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Ultrasound guided paracentesis and thoracentesis for hospitalists

Ultrasound guided paracentesis and thoracentesis for hospitalists. Deepti S Rao. Thanks. Jason Cohen Michel Boivin. Objectives. After this session you should be able to: Explain the rationale behind using ultrasound in thoracentesis and paracentesis

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Ultrasound guided paracentesis and thoracentesis for hospitalists

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  1. Ultrasound guided paracentesis and thoracentesis for hospitalists Deepti S Rao

  2. Thanks • Jason Cohen • Michel Boivin

  3. Objectives After this session you should be able to: • Explain the rationale behind using ultrasound in thoracentesis and paracentesis • Understand the objectives, outcomes and activities proposed in my research project • Discuss the feasability of doing this project in this group of hospitalists.

  4. Ultrasound in procedures • Central lines • Lots of literature including increased patient safety • Thoracentesis/Paracentesis • Not much literature

  5. Ultrasound in thoracentesis • Risk of complications up to 19% • Grogan et al. ArchivInt med, 1990 • 0% vs 29% reduction in pneumothorax when ultrasound used for needle placement • Raptopoulos et al. Am JournRoent, 1991. • 3% vs 18% • Irregardless of size of effusion, whether thoracentesis was diagnostic or therapeutic, and whether tap was dry.

  6. Ultrasound in thoracentesisARCH INTERN MED/VOL 170 (NO. 4), FEB 22, 2010 • Table 3. Unadjusted Odds Ratios for Pneumothorax by Procedural or Patient Factor (Direct Comparisons) • Variable No. of Studies No. of Patients With(Without) Variable Odds Ratio (95% Confidence Interval) • for Pneumothorax • Procedural Factors • Ultrasonography vs no ultrasonography 6 654 (1026) 0.3 (0.2-0.7) • Experienced operator vs inexperienced 4 308 (622) 0.7 (0.2-2.3) • Therapeuticthoracentesis vs diagnostic 12 1048 (1323) 2.6 (1.8-3.8) • Larger needle or catheter vs small needle 7 700 (1178) 2.5 (1.1-6.0) • 2 Needle passes vs 1 pass 3 145 (580) 2.5 (0.3-20.1) • Follow-up thoracentesisvs initial 3 377 (993) 1.1 (0.3-3.6) • Periprocedural Factors • Aspiration of air vsnone 2 19 (661) 104.0 (2.0-5355.0) • Periprocedural symptoms vsnone 3 57 (1504) 26.6 (2.7-262.5) • Patient Factors • Large effusion size vs small 7 758 (697) 1.3 (0.8-1.9) • Male vs female sex 3 272 (220) 0.8 (0.3-1.7) • ICU inpatient location vs non-ICU inpatient 3 142 (620) 0.9 (0.4-1.8) • Non-ICU inpatient location vs outpatient 2 213 (448) 1.0 (0.5-2.0) • Mechanical ventilation vs not 2 100 (589) 4.0 (0.95-16.8) • Loculated pleural effusion vsnonloculated 3 106 (377) 0.7 (0.3-1.7) • Abbreviation: ICU, intensive care unit. • Only studies that reported results for both the presence and absence of a variable.

  7. Ultrasound in thoracentesis • “X marks the spot” after a delay not associated in a reduction in pneumothorax rate • Raptopoulos et al. Am J of Roent, 1991

  8. Ultrasound in thoracentesis • Failed thoracentesis • 58% of clinically attempted dry taps had needle insertion sites below the diaphragm (Weingardt, J Clin Ultra, 1994) • Fluid can be successfully obtained in up to 88% of patients who had failed clinically directed thoracentesis(Kopman, Chest, 2006.) • Ultrasound increased rate of accurate site selection 26% and decreased number of dangerous needle insertions by 10% (Diacon, Chest 2003)

  9. Ultrasound in thoracentesis • In summary, the complication rate for thoracentesis is high and ultrasound can decrease that risk

  10. Ultrasound in paracentesis • Complications low (up to 2.7%) • Runyon, Arch Int Med, 1986 • Ultrasound may have a role in identifying smaller pockets of fluid • Physical exam can fail to find small amounts of fluid or the most easily accessible pocket of fluid • Ultrasound can detect pockets of fluid as small as 100cc

  11. Ultrasound in paracentesis • Ultrasound decreased the number of unsuccessful attempts by demonstrating which patients did not have sufficient ascites to tap • Nazeer, etal. American Journal of Emergency Medicine, 2005.

  12. So why do we want to do this? • Patient safety • Patient comfort (increased success in performing) • Resident learning and comfort • Basis for eventual simulation based procedural training

  13. Resident comfortHuang etal, The American Journal of Med, 2006 • Table 3 Lack of comfort, by procedure • Lack of comfort with All n 527 Central line n 268 Lumbar puncture n 95 Paracentesis n 81 Thoracentesis n 93 Pvalue* • Indications and • contraindications, n (%) 11 (2.1%) 6 (2.2%) 0 (0.0%) 0 (0.0%) 5 (6.0%) .017 • Obtaining consent, n (%) 10 (1.9%) 5 (1.9%) 2 (2.1%) 2 (2.5%) 1 (1.2%) .935 • Anatomy, n (%) 28 (5.3%) 19 (7.1%) 3 (3.2%) 1 (1.2%) 5 (6.0%) .040 • Equipment, n (%) 45 (8.5%) 19 (7.1%) 5 (5.3%) 10 (12.3%) 11 (13.3%) .001 • Sterile technique, n (%) 7 (1.3%) 6 (2.2%) 0 (0.0%) 1 (1.2%) 0 (0.0%) .494 • Patient positioning, n (%) 14 (2.7%) 6 (2.2%) 4 (4.2%) 2 (2.5%) 2 (2.4%) .191 • Interpreting the results, n • (%) • 25 (4.7%) 16 (6.0%) 2 (2.1%) 3 (3.7%) 4 (4.8%) .493 • Being supervised, n/total • (%)† • 5/206 (2.4%) 3/89 (3.4%) 0/27 (0.0%) 0/25 (0.0%) 2/65 (3.1%) .884 • Being unsupervised, • n/total (%)‡ • 119/321 (37.1%) 70/179 (39.1%) 23/68 (33.8%) 14/56 (25.0%) 12/18 (66.7%) .001 • Managing complications, • n (%) • 186 (35.3%) 87 (32.5%) 32 (33.7%) 28 (34.6%) 39 (47.0%) .003 • Mean number of aspects • with lack of comfort, n • (SD, range) • 0.85 (1.1, 0-8) 0.88 (1.2, 0-8) 0.75 (0.1, 0-4) 0.75 (1.0, 0-4) 0.98 (1.1, 0-6)

  14. Thoracentesis – Iatrogenic pneumothorax • AHRQ Healthcare Cost & Utilization Project, Nationwide Inpatient Sample database, 2000 • 7.45 million hospital d/c abstracts • 994 short-term acute care hospitals • 28 states • JMH: July 2007 through June 2008 • Procedure team: July 2007 through June 2008

  15. Healthcare toll per episode • 4 – 7 excess days in hospital length of stay • $17,000 - $45,000 in excess cost • 1% - 14% excess mortality

  16. In summary • Ultrasound decreases complication rates in thoracentesis and may reduce unnecessary procedures in paracentesis. • This can reduce risk to our patients. • This is a skill our residents should have exposure to.

  17. Curricula for teaching ultrasound • Didactics • Ultrasound physics • Machine usage • Indications • Anatomy • Supervised scanning • Hand on hand

  18. Judging competency • Multiple choice testing • Observed scanning • 5-10 scans ACEP: 3-4 hours didactics, 2-4 hours supervised scanning

  19. Research question • Can a multi-part learning curriculum aimed at inpatient medicine attendings increase the competency of internal medicine physicians in performing ultrasound guided paracentesis and thoracentesis? And will this increased competency lead to an increased use of ultrasound for these procedures on the medicine wards?

  20. Secondary objectives • Will this increase resident exposure/teaching to ultrasound • Will this decrease complication rates

  21. Outcomes

  22. Timeline

  23. Next steps • What do you think • Credentialing • Billing and Coding

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