Jones & Bartlett Learning Medicine Blog

    Ultrasound-guided Thoracentesis Reduces the Rate of Pneumothorax and Tube Thoracostomy

    Posted by Joseph Esherick on Nov 28, 2011 11:16:57 AM

    Dr. Joseph Esherick Monthly Blog – November 2011

    Numerous studies have shown that ultrasound guidance lowers the rate of complications and increases the success rate for virtually every hospital procedure compared with traditional landmark-based techniques.   This has proved to be the case for ultrasound-guided central lines, ultrasound-guided paracentesis, and ultrasound-guided lumbar punctures in obese patients.  This essay will focus on ultrasound-guided thoracentesis which has a decreased rate of pneumothorax and need for tube thoracostomy compared with the blind approach.

    Pleural effusions affect nearly 1.5 million people each year in the United States.  Many of these people require thoracentesis for pleural fluid analysis to either determine the etiology of their pleural effusions or as a therapeutic procedure to relieve dyspnea and hypoxia.  Examination of the pleural space with sonography is best carried out using a convex array 3.5- to 5 MHz probe.[1]   Ideally, the patient is in the sitting position and sonography should identify the uppermost extent of the pleural effusion and the location of the diaphragm.  The depth of insertion can also be approximated by using the depth markers on the ultrasound screen.  At this point, a mark can be made on the posterior thorax just above the rib at the optimal site for thoracentesis.  The thoracentesis can then be carried out in standard fashion with the patient in the same sitting position.   Alternatively, the convex array probe can be placed in a sterile sheath and the thoracentesis can be performed using real-time ultrasound guidance.  The complication rate is identical with either technique for ultrasound-guided thoracentesis...

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    Topics: Dr. Joseph Esherick, paracentesis, pleural effusion, thoracentesis, ultrasound-guided, Hospital Medicine Blog, hospital medicine, lumbar puncture, pneumothroax, ultrasound

    Bedside Ultrasound Increases the Success Rate for Difficult Lumbar Punctures

    Posted by Joseph Esherick on Jul 15, 2011 11:08:52 AM

    Dr. Joseph Esherick Monthly Blog – July 2011

    The traditional landmark-guided needle lumbar puncture technique was first described by Heinrich Quincke in 1891[1]This technique utilizes the iliac crest and the posterior lumbar spinous processes to determine the optimal sites for spinal needle introduction in either the L3-4 or the L2-3 interspinous spaces.  The landmark-guided technique of lumbar puncture is usually successful in experienced hands as long as the patient is not obese, pregnant, edematous, or have scoliosis, degenerative joint disease, or a history of lumbar spine surgery.  Patients who have any of these characteristics or conditions can lead to more difficult landmark-guided lumbar punctures.  It is in these cases when bedside ultrasound can increase the success rate of lumbar punctures.[2,3,4,5]    

    Ultrasound-guided regional neuraxial anesthesia has been described in the anesthesia literature since 1971.[6]   The literature reports a reduction in the number of attempts, need for repositioning, and interspaces accessed compared with landmark-guided spinal or epidural anesthesia.[7,8]  The use of bedside ultrasound to help guide difficult lumbar punctures has spread to the emergency room, ICU, and the hospital wards over the last 7 years.[9]   Observational studies have demonstrated that lumbar landmarks can be correctly identified using ultrasound about 76% of the time when they are difficult to palpate.[2,3,9]

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    Topics: Dr. Joseph Esherick, emergency physician, Heinrich Quincke, Authors, bedside ultrasound, Hospital Medicine Blog, emergency medicine, hospital medicine, hospitalist, landmark-guided, lumbar puncture

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