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Safe and Effective Bedside Thoracentesis: a Review of the Evidence for Practicing Clinicians

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Safe and Effective Bedside Thoracentesis: a Review of the Evidence for Practicing Clinicians REVIEW Safe and Effective Bedside Thoracentesis: A Review of the Evidence for Practicing Clinicians Richard Schildhouse, MD1,2*, Andrew Lai, MD, MPH3, Jeffrey H. Barsuk, MD, MS4, Michelle Mourad, MD3, Vineet Chopra, MD, MSc1,2 1Division of General Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan; 2Division of General Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; 3Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California; 4Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. BACKGROUND: Physicians often care for patients with cluded the finding that moderate coagulopathies (interna- pleural effusion, a condition that requires thoracentesis for tional normalized ratio less than 3 or a platelet count greater evaluation and treatment. We aim to identify the most recent than 25,000/µL) and mechanical ventilation did not increase advances related to safe and effective performance of tho- risk of postprocedural complications. Intraprocedurally, ul- racentesis. trasound use was associated with lower risk of pneumotho- METHODS: We performed a narrative review with a sys- rax, while pleural manometry can identify a nonexpanding tematic search of the literature. Two authors independently lung and may help reduce risk of re-expansion pulmonary reviewed search results and selected studies based on rel- edema. Postprocedurally, studies indicate that routine chest evance to thoracentesis; disagreements were resolved by X-ray is unwarranted, because bedside ultrasound can iden- consensus. Articles were categorized as those related to the tify pneumothorax. pre-, intra- and postprocedural aspects of thoracentesis. CONCLUSIONS: While the performance of thoracentesis is RESULTS: Sixty relevant studies were identified and includ- not without risk, clinicians can incorporate recent advanc- ed. Pre-procedural topics included methods for physician es into practice to mitigate patient harm and improve effec- training and maintenance of skills, such as simulation with tiveness. Journal of Hospital Medicine 2017;12:266-276. direct observation. Additionally, pre-procedural topics in- © 2017 Society of Hospital Medicine Pleural effusion can occur in myriad conditions including METHODS infection, heart failure, liver disease, and cancer.1 Conse- Information Sources and Search Strategy quently, physicians from many disciplines routinely en- With the assistance of a research librarian, we performed a counter both inpatients and outpatients with this diagnosis. systematic search of PubMed-indexed articles from January Often, evaluation and treatment require thoracentesis to 1, 2000 to September 30, 2015. Articles were identified us- obtain fluid for analysis or symptom relief. ing search terms such as thoracentesis, pleural effusion, safety, Although historically performed at the bedside without medical error, adverse event, and ultrasound in combination imaging guidance or intraprocedural monitoring, thoracen- with Boolean operators. Of note, as thoracentesis is indexed tesis performed in this fashion carries considerable risk of as a subgroup of paracentesis in PubMed, this term was also complications. In fact, it has 1 of the highest rates of iatro- included to increase the sensitivity of the search. The full genic pneumothorax among bedside procedures.2 However, search strategy is available in the Appendix. Any references recent advances in practice and adoption of newer technol- cited in this review outside of the date range of our search ogies have helped to mitigate risks associated with this pro- are provided only to give relevant background information cedure. These advances are relevant because approximately or establish the origin of commonly performed practices. 50% of thoracenteses are still performed at the bedside.3 In this review, we aim to identify the most recent key practices Study Eligibility and Selection Criteria that enhance the safety and the effectiveness of thoracente- Studies were included if they reported clinical aspects re- sis for practicing clinicians. lated to thoracentesis. We defined clinical aspects as those strategies that focused on operator training, procedural tech- niques, technology, management, or prevention of complica- *Address for correspondence and reprint requests: Richard J. Schildhouse, tions. Non-English language articles, animal studies, case re- MD, VA Ann Arbor Healthcare System, Department of Internal Medicine (111), 2215 Fuller Road, Ann Arbor, MI 48105; Telephone: 734-222-8961; Fax: 734- ports, conference proceedings, and abstracts were excluded. 913-0883; E-mail: [email protected] As our intention was to focus on the contemporary advances Additional Supporting Information may be found in the online version of this related to thoracentesis performance, (eg, ultrasound [US]), article. our search was limited to studies published after the year Received: June 6, 2016; Revised: September 5, 2016; Accepted: September 2000. Two authors, Drs. Schildhouse and Lai independently 18, 2016 screened studies to determine inclusion, excluding studies 2017 Society of Hospital Medicine DOI 10.12788/jhm.2716 with weak methodology, very small sample sizes, and those 266 An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 12 | No 4 | April 2017 Bedside Thoracentesis | Schildhouse et al only tangentially related to our aim. Disagreements regard- ing study inclusion were resolved by consensus. Drs. Lai, Barsuk, and Mourad identified additional studies by hand Articles identified through search Identification of PubMed electronic database review of reference lists and content experts (Figure 1). (N = 1170) Conceptual Framework All selected articles were categorized by temporal rela- Published prior to Screening January 1, 2000 tionship to thoracentesis as pre-, intra-, or postprocedure. (n = 417) Pre-procedural topics were those outcomes that had been identified and addressed before attempting thoracentesis, such as physician training or perceived risks of harm. In- Full-text articles assessed for eligibility (n = 753) traprocedural considerations included aspects such as use of bedside US, pleural manometry, and large-volume drainage. Finally, postprocedural factors were those related to evalu- Full text articles excluded: ation after thoracentesis, such as follow-up imaging. This (n = 697) Unrelated subject: 676 conceptual framework is outlined in Figure 2. Eligibility Author correspondence: 9 Case reports: 8 Other: 3 RESULTS Foreign language: 1 The PubMed search returned a total of 1170 manuscripts, of which 56 articles met inclusion criteria. Four additional articles were identified by experts and included in the study.4-7 There- Articles appropriate for inclusion (n = 56) fore, 60 articles were identified and included in this review. Study designs included cohort studies, case control studies, sys- tematic reviews, meta-analyses, narrative reviews, consensus Articles identified via expert review guidelines, and randomized controlled trials. A summary of all (n = 4) included articles by topic can be found in the Table. Articles included in review PRE-PROCEDURAL CONSIDERATIONS Included (n = 60) Physician Training Studies indicate that graduate medical education may not 8 adequately prepare clinicians to perform thoracentesis. In FIG. 1. Study eligibility and selection criteria. Pre-procedure Intraprocedure Postprocedure Physical Training Bedside Ultrasound Simulation-based learning Effusion confirmation Competency tools Risk of pneumothorax Patient Selection Intercostal Artery Identification Postprocedure Imaging Coagulopathies and anticoagulation Hemothorax and vessel tortuosity Need for chest X-ray Mechanical ventilation Color Doppler ultrasound Use of ultrasound Proper Skin Disinfection Pleural Manometry Risk of wound infection Re-expansion pulmonary edema (REPE) Use of sterile procedure Identification of a trapped lung Large-volume drainage and pneumothorax Thoracentesis process FIG. 2. Conceptual framework. An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 12 | No 4 | April 2017 267 Schildhouse et al | Bedside Thoracentesis fact, residents have the least exposure and confidence in British Thoracic Society (BTS) Pleural Disease Guideline performing thoracentesis when compared to other bedside 2010.19 Other recommendations include the 2012 Society procedures.9,10 In 1 survey, 69% of medical trainees desired for Interventional Radiology guidelines that endorse correc- more exposure to procedures, and 98% felt that procedur- tion of an INR greater than 2, or platelets less than 50,000/ al skills were important to master.11 Not surprisingly, then, µL, based almost exclusively on expert opinion.5 graduating internal medicine residents perform poorly when However, data suggest that thoracentesis may be safely assessed on a thoracentesis simulator.12 performed outside these parameters. For instance, a prospec- Supplemental training outside of residency is useful to tive study of approximately 9000 thoracenteses over 12 years develop and maintain skills for thoracentesis, such as sim- found that patients with an INR of 1.5-2.9 or platelets of ulation with direct observation in a zero-risk environment. 20,000 - 49,000/µL experienced rates of bleeding complica- In 1 study, “simulation-based mastery learning” combined tions similar to those with normal values.20
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