Two-Year Experience of 14 French Pigtail Catheters Placed by Procedure-Focused Hospitalists
BACKGROUND: Recent studies show small-bore chest tubes, commonly 14 French pigtail catheters (PCs), are noninferior to large-bore chest tubes for treating various conditions, and they are associated with better patient comfort. The Medical College of Wisconsin implemented a bedside procedure service (BPS) that has been trained in the placement of PCs as an adjunct to its interventional radiology department.
METHODS: The data regarding consults for PC placement was collected by the BPS over a 2-year period. Primary outcomes reviewed were insertion-related complications (IRCs), unsuccessful attempts (UAs), and adverse outcomes (AOs) because the authors believe these represent the safety and effectiveness of the group. It was determined which services consulted the BPS for PC placement, the indications for consults, and a brief review of declined PC consults.
RESULTS: Of the 124 accepted consults, the service had 3 IRCs (2.4%), 2 UAs (1.6%), and 3 AOs (2.4%). A total of 18 consults were declined. The BPS was consulted by 12 services with 8 primary reasons for PC placement.
CONCLUSIONS: At high-volume, tertiary care centers, and with the support of cardiothoracic surgical and interventional radiology services, procedure-focused hospitalists can safely serve as an adjunct service for PC placement in selected hospitalized patients.
© 2020 Society of Hospital Medicine
Over the last 15 years, studies have demonstrated the efficacy of small-bore chest tubes (SBCTs), or pigtail catheters (PCs, most commonly ≤14 French), in treating pneumothorax (PTX),1-5 traumatic hemothorax (THTX), hemopneumothorax (HPTX),6,7 parapneumonic effusions (PPEs),8,9 pleural infections,10 and symptomatic malignant pleural effusions.11 A randomized, controlled trial also showed that PC placement resulted in better pain scores, compared with large-bore chest tubes (LBCTs), for traumatic PTX.5 The British Thoracic Society does state that LBCTs may be needed for PTXs with very large air leaks, especially postoperatively. Further, LBCTs may be indicated if small-bore drainage fails, but otherwise they recommend PCs as first-line therapy for PTX, free flowing pleural effusions, and pleural infections.12
BEDSIDE PROCEDURE SERVICE DEVELOPMENT
The Medical College of Wisconsin (MCW) provides hospitalist services to
BPS Pigtail Catheter Training
CT surgery initially trained the BPS director in PC placement using the Seldinger technique in 2015. The director’s training period with CT surgery included direct observation by CT surgery providers for 5 PC placements. Prior to placing PCs, the director had performed approximately 400 ultrasound-guided thoracenteses. The BPS director then independently trained the remaining BPS and has placed or supervised over half of the service’s 124 PCs. Initial credentialing for each BPS physician requires 5 PC placements and 20 thoracenteses under direct supervision of credentialed BPS members. Credentialing is maintained by BPS physicians completing 3 PCs and 15 thoracenteses per year.
Newly credentialed providers are capable of independently placing most PCs. However, the requirements for credentialing are minimal and newly credentialed physicians still encounter PC placements with challenging factors not addressed in their training, such as anterior approach, small effusions, atypical effusion location, mild to moderate coagulopathy, recent therapeutic anticoagulation, and large body habitus. To address these challenges, the BPS has instituted an “on call” system. This system is typically staffed by the BPS director or associate director, already attending on a separate medical service. When needed, the “on call” physician will supervise the newer BPS members to ensure safety while the less experienced physician places the PC. Although rare, if an “on call” member is not available, then it is the practice of the BPS to recommend IR for PC placement.
