pneumothorax or of any complica- pleural space. However, if resistance to aspiration became tions. Poisson regression was used because all dependent notable relative to baseline resistance and/or the patient became variables were rare counted events. Random effects Poisson symptomatic with chest tightness, cough or pain referred to the regression adjusts SEs for multiple procedures for individual upper chest or neck, thoracentesis was terminated. If residual patients (clustering) and estimates an incidence rate ratio that is fluid was present in these circumstances, the possibility of closer to the relative risk than the OR when the incidence is trapped lung was noted. Vacuum bottles were used for fluid low. We first performed a univariate analysis of associations removal only in rare circumstances. Chest X-rays were only between any complications or pneumothorax and patients’ age, ordered after the procedure if there was a change in patient sex, BMI, Charlson score, INR, PTT, platelet counts, fluid symptoms or it was clinically necessary to document lung volume removed, procedure side (bilateral or unilateral), re-expansion. Patients were not treated with blood product whether the patient was on invasive or non-invasive or mechan- administration for coagulopathy or low platelets before the pro- ical ventilation, number of needle passes and supine positioning. cedure was performed. Only univariate associations at the p≤0.1 level were included in Data were collected prospectively by the proceduralist (MJA) further multivariate analysis. at the time of the procedure, including:
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