Pleural manometry during thoracocentesis in patients with malignant pleural effusion: A randomized controlled trial.

Background: Large-volume therapeutic thoracocentesis may be associated with pulmonary congestion or a more serious complication; re-expansion pulmonary edema (RPE). We investigated whether monitoring pleural pressure with manometry during thoracocentesis would prevent these pulmonary symptoms/RPE and allow larger volume drainage. Methods: We did a randomized controlled trial involving 110 patients with large malignant pleural effusions. Patients were randomly allocated to obtain thoracocentesis with or without pleural manometry. We measured the incidence of pulmonary congestion symptoms, total fluid aspirated, and pleural pressures in both groups. This trial is listed on ClinicalTrials.gov as NCT04420663. Results: The mean amount of total thoracocentesis fluid withdrawn from the control group was 945.4±78.9 (mL) and 1690.9±681.0 (mL) from the intervention group (P<0.001). Clinical symptoms of pulmonary congestion appeared in (n=20) (36.3%) of patients in the intervention group while no symptoms appeared in controls (P<0.001). The difference between opening and closing pressures between the non-symptomatic cluster and the symptomatic cluster was (32.8±15.6 versus 42.2±13) respectively (P=0.02). Total fluid withdrawn from the non-symptomatic cluster was 1828.5±505 mL in comparison to 1,450±875 mL in the symptomatic cluster (P=0.04). Conclusion: Pleural manometry can be used to increase the volume of fluid removed on each occasion in patients with malignant pleural effusion. In our study, pleural manometry was associated with a larger number of pulmonary congestion symptoms/RPE. We believe that manometry may be a useful tool to not exceed a 17 cm H2O gradient in pleural pressure which should be avoided to prevent pulmonary congestion symptoms or RPE. Pulmonary congestion symptoms/RPE are not related to the amount of volume withdrawn but to the gradient of pleural pressure drop. Our conclusion does support the adoption of pleural manometry whenever large-volume thoracocentesis is intended.

Association of patient safety indicator 03 and clinical outcome in a surgery hospital.

PURPOSE: Patient safety indicators (PSIs) were developed as a tool for hospitals to identify potentially preventable complications and improve patient safety performance. The study aimed at measuring the incidence of the Agency for Healthcare Research and Quality (AHRQ) PSI03 (pressure ulcer [PU] rate) and to identify the association between PSI03 and clinical outcomes including death, readmission within 30 days and length of stay (LOS) at the cardiothoracic surgery hospital at Ain Shams University, Cairo, Egypt. DESIGN/METHODOLOGY/APPROACH: An exploratory prospective cohort study was conducted to follow up patients, who fulfilled the inclusion criteria, from admission until one month after discharge at the cardiothoracic surgery hospital. Data were collected through basic information and follow-up sheets. The total number of included participants in the study was 330. FINDINGS: PSI03 incidence rate was 67.7 per 1,000 discharges. Patients aged 60 years and above had the highest risk among all age groups. In patients who developed PSI03, the risk ratio (RR) of death was 8.8 [95% CI (3.79-20.24)], RR of staying more than 30 days at the hospital was 1.5 [95% CI (1.249-1.872)] and of readmission within 30 days in patients who developed PSI03 was 1.5 [95% CI (0.38-6.15)]. In the study's hospital, the patients who developed PSI03 were at higher risk of death and stayed longer at the hospital than patients without PSI03. This study demonstrated a clear association between PSI03 and patient outcomes such as LOS and mortality. Early detection, prevention and proper management of PSI03 are recommended to decrease unfavorable clinical outcomes. ORIGINALITY/VALUE: The importance of PSIs lies in the fact that they facilitate the recognition of the adverse events and complications which occurred during hospitalization and give the hospitals a chance to improve the possible clinical outcomes. Therefore, the current study aimed at measuring the association between AHRQ PSI03 ( PU rate) and the clinical outcomes including death, readmission within 30 days and the LOS at the cardiothoracic surgery hospital at Ain Shams University. This study will provide the hospital management with baseline data for this type of adverse event and guide them to develop a system for identifying the high-risk group of patients and to upgrade relevant hospital policies and guidelines that lead to improved patient outcomes.

Single-Stage Complete Repair versus Multistage Repair of Tetralogy of Fallot with Borderline Pulmonary Arteries.

BACKGROUND: Tetralogy of Fallot is the most common cyanotic congenital heart defect. Borderline pulmonary anatomy has been associated with a higher risk of mortality and morbidity. Strategies to manage this condition-namely, single- or multistage repair-have long been debated. OBJECTIVE: The overall outcomes of patients with tetralogy of Fallot with borderline pulmonary arteries (McGoon ratio 1.3 to 1.7) with regard to the need for a single-stage or multistage repair and the outcome of each surgical management were evaluated. PATIENTS AND METHODS: A retrospective, nonrandomized comparative study designed to evaluate patient outcomes comprised 60 patients with tetralogy of Fallot with borderline pulmonary arteries who underwent surgery at the Cardiothoracic Surgery Academy, Ain Shams University, Cairo, Egypt, between January 2016 and December 2017. After gaining approval from the affiliated ethical and research committee, and informed consent of the guardians, the patients were assigned into one of two groups. Shunt group included 30 patients managed surgically by a modified Blalock-Taussig (MBT) shunt as a part of a multistage repair, and repair group included 30 patients managed surgically by single-stage complete repair. The medical records of the patients were reviewed, and data relating to age, sex, weight, and preoperative oxygen saturation were collected. All patients underwent preoperative echocardiography and multislice computed tomography (CT) with angiography. The follow-up was performed by echocardiography at discharge and at one month and six months after surgery. Multislice CT with angiography was performed in patients who received a shunt once the echocardiography showed acceptable pulmonary arteries. RESULTS: The patients' age ranged from 5 to 50 months with a mean age of 18.63 ± 9.15 (19.84 ± 12.34 for the shunt group and 17.43 ± 8.54 for the repair group). The weight ranged from 5 kg to 18 kg with a mean of 9.6 ± 2.53 (8.82 ± 2.79 for the shunt group and 10.41 ± 2.63 for the repair group). The mean preoperative O2 saturation was 68.95% ± 7.8% for the shunt group and 87.93% ± 6.18% for the repair group. The median McGoon ratio was 1.4 for the shunt group and 1.6 for the repair group, the difference of which was highly significant (P < .0001). The mortality rate in our study was 10% (10% for the shunt group and 10% for the repair group). The morbidity incidence rate was 26.6% for the shunt and repair groups. The ICU stay ranged from 2 to 31 days, with a median of three days for the shunt group (mean 3.61 ± 1.91) and four days for the repair group (mean 6.07 ± 6.63 days). The calculated P value showed a significant difference between the two groups concerning ICU stay. The postoperative SO2 significantly increased to a mean of 85.58 ± 7.05 in the shunt group and 98.14 ± 3.36 in the repair group (P < .0001). CONCLUSION: There was no statistically significant difference between multistage repair and single-stage complete repair regarding morbidity and mortality. Regarding ICU stay, patients in the single-stage had a better outcome. A McGoon ratio of 1.5 can be used as a guideline in the decision-making process.