Ultrasound guided paracentesis and thoracentesis for hospitalists

Deepti S Rao

Thanks

• Jason Cohen• Michel Boivin

Objectives

After this session you should be able to:1. Explain the rationale behind using ultrasound

in thoracentesis and paracentesis2. Understand the objectives, outcomes and

activities proposed in my research project3. Discuss the feasability of doing this project in

this group of hospitalists.

Ultrasound in procedures

• Central lines– Lots of literature including increased patient safety

• Thoracentesis/Paracentesis– Not much literature

Ultrasound in thoracentesis

• Risk of complications up to 19%• Grogan et al. Archiv Int med, 1990

– 0% vs 29% reduction in pneumothorax when ultrasound used for needle placement

• Raptopoulos et al. Am Journ Roent, 1991.

– 3% vs 18%– Irregardless of size of effusion, whether

thoracentesis was diagnostic or therapeutic, and whether tap was dry.

Ultrasound in thoracentesisARCH INTERN MED/VOL 170 (NO. 4), FEB 22, 2010

• Table 3. Unadjusted Odds Ratios for Pneumothorax by Procedural or Patient Factor (Direct Comparisons)

• Variable No. of Studies No. of Patients With(Without) Variable Odds Ratio (95% Confidence Interval)• for Pneumothorax

• Procedural Factors• Ultrasonography vs no ultrasonography 6 654 (1026) 0.3 (0.2-0.7)• Experienced operator vs inexperienced 4 308 (622) 0.7 (0.2-2.3)• Therapeutic thoracentesis vs diagnostic 12 1048 (1323) 2.6 (1.8-3.8)• Larger needle or catheter vs small needle 7 700 (1178) 2.5 (1.1-6.0)• 2 Needle passes vs 1 pass 3 145 (580) 2.5 (0.3-20.1)• Follow-up thoracentesis vs initial 3 377 (993) 1.1 (0.3-3.6)

• Periprocedural Factors• Aspiration of air vs none 2 19 (661) 104.0 (2.0-5355.0)• Periprocedural symptoms vs none 3 57 (1504) 26.6 (2.7-262.5)

• Patient Factors• Large effusion size vs small 7 758 (697) 1.3 (0.8-1.9)• Male vs female sex 3 272 (220) 0.8 (0.3-1.7)• ICU inpatient location vs non-ICU inpatient 3 142 (620) 0.9 (0.4-1.8)• Non-ICU inpatient location vs outpatient 2 213 (448) 1.0 (0.5-2.0)• Mechanical ventilation vs not 2 100 (589) 4.0 (0.95-16.8)• Loculated pleural effusion vs nonloculated 3 106 (377) 0.7 (0.3-1.7)

• Abbreviation: ICU, intensive care unit.• Only studies that reported results for both the presence and absence of a variable.

Ultrasound in thoracentesis

• “X marks the spot” after a delay not associated in a reduction in pneumothorax rate– Raptopoulos et al. Am J of Roent, 1991

Ultrasound in thoracentesis

• Failed thoracentesis– 58% of clinically attempted dry taps had needle

insertion sites below the diaphragm (Weingardt, J Clin Ultra, 1994)

– Fluid can be successfully obtained in up to 88% of patients who had failed clinically directed thoracentesis (Kopman, Chest, 2006.)

– Ultrasound increased rate of accurate site selection 26% and decreased number of dangerous needle insertions by 10% (Diacon, Chest 2003)

Ultrasound in thoracentesis

• In summary, the complication rate for thoracentesis is high and ultrasound can decrease that risk

Ultrasound in paracentesis

• Complications low (up to 2.7%)– Runyon, Arch Int Med, 1986

• Ultrasound may have a role in identifying smaller pockets of fluid– Physical exam can fail to find small amounts of

fluid or the most easily accessible pocket of fluid– Ultrasound can detect pockets of fluid as small as

100cc

Ultrasound in paracentesis

• Ultrasound decreased the number of unsuccessful attempts by demonstrating which patients did not have sufficient ascites to tap– Nazeer, etal. American Journal of Emergency Medicine, 2005.

So why do we want to do this?

• Patient safety• Patient comfort (increased success in

performing)• Resident learning and comfort• Basis for eventual simulation based procedural

training

Resident comfortHuang etal, The American Journal of Med, 2006

• Table 3 Lack of comfort, by procedure• Lack of comfort with All n 527 Central line n 268 Lumbar puncture n 95 Paracentesis n 81 Thoracentesis n 93 Pvalue*

• Indications and• contraindications, n (%) 11 (2.1%) 6 (2.2%) 0 (0.0%) 0 (0.0%) 5 (6.0%) .017• Obtaining consent, n (%) 10 (1.9%) 5 (1.9%) 2 (2.1%) 2 (2.5%) 1 (1.2%) .935• Anatomy, n (%) 28 (5.3%) 19 (7.1%) 3 (3.2%) 1 (1.2%) 5 (6.0%) .040• Equipment, n (%) 45 (8.5%) 19 (7.1%) 5 (5.3%) 10 (12.3%) 11 (13.3%) .001• Sterile technique, n (%) 7 (1.3%) 6 (2.2%) 0 (0.0%) 1 (1.2%) 0 (0.0%) .494• Patient positioning, n (%) 14 (2.7%) 6 (2.2%) 4 (4.2%) 2 (2.5%) 2 (2.4%) .191• Interpreting the results, n• (%)• 25 (4.7%) 16 (6.0%) 2 (2.1%) 3 (3.7%) 4 (4.8%) .493• Being supervised, n/total• (%)†• 5/206 (2.4%) 3/89 (3.4%) 0/27 (0.0%) 0/25 (0.0%) 2/65 (3.1%) .884• Being unsupervised,• n/total (%)‡• 119/321 (37.1%) 70/179 (39.1%) 23/68 (33.8%) 14/56 (25.0%) 12/18 (66.7%) .001• Managing complications,• n (%)• 186 (35.3%) 87 (32.5%) 32 (33.7%) 28 (34.6%) 39 (47.0%) .003• Mean number of aspects• with lack of comfort, n• (SD, range)• 0.85 (1.1, 0-8) 0.88 (1.2, 0-8) 0.75 (0.1, 0-4) 0.75 (1.0, 0-4) 0.98 (1.1, 0-6)

Thoracentesis – Iatrogenic pneumothorax

• AHRQ Healthcare Cost & Utilization Project, Nationwide Inpatient Sample database, 2000

• 7.45 million hospital d/c abstracts• 994 short-term acute care hospitals• 28 states• JMH: July 2007 through June 2008• Procedure team: July 2007 through June

2008

15

Number Incidence Rate

National n/a 2.68%

JMH 286 5.94%

Procedure team 89 1.12%*

16

Healthcare toll per episode

• 4 – 7 excess days in hospital length of stay

• $17,000 - $45,000 in excess cost

• 1% - 14% excess mortality

In summary

• Ultrasound decreases complication rates in thoracentesis and may reduce unnecessary procedures in paracentesis.

• This can reduce risk to our patients.• This is a skill our residents should have

exposure to.

Curricula for teaching ultrasound

• Didactics– Ultrasound physics– Machine usage– Indications– Anatomy

• Supervised scanning– Hand on hand

Judging competency

• Multiple choice testing• Observed scanning– 5-10 scans

ACEP: 3-4 hours didactics, 2-4 hours supervised scanning

Research question

• Can a multi-part learning curriculum aimed at inpatient medicine attendings increase the competency of internal medicine physicians in performing ultrasound guided paracentesis and thoracentesis? And will this increased competency lead to an increased use of ultrasound for these procedures on the medicine wards?

Secondary objectives

• Will this increase resident exposure/teaching to ultrasound

• Will this decrease complication rates

Outcomes

Outcome Measure Learning activitiesCompetence in ultrasound guided para/thora Pre- and post-multiple choice test on ultrasound

technology/anatomy Direct observation of working machine and id fluid

time 0, 1 month and 1 year

Didactic sessions/ online training Hands on trainings

Increased use of ultrasound on the wards Monthly questionnaire of attendings Chart review

Increased teaching/exposure of residents to ultrasound Monthly questionnaire of attendings Pre- and post- tests of residents on ward rotations

Decrease in complications Chart reviews pre and post intervention.

Timeline

Timeline

August 2011 Attend resident Thursday school sessions—Rao Start attending scheduled scanning session with Boivin—Rao

September 2011 Work with medical student to obtain HRRC approval and obtain medical record numbers and start chart reviews for complication rates

Review Didactic sessions available—lecture and online Organize didactic sessions/testing around didactic sessions Begin working on questionnaires

Fourth quarter 2011 Start scheduling supervised scanning sessions Continue with chart reviews

January 2012 Start testing physicians with direct observation of scanning and continue Start monthly questionnaires of ultrasound on wards for attendings and residents

January 2013 End of surveys/daya analysis

Next steps

• What do you think• Credentialing• Billing and Coding