Abdominal Paracentesis: Safety and Efficacy Comparing Medicine Resident Bedside Paracentesis vs. Paracentesis Performed by Interventional Radiology

Abstract

Background: Patients who are hospitalized for decompensated cirrhosis often require an abdominal paracentesis. Several studies and various societies have deemed this procedure to carry low risk of complications. However, Hospital Internists are increasingly referring this procedure to Interventional Radiology (IR) to perform. As a result, hospital costs, use of resources, and patient length of stay (LOS) have all risen. The primary aim of this study was to compare the complication rates after paracentesis performed at bedside by Internal Medicine Residents with those performed by Interventional Radiology Attendings. The secondary aim was to compare additional clinical outcomes including time to procedure, bacterial culture yield, and transfusion rates between the two groups. Methods and Findings:A retrospective analysis was conducted of all paracentesis procedures performed on patients admitted to a single large academic tertiary care medical center from July 2017 to April 2018. Data was queried based on procedure notes and orders placed in the electronic medical record. Clinical outcomes were assessed up to 48 hours post index procedure and compared between patients who had bedside and IRguided procedures. 118 paracentesis encounters were included in the final analysis. Complication rates regarding hemorrhage, persistent leakage of fluid, abdominal perforation, and ICU transfer were similar between bedside and IR paracentesis. As for secondary outcomes, a significant different was found with regards to time to procedure. The time from procedure referral to procedure completion was less in the bedside group (5.3 hours ± 6.8 vs. 22.5 hours ± 36.5; p=0.001). However, no statistical differences were found in terms of total hospital LOS, the number of units of red blood cell, platelet or fresh-frozen plasma transfused pre-and post-procedure, bacterial fluid culture yield, and the volume of ascites removed during therapeutic paracentesis. Conclusion:This study suggests that bedside abdominal paracentesis performed by Internal Medicine resident physicians and those performed by Interventional Radiologists have similar complication rates. Other clinical outcomes including volume removed during therapeutic paracentesis and the need for blood product transfusion were also shown to be comparable between the two groups whereas bedside paracentesis was found to be superior in terms of time to procedure. The findings of this study suggest that IR-guided paracentesis should not be favored routinely over bedside paracentesis.

Procedural Competency Among Hospitalists: A Literature Review and Future Considerations

“…Similarly, a prospective audit of 529 bedside procedures did not show any differences in complication rates between generalists and pulmonologists, once generalists underwent standardized training and used pleural safety checklists and ultrasound guidance 26 . An administrative database review of 130,000 inpatient thoracenteses across several university hospitals between 2010 and 2013 found that the risk of iatrogenic pneumothorax was similar among operators from IR, medicine, and pulmonary (2.8%, 2.9%, and 3.1%, respectively) 27 ; these findings have been reproduced in other studies 28 . Finally, the increasing adoption of procedural ultrasound permits procedures to be conducted more safely at the bedside, without the need to refer to radiology for imaging guidance 3‐5 …”

“…Moreover, referred procedures resulted in increased length of stay, which can incur additional costs. However, the data were conflicting; two studies did not show a statistical difference, 25,28 while others found an increased length of stay, 24,27,29 which might be due to the unavailability of specialists during off hours, thereby delaying nonemergent procedures 21 . Detailed cost analyses have controlled for the use of procedural facilities and blood transfusions among IR specialists and simulation training among generalists, showing that total costs were $663 per patient undergoing IR procedures compared with $134 per patient undergoing bedside procedures 30 …”

“…26 An administrative database review of 130,000 inpatient thoracenteses across several university hospitals between 2010 and 2013 found that the risk of iatrogenic pneumothorax was similar among operators from IR, medicine, and pulmonary (2.8%, 2.9%, and 3.1%, respectively) 27 ; these findings have been reproduced in other studies. 28 Finally, the increasing adoption of procedural ultrasound permits procedures to be conducted more safely at the bedside, without the need to refer to radiology for imaging guidance. [3][4][5] IR procedures also are associated with increased healthcare costs compared with bedside procedures.…”

Characteristics and impact of bedside procedure services in the United States: A systematic review

“…Additionally, as demonstrated by both Ritter et al 19 and Barsuk et al, 30 there is evidence that bedside procedures may be associated with reduced LOS. Furthermore, Berger et al 31 found that paracentesis procedures performed at the bedside (although not involving a dedicated procedure team) had a shorter time‐to‐procedure compared to those performed by IR. This is of much clinical consequence because delayed paracentesis in the setting of spontaneous bacterial peritonitis has been associated with increased mortality 10 …”