The Role of Ultrasound-Guided Therapeutic Thoracentesis in an Outpatient Transitional Care Program: A Case Series

Abstract

Background: Symptomatic pleural effusions create discomfort and are a frequent cause of hospitalization. Ultrasound-guided thoracentesis is a key palliative intervention to assist in the management of this vulnerable population. Our institution has created a multidisciplinary transitional care program to address the needs of those discharged from the hospital with chronic complex conditions, including symptomatic pleural effusions. Methods: This case series was performed in a transitional care clinic between May 8, 2017, and December 11, 2018. Eight unique patients with symptomatic pleural effusions were referred to our clinic posthospital discharge and treated with ultrasound-guided thoracentesis. A retrospective review was performed to assess procedure details, complications, and follow-up emergency department visits or hospital readmissions. Additionally, cost comparison data were obtained from the hospital financial system. Results: Of the 8 unique patients, 15 thoracenteses were performed over the 19-month period in the transitional care clinic. The median age of the cohort was 56 years old (range: 39-92 years). All patients reported an immediate relief of symptoms (dyspnea and/ or pain) and no procedural complications. The total cost of performing an ultrasound-guided thoracentesis in the transitional care clinic was 61.8% that of performing the procedure in the hospital (US$537.61 vs US$869.65). Conclusion: All 8 patients experienced an immediate relief in pleural effusion-related symptoms following thoracentesis. Our experience helps reveal the safety, efficacy, and cost-efficiency of ultrasound-guided thoracentesis in providing symptom management for patients with pleural effusions in a transitional care clinic.

Time to FOCUS - ‘Palliative Medicine Point-of-Care Ultrasound’

“…Application subset FAST 46 and eFAST 21 Focused assessment with sonography in trauma FEEL 47 Focused echocardiographic evaluation in life support (emergency life support) FATE 48 Focus assessed transthoracic echocardiography BLUE and FALLS 28 Critical care, emergency medicine lung ultrasound RUSH 49 Rapid ultrasound in shock and hypotension FoCUS 50 Focused cardiac ultrasound CAUSE 51 Cardiac arrest ultrasound examination SESAME 52 Starting lung ultrasound to rule out cardiac arrest POCUS-CA 53 Point of care ultrasound cardiorespiratory arrest RADiUS 54 Rapid assessment of dyspnoea with ultrasound VExUS 55 Venous excess ultrasound score (congestion) FASC 45 Focused assessment sonography in cancer PM-POCUS* Palliative medicine point-of-care ultrasound *New terminology proposed for ultrasound use in palliative medicine point-of-care ultrasound (PM-POCUS) with computed tomography imaging. [44] We propose an 8-point protocol for probe placement positions [Figure 7] for palliative medicine POCUS.…”

“…POCUS-guided pigtail catheter insertion which is as effective as the insertion of a chest tube could be performed in a community setting instead of shifting the patient to a hospital setting. [55] Linear high-frequency probes have simplified venous access in a palliative care setting and have rejuvenated pain practice accompanied by palliative care. [1] Bedside ultrasound could be used to perform outpatient-and inpatient-based pain management interventions for the control of pain.…”

“…POCUS-guided pigtail catheter insertion which is as effective as the insertion of a chest tube could be performed in a community setting instead of shifting the patient to a hospital setting. [ 55 ]…”

Point of care ultrasound for rapid assessment and treatment of palliative care patients in acute medical settings

“…Palliative thoracentesis with POCUS guidance can be performed on an outpatient basis and has been reported to be cost-effective [54]. In cases where repeated aspiration is required, tunneled indwelling pleural catheters can be considered, although the risks and benefits of this invasive intervention must be considered in each individual patient [55].…”

“…However, it is clear that research to examine POCUS-first diagnostic strategies assessing more complex questions in this population is sparse. Small case series demonstrate opportunities for more thorough health economic evaluation [8,54,91] of a POCUS-led strategy.…”