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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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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Thoracentesis-Associated Pneumothorax is Rare when Performed by Procedural Experts Using Ultrasound Guidance

Thoracentesis Course
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured Procedure, medical procedures, Respiratory diseases, Thoracentesis
More Tags – featured procedure, HPC updates, pneumothorax, thoracentesis, Ultrasound-guided thoracentesis
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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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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Safety of Draining Patients Dry During Large Volume Thoracentesis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Featured, medical procedures, Respiratory diseases, Thoracentesis
More Tags – featured, HPC updates, pneumothorax, re-expansion pulmonary edema, thoracentesis
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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Alternative Tests to Differentiate Pleural Effusion Exudates from Transudates

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, Mechanical Ventilation, medical procedures, Thoracentesis
More Tags – featured procedure, HPC updates, Pleural cholesterol, pleural effusion, pleural exudate, pleural transudate
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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Which cirrhotic patients are at high risk for bleeding during hospital procedures?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Featured Procedure, Hospital Procedures, Lumbar Puncture, medical procedures, Paracentesis, Thoracentesis
More Tags – Bleed risk, central line, HPC updates, paracentesis, Procedures in Cirrhotic Patients, thoracentesis
How do we assess a cirrhotic patients bleed risk prior to a planned bedside procedure?  Can our standard platelet count and coagulation studies, prothrombin time (PT/INR) and partial thromboplastin time (aPTT), accurately predict bleed risk in cirrhotic patients?  The quick…
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Review of the Management of Hepatic Hydrothorax

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured, Gastrointestinal diseases, medical procedures, Thoracentesis
More Tags – ascites, cirrhosis, featured, hepatic hydrothorax, HPC updates, pleural effusion, thoracentesis
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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Safety of Thoracentesis with Coagulopathy or Thrombocytopenia

Thoracentesis Course
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured Procedure, Hematology, medical procedures, Thoracentesis
More Tags – coagulopathy, featured, featured procedure, HPC updates, thoracentesis, thrombocytopenia
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

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, medical procedures, Paracentesis, Thoracentesis
More Tags – HPC updates, Pleural cholesterol, pleural effusion, pleural exudate, pleural transudate
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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Anticoagulation is Likely Beneficial for Portal Vein Thrombosis in Cirrhosis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Gastrointestinal diseases, Hematology, Medical General, medical procedures, Thoracentesis
More Tags – anticoagulation, cirrhosis, HPC updates, portal vein thrombosis
The optimal treatment of portal vein thrombosis in patients with cirrhosis has been a topic of debate for quite some time.  To this date there have been no large prospective, randomized controlled trials to help guide management in these patients. …
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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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The Risk that Chest Pain Represents Acute Coronary Syndrome

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, medical procedures, Thoracentesis, Traumatology
More Tags – acute coronary syndrome, chest pain, HPC updates, unstable angina
This meta-analysis examined 58 prospective ED studies that involved diagnostic test accuracy among patients with suspected Non-ST elevation ACS. The meta-analysis found that the following clinical findings predicted excess ACS risk in patients presenting with chest pain: hypotension (systolic blood…
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The Insertion Site for a Thoracentesis Should not be Close to the Spine

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Medical General, medical procedures, Thoracentesis
More Tags – Catheter, Guidelines, HPC updates, Saftey techniques, thoracentesis, Ultrasound-guided thoracentesis
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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