Periprocedural Bleeding Risk for Thrombocytopenia, Coagulopathy, Antiplatelets and Anticoagulation

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, Central line, Chest Tube, Featured Procedure, Hematology, Lumbar Puncture, Medical General, medical procedures, Paracentesis, Thoracentesis
More Tags – anticoagulation, antiplatelets, central lines, chest tubes, coagulopathy, featured procedure, HPC updates, lumbar puncture, paracentesis, procedures, sir anticoagulation guidelines, sir guidelines anticoagulation, thoracentesis
This blog summarizes the 2019 Society of Interventional Radiology (SIR) for Periprocedural Management of Image-guided Procedures with regards to thrombocytopenia, coagulopathies, antiplatelets and anticoagulation.  The SIR guidelines are summarized as follows: Anticoagulation with heparin, LMWH, fondaparinux, argatroban, warfarin, DOAC, clopidogrel, ticagrelor…
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Recommendations for Invasive Hospital Procedures in Patients with Cirrhosis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Chest Tube, Featured, Gastrointestinal diseases, Hospital Procedures, Paracentesis, Thoracentesis
More Tags – Arterial line placement, central line placement, chest tube placement, cirrhosis, DIC, featured, HPC updates, hyperfibrinolysis, paracentesis, thoracentesis, tube thoracostomy
This blog aims to summarize the data available on how to safely perform invasive hospital procedures in patients with cirrhosis. Unfortunately, no prospective randomized controlled trials have been conducted to inform the practice of procedural medicine in cirrhotic patients. Therefore,…
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Airway Management in COVID-positive Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Central line, Chest Tube, Endotracheal Intubation, Featured Procedure, Glidescope Intubation, King Tube, Laryngeal Mask Airway, Mechanical Ventilation, medical procedures, Respiratory diseases
More Tags – airway management, COVID, featured procedure, HPC updates, intubation
A number of additional factors must be considered with airway management in COVID-positive patients. Hospital Procedures Consultants (HPC) can provide simulation-based training to prepare providers for airway management in COVID-positive patients. The first essential consideration is to place the patient into a…
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Safety of Thoracentesis and Tube Thoracostomy in Patients with Uncorrected Coagulopathies

Tube Thoracostomy Insertion Procedure
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Chest Tube, Endotracheal Intubation, Featured, Hematology, medical procedures, Thoracentesis
More Tags – anticoagulation, antiplatelets, chest tube placement, coagulopathy, featured, HPC updates, thoracentesis, tube thoracostomy
Traditionally, it was felt that the INR had to be less than 1.5 and platelets had to be at least 50,000/µL to perform most bedside procedures. With more clinical evidence, we now know that low-risk bedside procedures can be performed…
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How to Place a Chest Tube in a Safe and Humane Fashion

Hospital Procedure Consultants
More Articles – Cardiovascular diseases, Chest Tube, Featured Procedure, King Tube, medical procedures, Procedural Sedation
More Tags – chest tube, featured procedure, HPC updates, procedural sedation, tube thoracostomy
Chest tube placement, or tube thoracostomy, can be an anxiety-provoking procedure for both the patient AND the operator.  It can also be a very gratifying procedure for the operator when performed successfully and without patient discomfort. Here are a few…
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Management of Pleural Infections

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Chest Tube, Featured, Infections, King Tube, medical procedures, Respiratory diseases, Thoracentesis
More Tags – chest tube, empyema, featured, HPC updates, parapneumonic effusion, pleural effusion, thoracentesis, tube thoracostomy
Complicated parapneumonic effusions frequently represent pleural space infections. Approximately 1 in 7 cases of pneumonia have an associated parapneumonic effusion (PPE) on chest x-ray. Most of these effusions are small and usually resolve spontaneously with prompt antibiotic administration. However, moderate-to-large…
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In-person Procedural Education in the Era of COVID19

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Chest Tube, Emergency Procedures, Featured, Glidescope Intubation, Lumbar Puncture, Paracentesis, Thoracentesis
More Tags – chest tube placement, emergency procedures course, featured, hospital procedures course, HPC updates, intubation, lumbar puncture, medical procedures course, paracentesis, POCUS, thoracentesis, Vascular access
Medical procedural education in the era of COVID19 is still best conducted via HANDS-ON simulation-based procedural training. Procedural skills can NOT be attained via remote education, but in-person training must be conducted safely. There are many topics and skills that can be successfully be taught online,…
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The subclavian vein may be the preferred location over IJ and Femoral Locations for Central Line Placement

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Chest Tube, Featured Procedure, Infections
More Tags – central line complications, central line placement, central lines, featured procedure, HPC updates
Where to place a central venous catheter is a decision driven mainly by individual preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause…
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Does chest tube location or size matter for tube thoracostomy in trauma patients?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, Featured Procedure, medical procedures
More Tags – chest tube, chest tube position, chest tube size, HPC updates, tube thoracostomy
Traditional teaching is that chest tubes placed to evacuate a pneumothorax should be directed anterior and superior and to evacuate fluid should be directed posterior and inferior. A recent study examined the effect of specific chest tube position on chest…
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Ultrasound-guided Tube Thoracostomy Improves Optimal Insertion Site Selection

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, Emergency Procedures, Featured, medical procedures
More Tags – chest tube, featured, HPC updates, tube thoracostomy, ultrasound
The optimal insertion site for tube thoracostomy is at the mid-axillary line in the triangle of safety.  This avoids any major nerves or arteries aside from the intercostal vessels.  Ultrasound-guided localization of this site performed better than palpation. In semi-elective…
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Factors that influence Pleural Fluid pH after Thoracentesis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures, Respiratory diseases, Thoracentesis
More Tags – chest tube, HPC updates, pleural fluid analysis, thoracentesis, tube thoracostomy
Pleural fluid pH is an important measure for determining the clinical management of pleural diseases. For example, a pleural fluid pH <7.2 in patients with suspected pleural infection should mandate the placement of a chest tube. However, pleural fluid pH…
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Conservative Fluid Management Decreases Ventilator Days but not Mortality Compared with Liberal Fluid Management in ARDS

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures, Respiratory diseases
More Tags – ARDS, Central venous pressure, Conservative fluid management, CVP, FACTT, FACTT Conservative, FACTT Liberal, FACTT Lite, Fluid and Catheter Treatment Trial, HPC updates, mechanical ventilation, Pulmonary artery occlusion pressure
A retrospective study compared the performance of Fluid and Catheter Treatment Trial (FACTT) Lite, FACTT Conservative, and FACTT Liberal. The prior FACTT demonstrated that conservative fluids is superior to liberal fluids for ARDS. A simplified conservative fluid protocol (FACTT Lite)…
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New Guidelines for Chest Tube Removal

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures
More Tags – chest tube, Chest tube removal, Guidelines, HPC updates, tube thoracostomy
A collection of recent studies has helped determine the best protocol for removing chest tubes. For instance, a trial of water seal for at least six hours is recommended before discontinuation. The water seal reduces the need for another chest…
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What Size Catheter Should I Use For Needle Decompression For a Tension Pneumothorax?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures, Needle Decompression, Respiratory diseases, Traumatology
More Tags – chest tube, Chest wall thickness, HPC updates, Needle decompression catheter, Pleural space, Tension pneumothorax, tube thoracostomy
A recent meta-analysis of 13 studies that were investigating needle decompression compared data of sample size, mean chest wall thickness, and decompression success rates. The meta-analysis concluded that the needle decompression catheter should be at least 6.5 cm in length…
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Ultrasound-Guided Thoracentesis is Probably Safe Even When Patients are Taking Clopidogrel (Plavix)

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, Hematology, King Tube, Medical General, medical procedures, Thoracentesis, Traumatology
More Tags – Clopidogrel, HPC updates, Plavix, Risks, Small-bore chest tube, thoracentesis
A prospective cohort single center study was conducted to analyze the risk associated with patients undergoing thoracentesis or small-bore chest tube placement while taking clopidogrel. Twenty-five patients taking clopidogrel gave consent to remain on the antiplatelet medication while undergoing thoracentesis…
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