In the Literature

The Hospitalist. 2010 August;2010(08):

August 1, 2010|The Hospitalist

Dimitriy Levin, MD;Jeffrey Carter, MD;Erin Egan, MD, JD;Jonathan Pell, MD;Laura Rosenthal, MSN, ACNP,nichole Zehnder, MD

In This Edition

Literature at a Glance

A guide to this month’s studies

Risk factors for iatrogenic pneumothorax
Residency acceptance and use of pharmaceutical industry funding
Early cholecystectomy outcomes for gallstone pancreatitis
Use of microbial DNA in sepsis
Adding rifampicin to vancomycin in MRSA pneumonia
Rate and outcomes of culture-negative severe sepsis
Rates of surgical comanagement in U.S. hospitals
Probiotics and rates of ventilator-associated pneumonia

Ultrasound Guidance and Operator Experience Decrease Risk of Pneumothorax Following Thoracentesis

Clinical question: How often does pneumothorax happen following thoracentesis, and what factors are associated with increased risk of this complication?

Background: Procedural complications are an important source of adverse events in the hospital. Iatrogenic pneumothorax after thoracentesis results in increased hospital length of stay, morbidity, and mortality. Large variation exists in reported pneumothorax rates, and little is known about procedure- and patient-specific factors associated with development of this complication.

Study design: Systematic review and meta-analysis.

Setting: Review of 24 MEDLINE-indexed studies from January 1966 to April 2009.

Synopsis: A total of 349 pneumothoraces were reported after 6,605 thoracenteses (overall incidence 6.0%). Chest-tube insertion was required in 34.1% of the cases. Risk for pneumothorax was significantly higher when larger needles or catheters were used compared with needles smaller than 20-gauge (odds ratio 2.5, 95% confidence interval [CI], 1.1-6.0) and after therapeutic thoracentesis compared with diagnostic procedures (OR 2.6, 95% CI, 1.8-3.8).

Procedures requiring two or more needle passes did not significantly increase pneumothorax risk (OR 2.5, 95% CI, 0.3-20.1). In contrast, pneumothorax rates were significantly lower when using ultrasound guidance (OR 0.3, 95% CI, 0.2-0.7) and with experienced operators (3.9% vs. 8.5%, P=0.04).

Examining patient risk factors, pneumothorax rates were similar regardless of effusion size and patient gender. Additionally, rates were similar among non-ICU inpatients, ICU inpatients, and outpatients. Data did show a trend toward increased risk of pneumothorax with mechanical ventilation (OR 4.0, 95% CI, 0.95-16.8), although no study directly compared rates in ICU patients with and without mechanical ventilation.

Bottom line: Ultrasound guidance is a modifiable factor that decreases the risk of post-thoracentesis pneumothorax. Pneumothorax rates are lower when performed by experienced clinicians, providing an important opportunity to reduce procedure-related complications by increasing direct trainee supervision.

Citation: Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170(4):332-339.

Clinical Shorts

PATIENTS DIAGNOSED WITH PULMONARY EMBOLISM EXPERIENCE HIGH MORBIDITY AND MORTALITY AT LONG-TERM FOLLOW-UP

This prospective cohort study found that within four years of being diagnosed with a pulmonary embolism, 49% of patients had experienced a major adverse clinical event or died.

Citation: Klok FA, Zondag W, van Kralingen KW, et al. Patient outcomes after acute pulmonary embolism. A pooled survival analysis of different adverse events. Am J Respir Crit Care Med. 2010;181(5):501-506.

UNIVERSAL SURVEILLANCE WITH PULSE OXIMETRY DECREASES THE NEED FOR ICU TRANSFERS

Implementation of continuous pulse-ox monitoring in all post-operative patients decreased early-response-team activations and ICU transfers by half.

Citation: Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology. 2010;112(2):282-287.

Pharmaceutical Industry Support Is Common in U.S. Internal-Medicine Residency Programs

Clinical question: What are the current attitudes of program directors regarding pharmaceutical industry support of internal-medicine residency activities? What are the potential associations between program characteristics and acceptance of industry support?

Background: Increasing evidence suggests that interactions with the pharmaceutical industry influence physician attitudes and practices. Recently, the Association of American Medical Colleges (AAMC) proposed that academic medical centers prohibit the acceptance of all gifts and restrict access by pharmaceutical industry representatives.