Ultrasound-guided thoracentesis in surgical intensive care patients

Abstract

Sir: To evaluate drainage volume, complications, and the diagnostic value of ultrasound-guided (US-guided) thoracentesis in a surgical intensive care unit (SICU), a prospective analysis was performed of all patients who had undergone thoracentesis in the SICU from January 1995 to December 1997. In addition, the impact of patient compliance on the complication rate was observed. Statistical analysis was carried out by the SPSS 8.0 software package using the Spearman rank test.Thoracentesis was performed under 5.0 MHz US scan control with a 2.1-mm needle at the bedside. Chest radiography was performed before and after thoracentesis. A total of 338 thoracenteses were performed in 203 patients (mean age 65.4 years); 59 patients (29 %) were treated because of a gastrointestinal neoplasm, 49 (24 %) were trauma patients, who had a thoracentesis generally after thoracic trauma, 37 patients (18 %) had the procedure after other abdominal surgery, and 20 patients (10 %) had pancreatitis. The remaining 38 patients (19 %) underwent other operative procedures. In 83 cases thoracentesis was carried out in ventilated patients, in 139 cases patients were awake but not compliant, and in 116 cases of thoracentesis patients were alert and cooperative.The average volume of pleural drainage was 616 ml (range 1±4000 ml, SD 454 ml). Altogether, 135 patients (67 %) underwent thoracentesis once, 32 patients (16 %) had a second thoracentesis, 18 patients (9 %) three times and 18 patients (9 %) had more than three. If more than one thoracentesis was necessary, the average period of time between two procedures was 5.2 days (range 1±28 days). In 6 patients (3 %) with neoplasms, pleural infiltration of the neoplasm was verified. In 9 cases (4.4 %), bacteria in the pleural effusions were detected. Complications appeared in 8 procedures (2.4 %): 4 patients (1.2 %) developed a pneumothorax, in one of whom it was drained. Two patients (0.6 %) with initial hemothorax had recurrent hemothoraces and underwent tube drainage, after two thoracenteses (0.6 %) a new hemothorax required thoracotomy.Statistics on the complication rate showed no correlation related to patient compliance (p = 0.38).

Pleural effusions on the intensive care unit; Hidden morbidity with therapeutic potential

“…A similar complication rate was found in a study of parapneumonic effusions in mechanically ventilated patients, with 2/94 (2%) of patients developing a haemothorax 48 . In a surgical ICU with a series of 135 patients having 338 procedures, the complication rate was again similar, with four patients (1.2%) developing pneumothoraces and four developing haemothoraces 54 …”

“…48 In a surgical ICU with a series of 135 patients having 338 procedures, the complication rate was again similar, with four patients (1.2%) developing pneumothoraces and four developing haemothoraces. 54 In a systematic review of studies of thoracocentesis in ventilated patients, Goligher et al 11 found the pooled risk of pneumothorax was 3.4% (95% confidence interval: 1.7-6.5)-20 events in 14 studies including 965 patients. The pooled risk of haemothorax was 1.6% (95% confidence interval: 0.8-3.3%)four events in 10 studies with 721 patients.…”

Quantitative assessment of pleural effusion in critically ill patients by means of ultrasonography*

“…Among 187 sonographically guided procedures, the success rate approached 95%, with a complication rate of only 3% (23). A liberal use of ultrasonography to guide thoracentesis has recently been advocated to increase the safety of this invasive procedure, especially in ventilated ICU patients (10,11,21).…”

“…Quantitative assessment of the volume of pleural effusions would be crucial to help select critically ill patients for thoracentesis. Pleural ultrasonography has been shown to efficiently guide thoracentesis in ICU patients (10,11) and to predict the volume of pleural effusion in ambulatory patients (12). However, its ability to quantitatively assess pleural effusions in the ICU setting has not yet been evaluated.…”

Real-time ultrasound-guided thoracentesis in the intensive care unit: prevalence of mechanical complications

“…Barnes et al [24] and Gervais et al [26], in retrospective studies on ultrasound-guided thoracentesis performed by interventional radiologists, reported pneumothorax rates of 4.9% and 2.3%, respectively. Petersen et al [27] reported a series of 338 ultrasoundguided thoracentesis in the ICU, with four pneumothoraces (1.2%). Lichtenstein et al [28] and Mayo et al [29] reported pneumothorax rates in patients receiving mechanical ventilation of 0 and 1.3%, respectively.…”