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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Original studies of ultrasound-guided thoracentesis concluded a 2% risk of pneumothorax. A recent single center study of 9320 thoracenteses over 12 years all by procedural experts had pneumothorax rate of 0.6%. This same study also demonstrated a very low incidence…
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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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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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This blog will offer some expert recommendations to help guide the safety of hospital procedures at different platelet and coagulation profiles.  Unfortunately, there are no strong evidence-based guidelines for hospital procedures dedicated to the study of patients with decompensated cirrhosis.…
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A historical myth in procedural medicine is the operator should limit removal of pleural fluid to 1.5 L during thoracentesis because of the risk of re-expansion pulmonary edema or pneumothorax.  New evidence supports safety of large volume thoracentesis until no…
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How to Differentiate Pleural Effusion Exudates from Transudates   Historically, Light’s criteria have been used to classify pleural effusions into transudates or exudates.  Light’s criteria were established by Dr. Richard Light in 1972.[1]  These criteria maximize sensitivity but have a…
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This blog summarizes a recent update reviewing current management recommendations for hepatic hydrothorax (HH).  Hepatic hydrothorax is a complication of decompensated cirrhosis with portal hypertension.  Sixty percent of patients accumulate both ascitic fluid and pleural fluid as a result of portal…
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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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Historically, it was felt that a platelet count below 50,000 or an INR>1.5 was a contraindication to thoracentesis because of an increased bleeding risk.  These were arbitrary cut-offs that have since been challenged with newer kits and the use of…
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How to Differentiate Pleural Effusion Exudates from Transudates Historically, Light’s criteria have been used to classify pleural effusions into transudates or exudates.  Light’s criteria were established by Dr. Richard Light in 1972.[1]  These criteria maximize sensitivity but have a lower…
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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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Recent studies have determined the best technique for improving the safety of thoracentesis. The patient should be sitting as upright as possible. Then, ultrasound the posterior back and locate a catheter insertion point at least 6 cm lateral to the…
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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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Thoracentesis is one of the most common bedside procedures performed in U.S. hospitals.  There are about 173,000 thoracenteses performed each year in the U.S.  A systematic review and meta-analysis in 2010 concluded that thoracentesis-related pneumothorax occurs 6% of the time…
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