Lumbar punctures are frequently performed in the emergency department (ED). After measuring the opening pressure with a manometer, the proceduralist allows the cerebrospinal fluid to drip out of the spinal needle into collection tubes. Routine tests typically involve approximately 4 to 8 mL to allow sufficient diagnosis (cell count, glucose, protein, and culture). More frequently, studies including polymerase chain reaction, cytology, and flow cytometry are requested. Routinely, 15 mL or more is required to complete multiple tests ordered by consulting physicians,1National Health Service (UK), Gloucestershire HospitalsCerebrospinal fluid (CSF) sample requirements.https://www.gloshospitals.nhs.uk/our-services/services-we-offer/pathology/tests-and-investigations/cerebral-spinal-fluid-csf-sample-requirementsDate accessed: June 22, 2020Google Scholar and sometimes 30 to 40 mL is requested for evaluation of normal-pressure hydrocephalus or cryptococcus meningitis. The “drip” method can become excruciatingly time consuming, especially in a busy ED. Lack of adequate fluid collection often results in repeated lumbar puncture, which could increase patient morbidity. At our institution, our proceduralists have been using a method of obtaining cerebrospinal fluid safely but with increased efficiency by using a 3-mL Luer lock syringe (BD, Franklin Lakes, NJ) included with the standard lumbar puncture tray (PHS, Temecula, CA). We attach the 3-way stopcock to the spinal needle, followed by a soft extension tube with the 3-mL syringe attached (Figure). By smoothly guiding the cerebrospinal fluid into the syringe, at approximately 0.1 mL every 3 to 5 seconds, we can fill the entire syringe quickly, even for large-volume lumbar punctures. Gentle aspiration of cerebrospinal fluid has been reported by experts2Pulac J.L. Response to post lumbar puncture headache.J R Soc Med. 1983; 76: 84Crossref Google Scholar, 3Martins R.T. Toson B. Martinez de Souza R.K. et al.Post-dural puncture headache incidence after cerebrospinal fluid aspiration. A prospective observational study.Arq Neuropsiquiatr. 2020; 78: 187-192Crossref PubMed Google Scholar, 4Strachan A. Train J. Lumbar puncture and headache. Aspirating cerebrospinal fluid speeds up procedure.BMJ. 1998; 316: 1018-1019Crossref PubMed Google Scholar and used in research studies without any complications,5Rembach A. Evered L.A. Li Q. et al.Alzheimer’s disease cerebrospinal fluid biomarkers are not influenced by gravity drip or aspiration extraction methodology.Alzheimers Res Ther. 2015; 7: 71Crossref PubMed Scopus (13) Google Scholar although it is generally decried as unsafe.6Wright B.L.C. Lai J.T.F. Sinclair A.J. Cerebrospinal fluid and lumbar puncture: a practical review.J Neurol. 2010; 259: 1530-1545Crossref Scopus (109) Google Scholar,7Boon J.M. Abrahams P.H. Meiring J.H. et al.Lumbar puncture: anatomical review of a clinical skill.Clin Anat. 2004; 17: 544-553Crossref PubMed Scopus (92) Google Scholar We use a 3-mL syringe because it generates a smaller amount of negative pressure and allows increased feedback while keeping the flow rate appropriate.8Carson D. Serpell M. Choosing the best needle for diagnostic lumbar puncture.Neurology. 1996; 47: 33-37Crossref PubMed Scopus (84) Google Scholar When the pressure is elevated, cerebrospinal fluid collection can be sped up easily. When there is needle malposition or flow problems, the flow stops, and it is detected immediately, allowing the needle to be readjusted or repositioned. This is especially important in difficult cases such as patients with obesity, spinal hardware, or scoliosis. When the cerebrospinal pressure decreases, there is also a subtle increase in resistance in the syringe, which prompts the proceduralist to stop the procedure for safety, especially useful with lower opening pressures or higher-volume lumbar punctures. It is also easier to accurately collect exact amounts of cerebrospinal fluid and avoid waste. Compared with dripping, up to 30 minutes could be saved anecdotally. With decreased time, we also experience an increase in patient compliance and procedure success rates because many patients who require lumbar puncture have altered mental status and would better tolerate a shorter procedure while avoiding sedation. Meticulous follow-up is obtained for all patients within 24 hours after lumbar puncture. Despite that M.J.A. has conducted greater than 10,000 lumbar punctures and M.X.Y. has conducted greater than 500 with this method, we have not experienced any complications directly related to using the 3-mL syringe. The guided aspiration of cerebrospinal fluid during a lumbar puncture by using a small syringe leads to increased efficiency and higher completion rates without sacrificing safety.

A 23-year-old previously healthy female (body mass index = 18.3) on vacation was learning how to surf for the first time. She was in the water for about 1 hour and noticed she had trouble standing up on the surfboard. She was able to paddle back to the shallow waters, but could not walk, and had to be carried out by her boyfriend. In the car, she developed further weakness and numbness of her bilateral lower extremities to the point of losing all sensory input and motor function. She also reported mild lower back pain. She had suffered no injuries, and had no prior history of neck or back injuries. Prior to going into the water, she reported brief dryland practice jumping onto the surfboard. She also extended her spine and neck while on the surfboard, which is typical when performing surfing maneuvers. She had a history of depression, which was well controlled on bupropion and sertraline. Her family history was unremarkable, especially for neurologic diseases. She reported no drug-related or risky sexual behavior. She drank 1 to 2 drinks twice per week. She did not take birth control pills and did not smoke.

Small chest tubes and pigtail catheters are frequently placed at our institution for pleural drainage of pneumothorax and pleural effusions. After placement of a chest tube, secure fixation of the device is paramount to prevent dislodgment and patient discomfort. Traditionally, the chest tube has been anchored with suture, wound around the chest tube in a figure eight fashion, and sutured to the adjacent skin of the patient. This has been the standard of practice for many years. Other methods such as the “Roman sandal”1Inzirillo F. Giorgetta C. Eugenio R. et al.“Roman Sandal” modified method for securing the chest drain to the skin.Gen Thorac Cardiovasc Surg. 2013; 61: 171-173Crossref PubMed Scopus (11) Google Scholar or a modified mattress suture2Rashid M.A. Wikstrom T. Ortenwall P. A simple technique for anchoring chest tubes.Eur Respir J. 1998; 12: 958-959Crossref PubMed Scopus (18) Google Scholar have been developed and tried, but either with multiple skin punctures or limited success.1Inzirillo F. Giorgetta C. Eugenio R. et al.“Roman Sandal” modified method for securing the chest drain to the skin.Gen Thorac Cardiovasc Surg. 2013; 61: 171-173Crossref PubMed Scopus (11) Google Scholar, 3Howes R.J. Calder A. Hollingsworth A. et al.The end of the “Roman Sandal”: an observational study of methods of securing chest drains in a deployed military setting.J R Nav Med Serv. 2015; 101: 42-46PubMed Google Scholar Most of the small chest tubes and pigtail catheters come bundled in a kit for the convenience of the operator. Other than a 3-0 or 2-0 silk suture, no additional anchoring materials are generally included in this packaging. In our practice setting, using this standard technique, we have been plagued with dislodgement of the catheters. Skin irritation becomes an issue with aggressive suturing techniques. Ultimately, we began securing the catheters by using an alternative method with materials readily available and not requiring any skin puncture. The principal material is a STATLOCK Foley 2-way catheter stabilization device (BARD FOL0102; Bard Access Systems, Inc, Salt Lake City, UT), which is readily available throughout the medical center. Once the chest tube is placed, the stabilization device with a V cut into it is placed at the entry site. The catheter is placed through the anchoring clip, which is then closed securely. Given the different catheter sizes and the size of the anchoring clip, the catheter may be loose inside the clip. To prevent any slippage, however, the silk suture included in the chest tube kit is then used to tie the catheter to the stabilization device, as shown in Figures 1 and 2. This securely fastens the catheter to the stabilization device. No skin puncture is needed because the stabilization device is secured against the patient’s skin.Figure 2The chest tube secured within the STATLOCK device with silk suture. No skin punctures are needed. The chest tube can be easily removed.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Since implementing this technique for 130 placements during the past 563 days, we have had only 2 dislodgements. Although there are no baseline data available for the preimplementation period, anecdotally this has been a significant improvement. Additionally, because no sutures are placed in the patient, there is no skin irritation from suturing, and removal of the catheter is very easy, without the need for an instrument kit. The device itself is latex free and can accommodate catheters as large as 26 French (our most commonly placed catheters are 12 to 16 French). Additionally, the device is readily available at most medical centers and will not require additional inventory or incur additional cost of acquisition. Most important, our anecdotal experience is that patients genuinely appreciate this method of securing the chest tubes because no sutures are required.

Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low-frequency probe. Experts recommend a "2-probe technique, " which incorporates a high-frequency ultrasound probe in addition to the low-frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2-probe technique, so we performed a pre- to postintervention study to evaluate its effect on paracentesis-related bleeding complications. From February 2010 to August 2011, procedures were performed using only low-frequency probes (preintervention group), while the 2-probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis-related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = 0.07). This clinically meaningful trend suggests that using the 2-probe technique might prevent paracentesis-related major bleeding.

Pleural effusions occur frequently in mechanically ventilated patients, but no consensus exists regarding the clinical benefit of effusion drainage. We sought to determine the impact of thoracentesis on gas exchange in patients with differing severities of acute lung injury (ALI). A retrospective analysis was conducted on therapeutic thoracenteses performed on intubated patients in an adult surgical intensive care unit of a tertiary center. Effusions judged by ultrasound to be 400 mL or larger were drained. Subjects were divided into groups based on their initial P:F ratios: normal >300, ALI 200 to 300, and acute respiratory distress syndrome (ARDS) <200. Baseline characteristics, physiologic variables, arterial blood gases, and ventilator settings before and after the intervention were analyzed. The primary end point was the change in measures of oxygenation. Significant improvements in P:F ratios (mean ± SD) were seen only in patients with ARDS (50.4 ± 38.5, P = 0.001) and ALI (90.6 ± 161.7, P = 0.022). Statistically significant improvement was observed in the pO2 (31.1, P = 0.005) and O2 saturation (4.1, P < 0.001) of the ARDS group. The volume of effusion removed did not correlate with changes in individual patient's oxygenation. These data support the role of therapeutic thoracentesis for intubated patients with abnormal P:F ratios.

Abstract Background: The need for peripheral intravenous (IV) access in anatomically challenging patients is becoming a more commonly encountered clinical problem. The significant investment devoted to physician training for ultrasound-guided vascular access has not yet been matched by a similar commitment to nursing. Nurses, paramedics, and physicians are becoming more enthusiastic about peripheral IV access with ultrasound (PIVUS); however, institutional and clinician support has not yet been forthcoming. The learning curve for PIVUS has never been rigorously studied, and may be flatter than previously assumed. Methods: Registered nurses were selected to participate as trainees. Training involved 1:1 sessions consisting of formal orientation to portable ultrasound, mentoring, and practice sessions with a nurse practitioner who has expertise in ultrasound-guided peripheral vascular access; hands-on, supervised practice cannulating vessels on a nonhuman tissue simulator; and supervised attempts on live patients. Results: Seven of 8 trainees completed the training. The average number of patient encounters required to achieve 10 successful IV placements was 25 (range =18–32). The average time required for successful vessel cannulation was 19.57 minutes (range =5–62 minutes). An average of 25 attempts was required to achieve proficiency, and average of 50 cases was required to maintain consistency. Conclusions: In today's practice environment, PIVUS skills are increasingly important. The results of our study demonstrate that, with appropriate hands-on training and supervision, these skills can be effectively taught to registered nurses.

BACKGROUND:Despite a lack of evidence in the literature, several assumptions exist about the safety of thoracentesis in clinical guidelines and practice patterns. We aimed to evaluate specific demographic and clinical factors that have been commonly associated with complications such as iatrogenic pneumothorax, re-expansion pulmonary oedema (REPE) and bleeding.METHODS:We performed a cohort study of inpatients who underwent thoracenteses at Cedars-Sinai Medical Center (CSMC) from August 2001 to October 2013. Data were collected prospectively including information on volume of fluid removed, procedure side, whether the patient was on positive pressure ventilation, number of needle passes and supine positioning. Iatrogenic pneumothorax, REPE and bleeding were tracked for 24 h after the procedure or until a clinical question was reconciled. Demographic and clinical characteristics were obtained through query of electronic medical records.RESULTS:CSMC performed 9320 inpatient thoracenteses on 4618 patients during the study period. There were 57 (0.61%) iatrogenic pneumothoraces, 10 (0.01%) incidents of REPE and 17 (0.18%) bleeding episodes. Iatrogenic pneumothorax was significantly associated with removal of >1500 mL fluid (p<0.0001), unilateral procedures (p=0.001) and more than one needle pass through the skin (p=0.001). For every 1 mL of fluid removed there was a 0.18% increased risk of REPE (95% CI 0.09% to 0.26%). There were no significant associations between bleeding and demographic or clinical variables including International Normalised Ratio, partial thromboplastin time and platelet counts.CONCLUSIONS:Our series of thoracenteses had a very low complication rate. Current clinical guidelines and practice patterns may not reflect evidence-based best practices.

Introduction: Pleural effusions are a frequent occurrence in critically ill patients, but there is little agreement regarding the benefit of their drainage in mechanically ventilated patients. We determined the effects of thoracentesis upon gas exchange and hemodynamics in intubated patients with di

Paracentesis is a commonly performed procedure in both inpatient and outpatient settings. Useful for diagnostic and therapeutic purposes, prior studies have documented the inherent safety of this procedure. In proper hands, modern techniques such as the use of safety (Turkel) tipped needles and ultrasound localization have reduced the risk of major complications to less than 1%. Nevertheless, major bleeding remains a dreaded complication of this procedure, especially in patients with liver failure. Our historical experience has been that this complication is unpredictable, likely because of procedural injury to an abdominal wall artery or peritoneal varix. The authors report a case where the risk of vascular injury was mitigated using portable ultrasound and suggest a simple procedure for future risk reduction.

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Total paracentesis with albumin replacement has become the mainstay of treatment for refractory ascites in patients with decompensated hepatic cirrhosis. The authors report one of the largest volume single-tap paracenteses in the literature (38.8 L), discuss issues surrounding the safety of this procedure, and review the challenges inherent to managing these complex patients.

PURPOSE: A new category of handheld devices has recently emerged that are even smaller than current portable models, with their main advantages being increased portability and affordability relative to their counterparts. However, these new devices have not yet been thoroughly evaluated in the clinical setting. METHODS: A prospective, non-blinded, three-phase study was designed to evaluate a handheld ultrasound device as compared to a common compact ultrasound machine for the performance of paracenteses and thoracenteses on human patients. RESULTS: For the vast majority of straight-forward evaluations, the handheld device was sufficient to safely complete the procedure without further imaging. For difficult cases with smaller fluid collections or anatomic aberrations, further localization with the common compact machine continued to be useful to improve the operator's confidence in the findings. CONCLUSION: This novice handheld device represents only one of what appears to be a growing number of new ultra-portable ultrasound devices on the market. These devices represent a new and exciting form of ultrasound technology that may benefit patients and physicians in multiple venues. While they are unlikely to replace standard ultrasound devices for many of the more complex applications, their extreme portability allows for ultrasound imaging in more diverse situations that has previously been practical. Based on our limited experience, the image quality is adequate and the learning curve is reasonable. Future integration of PDA technology could further the utility of these devices and additional study will be important to further define their appropriate niche and clinical utility.

At a time when excitement for adopting new ultrasonography applications is at a high, Stein et al1Stein J. George B. River G. et al.Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial.Ann Emerg Med. 2009; 54: 33-40Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar are to be congratulated for applying critical judgment to the application of real-time ultrasonography for peripheral venous access. With the advent of higher quality, mobile machines, the use of ultrasound for vascular access and other procedural services is being enthusiastically encouraged for physicians, nurses and emergency medicine technicians. At our institution, Cedars-Sinai Medical Center, our Procedure Center is responsible for the vast majority of peripherally inserted central catheters, thoracenteses, paracenteses, and lumbar punctures, and we also frequently get asked to assist with peripheral IV access.2Ault M.J. Rosen B.T. Proceduralists—leading patient safety initiatives.New Engl J Med. 2007; 356: 1789-1790Crossref PubMed Scopus (4) Google Scholar We use ultrasonography for all of these applications, as endorsed by Blackstock and Stone,3Blackstock U. Stone M.B. Emergency ultrasonography and error reduction.Ann Emerg Med. 2009; 54: 53-55Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar and we share in their dismay that only 34% of emergency physicians are using (or have access to) this transformative and proven patient-safety technology. The negative results of Stein et al's study do not come to us as a surprise, but the results should not be misinterpreted as justification to not invest in ultrasonography. As with any new technique there is a learning curve before proficiency can be achieved, and the small caliber of peripheral vessels makes for perhaps the greatest challenge with regards to the successful application of ultrasonographically guided access. We believe the key lesson from Stein's study is to illustrate the critical need for dedicated training in order to reap the benefit from ultrasonographically guided procedures. Having learned this lesson at our own institution, standard policy for new proceduralists joining our Procedure Center requires a threshold of 200 ultrasonographically guided lines to be completed to demonstrate full facility with ultrasound. We have found that, regardless of the trainee's background, it routinely requires at least 50 lines to be able to reliably establish vascular access with ultrasonography guidance. Ultrasonography is a powerful instrument for patient safety and comfort when placed in properly trained and experienced hands. As Stein's study shows, however, it does not provide an automatic or easy fix to a difficult vascular access problem. While we by no means intend to discourage the widespread adaptation of this technology, it is worth remembering that the ultrasound probe is not a magic wand. Ultrasonographically Guided Peripheral Intravenous Cannulation in Emergency Department Patients With Difficult Intravenous Access: A Randomized TrialAnnals of Emergency MedicineVol. 54Issue 1PreviewWe seek to compare ultrasonographically guided peripheral intravenous access to a non–ultrasonographically guided method in a randomized trial of emergency department patients with difficult intravenous access. Full-Text PDF