Diagnostic value of routine chest tube tip culture in surgery for noninfectious lung disease

Background Evaluation of the diagnostic value of routine chest tube tip culture for detection of postoperative infection after surgery for noninfectious lung disease. Methods Included subjects were patients who underwent lung surgery between January 1st 2013 and January 1st 2018 in University Medical Centre Utrecht and of whom a chest tube tip was cultured. Postoperative outcomes included pneumonia, surgical site infection, and empyema within 30 days after surgery. Univariable analysis for diagnostic accuracy of chest tube tip culture results predicting these postoperative outcomes was performed, as well as multivariable analysis using penalized firth logistic regression. Results Patients developed one or more postoperative infections in 42 out of 210 (20%) lung surgeries. Pneumonia, surgical site infection, and empyema were found in 36 (17%), 8 (4%), and 2 (1%) cases respectively. Chest tube tip culture had a sensitivity of 31%, a specificity of 83%, a positive predictive value of 32%, and a negative predictive value of 83% for postoperative infections. In the subgroup of patients who did not have evidence of postoperative infection at the time of chest tube removal, the drain tip culture’s positive and negative predictive value changed to 18% and 92% respectively. Adding additional variables to chest tube tip culture in a prediction model resulting in only limited improvement in diagnostic performance. Conclusions We found insufficient diagnostic performance to support the practice of routine chest tube tip culture after surgery for noninfectious lung disease. Therefore, routine chest tube tip culture is not advisable and should be omitted to unburden the healthcare process and prevent low value care together with extra costs.

Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion

IntroductionAvoiding low value medical practices is an important focus in current healthcare utilisation. Despite advantages of point-of-care ultrasound (POCUS) over chest X-ray including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation has slow rate of adoption. This demonstrates a gap that is ripe for the development of an intervention.MethodsThe intervention is a deimplementation programme called DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol) that will be created to address one unnecessary imaging modality in the acute care environment. We propose a three-phase approach to changing low-value practices. In phase 1, we will be guided by the Consolidated Framework for Implementation Research framework to explore barriers and facilitators of POCUS for CVC confirmation in a single centre, large tertiary, academic hospital via focus groups. The qualitative methods will inform the development and adaptation of strategies that address identified determinants of change. In phase 2, the multifaceted strategies will be conceptualised using Morgan’s framework for understanding and reducing medical overuse. In phase 3, we will locally implement these strategies and assess them using Proctor’s outcomes (adoption, deadoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on the programme. Secondary outcomes will include POCUS-guided CVC confirmation efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS confirmation after CVC insertion.With limited data available to inform interventions that use concurrent implementation and deimplementation strategies to substitute chest X-ray for POCUS using the DRAUP programme, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that will expand the knowledge of implementation approaches to replacing low value or unnecessary care in acute care environments.Ethics and disseminationApproval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.Trial registration numberClinicalTrials.gov Identifier, NCT04324762, registered on 27 March 2020.

Iatrogenic hydrohemothorax during percutaneous nephrolithotomy: A case report

Background: Percutaneous nephrolithotomy (PNL) is a widely used surgical method for renal stone management. However, it can be associated with several complications. Case: We report an acute hemothorax during PNL in 57-year-old male patient with a stone. After observing air bubbles at the diaphragm on the laparoscopic screen, we considered pulmonary complications. A chest radiograph demonstrated a shade that measured 130 mm wide and 70 mm long and fluid retention on the right side of the chest. During drainage of 200 ml of blood through a chest tube, the patient’s vital signs became unstable. After the patient received hydration and intravenous injection of vasopressor, his vital signs stabilized. Conclusions: Pulmonary complications due to pleural injury during PNL can result in death, but the complications can be managed by early diagnosis and treatment. Close cooperation between surgeon and anesthesiologist and routine chest radiographs after PNL can reduce the pulmonary complications.

Is Routine Chest X-ray After Ultrasound and Intracavitary Electrocardiogram Guided Peripherally Inserted Central Catheter Insertion Choosing Wisely? A Population-based Retrospective Study of 2857 Patients With Cancer

Background: In China, routine chest X-ray (CXR) is generally required for peripherally inserted central venous catheters (PICC) to determine the position of the catheter tip. The aim of this study is to assess the value of a routine post-procedural CXR in the era of ultrasound and intracavitary electrocardiography(IC-ECG) -guided PICC insertion. Methods: A retrospective population-based cohort study was conducted to review the clinical records of all patients who had PICCs in the Venous Access Center of Beijing Cancer Hospital between January 1, 2019 and June 30, 2020. The incidence of catheter misplacement after insertion was measured. A logistic regression analysis was performed to examine potential risk factors associated with PICC-related complications and a cost analysis to assess the economic impact of the use of CXR.Results: There were 2,857 samples from 2,647 patients included. The overall incidence of intraoperative and postoperative catheter misplacement was 7.4% (n=210) and 0.67% (n=19), respectively. There was a high risk of postoperative catheter misplacement when the left-arm was chosen for placement (OR: 10.478; 95% CI: 3.467-31.670; p<0.001). The cost of performing CXR for screening of PICC-related complications was $23,808 per year, and that of using CXR to diagnose one case of catheter misplacement was $1253.Conclusion: This study confirms that misplacement of PICCs guided by ultrasound and IC-ECG is rare and that postoperative CXR is very costly. In our setting, routine postoperative CXR is unnecessary and not a wise option.

Routine chest X-rays after pigtail chest tube removal rarely change management in children

Background The need for chest X-rays (CXR) following large-bore chest tube removal has been questioned; however, the utility of CXRs following removal of small-bore pigtail chest tubes is unknown. We hypothesized that CXRs obtained following removal of pigtail chest tubes would not change management. Methods Patients < 18 years old with pigtail chest tubes placed 2014–2019 at a tertiary children’s hospital were reviewed. Exclusion criteria were age < 1 month, death or transfer with a chest tube in place, or pigtail chest tube replacement by large-bore chest tube. The primary outcome was chest tube reinsertion. Results 111 patients underwent 123 pigtail chest tube insertions; 12 patients had bilateral chest tubes. The median age was 5.8 years old. Indications were pneumothorax (n = 53), pleural effusion (n = 54), chylothorax (n = 6), empyema (n = 5), and hemothorax (n = 3). Post-pull CXRs were obtained in 121/123 cases (98.4%). The two children without post-pull CXRs did not require chest tube reinsertion. Two patients required chest tube reinsertion (1.6%), both for re-accumulation of their chylothorax. Conclusions Post-pull chest X-rays are done nearly universally following pigtail chest tube removal but rarely change management. Providers should obtain post-pull imaging based on symptoms and underlying diagnosis, with higher suspicion for recurrence in children with chylothorax.

Measurement of Epicardial Fat Using Non-contrast Routine Chest-CT: A Consideration of Threshold Adjusting for Fatty Attenuation

Background：Role of epicardial fat (EF) had expended from a marker of cardiovascular risk to indicators of several systemic physiological effects and needed to be measured in more scenarios. The present study aimed to determine whether the EF volume (EFV) and mean attenuation (EFA) measured on non-contrast routine chest-CT (RCCT) could be more consistent with that on coronary CT angiography (CCTA) by adjusting the threshold of fatty attenuation. Methods: Totally 83 subjects simultaneously underwent CCTA and RCCT were enrolled. EFV and EFA were quantified on CCTA using threshold of (N30) (-190HU, -30HU) as reference, and also measured on RCCT using threshold of N30, N40 (-190HU, -40HU), N45 (-190HU, -45HU) respectively. Correlation and agreement of EF metrics between two models and differences between groups with coronary plaque (Plaque (+)) and without plaque (Plaque (-)) were analyzed. Results: EFV and EFA from RCCT using N30, N40 and N45 correlated well with reference (EFV: r2=0.974, 0.976, 0.972, P<0.001; EFA: r2=0.516, 0.500, 0.477, P<0.001). Threshold adjusting was able to reduce the mean difference, while increase the difference of EFA. Data measured on CCTA and RCCT both demonstrated the significantly larger EFV of Plaque (+) group than Plaque (-) group (P<0.05). The significantly difference of EFA was only shown on RCCT using N30 (Plaque (+) vs (-): -80±4.4HU vs-78±4HU, P=0.030). Conclusion: The consistency of EFV measured on RCCT could be improved through adjustment of attenuation threshold. The EFA assessment may have additional information relating to underlying pathophysiological status.