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

Abstract

Background

The use of thoracic ultrasound during thoracentesis reduces complications. The aim of this study was to determine the prevalence of complications for real-time ultrasound-guided thoracentesis performed by intensivists. As a secondary objective, the change in oxygenation before and after the procedure was evaluated.

Patients and methods

An observational prospective study was conducted. A total of 81 cases of real-time ultrasound-guided thoracentesis performed by intensivists in the intensive care unit (ICU) of Méderi Major University Hospital, Bogotá, Colombia, between August 2018 and August 2019 were analyzed.

Thoracentesis performed by interventional radiologists and using techniques different from the focus of this study were excluded from the analysis.

Results

There was one pneumothorax, for a prevalence rate of mechanical complications in this population of 1.2%.

The mean partial oxygen pressure to inspired oxygen fraction ratio (PaO2/FiO2) prior to the procedure was 198.1 (95% CI 184.75–211.45), with a PaO2/FiO2 after the procedure of 224.6 (95% CI 213.08–226.12) (p < 0.05).

Conclusions

Real-time ultrasound-guided thoracentesis performed by intensivists is a safe procedure and leads to a significant improvement in oxygenation rates.

Future studies are required to determine the impact of these results on other outcomes, such as mortality, ICU stay, and days of mechanical ventilation

Background

Pleural effusion is a frequent finding in the intensive care unit (ICU), and it can cause hypoxemia and alterations in lung mechanics [1].

The prevalence of pleural effusion in the ICU can vary between 40 and 60% [2].

The commonly reported causes of pleural effusion in this population are infectious exudates (43%), non-infectious exudates (33%) and transudates (24%) [3]. In postoperative patients undergoing cardiovascular surgery, up to 7% present with pleural effusion, the most common cause being hemothorax in up to 50% of cases, with dyspnea as the predominant symptom [4].

Pleural effusions with documented volumes greater than 500 ml affect gas exchange, hemodynamic stability and respiratory work, and it has been demonstrated that drainage of pleural effusions in ICU patients under mechanical ventilation is related to improved oxygenation indices, increased end-expiratory volume and decreased transpulmonary pressure [5].

A recent meta-analysis that included 31 studies with 2265 patients showed that drainage of pleural fluid produces improvement in PaO2/FiO2 as an oxygenation index and tends to increase end-expiratory volume [6].

Thoracentesis is a percutaneous procedure for collecting pleural fluid, and it has diagnostic utility and therapeutic applications. It is recommended for pleural effusions of unknown cause, because it allows defining the cause of the effusion and has therapeutic utility in large-volume pleural effusions associated with respiratory distress [7].

Thoracentesis should not be performed for bilateral effusions in a clinical picture strongly suggestive of transudate (e.g., cardiac failure), unless the presentation is atypical or does not respond to clinical management [89].

Complications related to the performance of blind thoracentesis include a high incidence of pneumothorax (11%) [10]; for this reason, the use of ultrasound guidance is strongly recommended for performing interventions in the pleural space and using small-diameter catheters [1112].

In turn, the diagnostic sensitivity of ultrasound for pleural effusion is higher compared to that of chest X-ray and allows identifying the pleural fluid characteristics that differentiate complicated and uncomplicated effusions and homogeneous and heterogeneous effusions [13].

In addition, the routine implementation of pulmonary ultrasound in the ICU decreases the number of chest X-rays, with a reduction in medical costs and radiation exposure, without affecting the clinical results [14].

Various techniques have been developed to estimate the volume of pleural fluid by ultrasound, with a good correlation between the drained liquid and that calculated prior to the procedure, finding that distances between the diaphragm and the visceral pleura greater than 30 mm are related to pleural effusions greater than 500 ml [15].

Balik et al. described a formula to calculate the pleural effusion volume by ultrasound by measuring the maximal interpleural distance (Sep) in millimeters (mm) in end-expiration at the lung base in a posterior axillary line and multiplying this value by 20, quantifying the pleural fluid volume (Vpl) in milliliters (ml) [16].

The method described by Balik et al. was validated in patients under invasive mechanical ventilation in a supine position with mild trunk elevation at 15°; however, the mean prediction error of this equation is high (158 ± 160 ml) [1617].

The position of the patient influences the volume calculated by this method because when elevating the headboard, the free pleural fluid experiences the effects of gravity and can increase the interpleural distance [18].

In Balik et al.’s original work, no difference in correlation of interpleural distance with the right- and left-side drained volumes was found [16]; however, other studies have found a better correlation on the right side [1920]. This is secondary to the fact that on the left side, the heart increases the level of a pleural effusion, like a stone in a container with water, leading to overestimation of the interpleural distance [18].

The aim of this observational study was to determine the prevalence of complications of real-time ultrasound-guided thoracentesis performed by intensivists.

As a secondary objective, the change in oxygenation before and after the procedure was evaluated.

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Andrés Felipe Yepes, Claudia Inés Birchenall Jiménez, Mario Andrés Mercado Díaz & Darío Isaías Pinilla Rojas.  

Correspondence to David Rene Rodriguez Lima.

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