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
DISCUSSION
To our knowledge, this is the first report of the experience of procedure-focused hospitalists with PC placement in a partnership with CT surgery. We believe that, at high volume, tertiary care centers similar to Froedtert Hospital, internal medicine–trained, procedure-focused hospitalists can serve as adjuncts to surgery, pulmonary, and IR services in the placement of PCs in hospitalized patients that do not require procedural sedation.
Given the development of this service and the nature of its shared operations with CT surgery, we do not believe that the BPS has an appropriate comparison in the literature; however, the IRCs are similar to previous papers describing PC placement.5-7,14 Notably, the IRC and AO rates were low, both 2.4%, which indicates safe placement of PCs. Kulvatunyou et al and Bauman et al reported on PC placement from a surgical perspective and reported IRC rates of 4%-10%.5-7,14 These higher IRC rates likely have a few reasons. First, Kulvatunyou et al and Bauman et al did not use ultrasound guidance. Use of ultrasound guidance may have significantly lowered their IRC rate. Second, the definition of IRC used by Kulvatunyou et al and Bauman et al included dislodgements, but we do not believe this to be an IRC. Dislodgements can happen for several reasons, frequently a result of patient movement or forgetfulness, not because of improper placement. Third, the PCs with this BPS are placed primarily by attending physicians. Resident roles on our BPS in PC placement are primarily as assistants, whereas Kulvatunyou et al and Bauman et al note that both attendings and residents, under attending supervision, placed PCs; however, it is not clear what percentage of PCs were placed by attendings or residents in their studies. Finally, this BPS’s IRCs are self-reported, so they could be perceived as falsely low, but given the small number of physicians involved in the group and its standardized follow-up, we do not suspect this is truly contributing to the low rates.
Other complication rates regarding the use of wire-guided SBCTs and PCs range from 0% to 42%15-20; however, several differences including tube size, physician training, and PC indication make these studies imperfect comparisons. The most notable difference in our opinion is the variable definition, or lack of definition, of a complication. One study did not define their complications,19 while other studies list subjective measures like pain,16,20 cough,16 bleeding, 16,20 and hematomas4,15 as complications. We believe that the lack of consensus definition for PC complication or IRC contributes to the large range of complication rates in the literature. This problem is likely not unique to PC placement, but is instead true across all bedside procedures. In a shared-practice model between hospitalists and CT surgeons, we believe the definition of IRC in this paper is adequate in capturing most complications. The only complication we are currently unable to track well is infection. We consider other items discussed previously, such as pain, cough (often from lung re-expansion), minor bleeding, and even small hematomas, to be a part of the procedure and not a complication.
Finally, regarding the IRCs and associated death, this was a tragic event. Complications for all of the BPS’s procedures are infrequent (0.35% over the same time period) and reviewed between the BPS director and the attending who performed the procedure; in addition, given this mortality, the case was reviewed immediately in detail with our CT surgery colleagues. On review, it was easy to determine that the operator had found a clear lung tip and sonographic signs of PTX; however, CXR review did demonstrate a medial placement of the PC. This was judged to be a poor placement location (even with imaging demonstrating PTX in that area) given the well-known “triangle of safety” defined by the British Thoracic Society.12
After review, the primary emphasis for PC placement was safe location. The BPS now strives to place PCs for PTX only in the “triangle of safety.” The BPS believe that most PTXs can be addressed with this placement. In the rare case of a PTX requiring an anterior approach, only the BPS director currently places apical PCs for PTX while on service or “on call.” He discusses the placement with pulmonary and CT surgery directly to determine that the PC is of absolute necessity.
Given the focus on appropriate location, no formal changes were made to the procedural imaging practice described in Table 1. We realize that vascular imaging would seem necessary after this patient’s mammary artery laceration; however, safe location, in addition to the BPS’s current image requirements, is believed to minimize this risk. We feel the imaging criteria align with recommendation No. 5 of the Society of Hospital Medicine’s Position Statement for Ultrasound Guidance for Adult Thoracentesis.21 Some BPS members use vascular ultrasound imaging to confirm absence of vascularity, but it is not required and occasionally not possible, such as in the occasional case of PTX with subcutaneous emphysema.
The UA rate is low without a natural comparator in the literature. It is important to clarify the difference between the UAs and the frequently mentioned “failure rate” (FR) in Kulvatunyou et al and Bauman et al6,7,14 We classify UAs as the inability, for any reason, to access the pleural space and insert a PC. At this stage, these UAs appear to reflect the service’s new experience with PC placement and inability to provide procedural sedation. Kulvatunyou et al and Bauman et al’s FR is defined as an initial PC successfully placed into the pleural space that then required a second PC or intervention (frequently VATS) to resolve the PTX or retained HTX.
We believe calculating the failure rate will be helpful in demonstrating the value of our BPS and our shared-practice model. We look forward to publishing this and other future research, including determination of the cost and time saved by the BPS for PCs and other procedures.
Limitations of this study include its retrospective nature, results from a single center’s experience, and lack of a comparison group.
Our institution feels that there is great benefit in having a BPS operated by procedure-focused hospitalists. It would also be important to determine if our model can be replicated by another institution.
