Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission.

BACKGROUND AND AIM: Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS: A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS: Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION: When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.

Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn.

BACKGROUND: Pneumothorax occurs more frequently in the neonatal period than at any other time of life and is associated with increased mortality and morbidity. It can be treated with either aspiration with a syringe (using a needle or an angiocatheter) or a chest tube inserted in the anterior pleural space and then connected to a Heimlich valve or an underwater seal with continuous suction. OBJECTIVES: To compare the efficacy and safety of needle aspiration (either with immediate removal of the needle or with the needle left in situ) to intercostal tube drainage in the management of neonatal pneumothorax (PTX). SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 4 June 2018), Embase (1980 to 4 June 2018), and CINAHL (1982 to 4 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing needle aspiration (either with the needle or angiocatheter left in situ or removed immediately after aspiration) to intercostal tube drainage in newborn infants with pneumothorax. DATA COLLECTION AND ANALYSIS: For each of the included trials, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, kind of needle and chest tube, choice of intercostal space, pressure and device for drainage) and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcomes considered in this review are mortality during the neonatal period and during hospitalisation.We used the GRADE approach to assess the quality of evidence. MAIN RESULTS: Two randomised controlled trials (142 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality when the needle was removed immediately after aspiration (risk ratio (RR) 3.92, 95% confidence interval (CI) 0.88 to 17.58; participants = 70; studies = 1) or left in situ (RR 1.50, 95% CI 0.27 to 8.45; participants = 72; studies = 1) or complications related to the procedure. With immediate removal of the needle following aspiration, 30% of the newborns did not require the placement of an intercostal tube drainage. None of the 36 newborns treated with needle aspiration with the angiocatheter left in situ required the placement of an intercostal tube drainage. Overall, the quality of the evidence supporting this finding is very low. AUTHORS' CONCLUSIONS: There is insufficient evidence to establish the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax. The two included trials showed no differences in mortality; however the information size is low. Needle aspiration reduces the need for intercostal tube drainage placement. Limited or no evidence is available on other clinically relevant outcomes.

Mortality Following Catheter Drainage Versus Thoracentesis in Cirrhotic Patients with Pleural Effusion.

BACKGROUND: Pleural effusion is an abnormal collection of body fluids that may cause related morbidity or mortality in cirrhotic patients. There are insufficient data to determine the optimal method of drainage, for symptomatic relief in cirrhotic patients with pleural effusion. AIMS: In this study, we compare the mortality outcomes of catheter drainage versus thoracentesis in cirrhotic patients. METHODS: The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify cirrhotic patients with pleural effusion requiring drainage between January 1, 2007, and December 31, 2010. In all, 2556 cirrhotic patients with pleural effusion were selected for the study and divided into the two groups (n = 1278/group) after propensity score matching. RESULTS: The mean age was 61.0 ± 14.3 years, and 68.9% (1761/2556) were men. The overall 30-day mortality was 21.0% (538/2556) and was higher in patients treated with catheter drainage than those treated with thoracentesis (23.5 vs. 18.6%, respectively, P < 0.001 by log-rank test). After Cox proportional hazard regression analysis adjusted by patient sex, age, and comorbid disorders, the risk of 30-day mortality was significantly higher in cirrhotic patients who accepted catheter drainage compared to thoracentesis (hazard ratio 1.30, 95% confidence interval 1.10-1.54, P = 0.003). Old age, hepatic encephalopathy, bleeding esophageal varices, hepatocellular carcinoma, ascites, and pneumonia were associated with higher risks for 30-day mortality. CONCLUSION: In cirrhotic patients with pleural effusion requiring drainage, catheter drainage is associated with higher mortality compared to thoracentesis.