Vascular Ultrasonography: A Novel Method to Reduce Paracentesis Related Major Bleeding.

Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low-frequency probe. Experts recommend a "2-probe technique, " which incorporates a high-frequency ultrasound probe in addition to the low-frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2-probe technique, so we performed a pre- to postintervention study to evaluate its effect on paracentesis-related bleeding complications. From February 2010 to August 2011, procedures were performed using only low-frequency probes (preintervention group), while the 2-probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis-related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = 0.07). This clinically meaningful trend suggests that using the 2-probe technique might prevent paracentesis-related major bleeding.

Thoracentesis outcomes: a 12-year experience.

BACKGROUND: Despite a lack of evidence in the literature, several assumptions exist about the safety of thoracentesis in clinical guidelines and practice patterns. We aimed to evaluate specific demographic and clinical factors that have been commonly associated with complications such as iatrogenic pneumothorax, re-expansion pulmonary oedema (REPE) and bleeding. METHODS: We performed a cohort study of inpatients who underwent thoracenteses at Cedars-Sinai Medical Center (CSMC) from August 2001 to October 2013. Data were collected prospectively including information on volume of fluid removed, procedure side, whether the patient was on positive pressure ventilation, number of needle passes and supine positioning. Iatrogenic pneumothorax, REPE and bleeding were tracked for 24 h after the procedure or until a clinical question was reconciled. Demographic and clinical characteristics were obtained through query of electronic medical records. RESULTS: CSMC performed 9320 inpatient thoracenteses on 4618 patients during the study period. There were 57 (0.61%) iatrogenic pneumothoraces, 10 (0.01%) incidents of REPE and 17 (0.18%) bleeding episodes. Iatrogenic pneumothorax was significantly associated with removal of >1500 mL fluid (p<0.0001), unilateral procedures (p=0.001) and more than one needle pass through the skin (p=0.001). For every 1 mL of fluid removed there was a 0.18% increased risk of REPE (95% CI 0.09% to 0.26%). There were no significant associations between bleeding and demographic or clinical variables including International Normalised Ratio, partial thromboplastin time and platelet counts. CONCLUSIONS: Our series of thoracenteses had a very low complication rate. Current clinical guidelines and practice patterns may not reflect evidence-based best practices.

Portable ultrasound: the next generation arrives.

PURPOSE: A new category of handheld devices has recently emerged that are even smaller than current portable models, with their main advantages being increased portability and affordability relative to their counterparts. However, these new devices have not yet been thoroughly evaluated in the clinical setting. METHODS: A prospective, non-blinded, three-phase study was designed to evaluate a handheld ultrasound device as compared to a common compact ultrasound machine for the performance of paracenteses and thoracenteses on human patients. RESULTS: For the vast majority of straight-forward evaluations, the handheld device was sufficient to safely complete the procedure without further imaging. For difficult cases with smaller fluid collections or anatomic aberrations, further localization with the common compact machine continued to be useful to improve the operator's confidence in the findings. CONCLUSION: This novice handheld device represents only one of what appears to be a growing number of new ultra-portable ultrasound devices on the market. These devices represent a new and exciting form of ultrasound technology that may benefit patients and physicians in multiple venues. While they are unlikely to replace standard ultrasound devices for many of the more complex applications, their extreme portability allows for ultrasound imaging in more diverse situations that has previously been practical. Based on our limited experience, the image quality is adequate and the learning curve is reasonable. Future integration of PDA technology could further the utility of these devices and additional study will be important to further define their appropriate niche and clinical utility.

The use of tissue models for vascular access training. Phase I of the procedural patient safety initiative.

INTRODUCTION: Following the Institute of Medicine report "To Err is Human," the Agency for Healthcare Research and Quality identified proper central venous catheter (CVC) insertion techniques and wide sterile barriers (WSB) as 2 major quality indicators for patient safety. However, no standard currently exists to teach proper procedural techniques to physicians. AIM: To determine whether our nonhuman tissue model is an effective tool for teaching physicians proper wide sterile barrier technique, ultrasound guidance for CVC placement, and sharps safety. PARTICIPANTS: Educational sessions were organized for physicians at Cedars-Sinai Medical Center. Participants had a hands-on opportunity to practice procedural skills using a nonhuman tissue model, under the direct supervision of experienced proceduralists. PROGRAM EVALUATION: An anonymous survey was distributed to participants both before and after training, measuring their reactions to all aspects of the educational sessions relative to their prior experience level. DISCUSSION: The sessions were rated highly worthwhile, and statistically significant improvements were seen in comfort levels with ultrasound-guided vascular access and WSB (P<.001). Given the revitalized importance of patient safety and the emphasis on reducing medical errors, further studies on the utility of nonhuman tissue models for procedural training should be enthusiastically pursued.

Percutaneous dilatational tracheostomy for emergent airway access.

The study objective of this article was to evaluate percutaneous dilatational tracheostomy (PDT) for emergent airway access. This is a case series of 9 patients who presented over a 58-month period. All patients were in severe respiratory difficulty where intubation by conventional means was unsuccessful. All 9 patients were successfully intubated using PDT technique. No technical complications were noted, specifically bleeding, extratracheal placement, or prolonged procedure time. Six patients ultimately died, 2 from anoxic encephalopathy due to failed resuscitation and 4 from comorbid illness. Three patients ultimately survived to hospital discharge. The authors conclude that PDT can effectively establish a surgical airway in an emergent setting. The major advantage of this technique is the ability to gain and maintain competence in an elective, controlled environment. The authors believe that PDT may play a role in the management of the emergent surgical airway.