Procedures
Bronchoscopy
Weiss SM, Hert RC, Gianola FJ et al. Complications of fiberoptic bronchoscopy in thrombocytopenic patients. Chest 1993;104:1025-8. Established safety of transnasal bronchs in thrombocytopenic patients.
PMID: 8404159
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Herth FJF, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest 2002;122:1461-4 Prospective study compared 285 patients taking ASA within 24 hrs of TBB to 932 non-ASA users and found no difference in the risk of minor, moderate, or major bleeding.
PMID: 12377879
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***See also Lung Cancer Staging
Thoracentesis
Jones PW, Moyers JP, Rogers JT et al. Ultrasound-guided thoracentesis: is it a safer method? Chest 2003; 123:418-423. Prospective descriptive study of 605 patients referred for a total of 941 ultrasound-guided thoracenteses. 2.5% sustained a pneumothorax of whom a third received a chest tube; this is a lower incidence than most reported studies without ultrasound guidance, but all procedures were performed by 7 experienced interventional radiologists. As with previous studies, the yield of routine post-procedure films was low in asymptomatic patients; 3 of 907 had a pneumothorax managed with a chest tube. Of note, 2 of 373 patients (0.5%) developed re-expansion pulmonary edema following removal of > 1 liter of fluid. Investigators terminated fluid removal if the patient developed dyspnea or excessive cough.
PMID: 12576360
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Swiderek J, Morcos S, Donthireddy V, et al. Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest 2010;137:68-73. Prospective single center study of 103 patients with known or suspected malignant effusion. Three aliquots (10 mL, 60 mL, and >150 mL) were collected from each procedure and examined by direct smear/cytospin and by cell block analysis. Aliquots of 60 mL or >150 mL had significantly higher sensitivity and negative predictive value than aliquots of 10 mL, suggesting larger volumes are of diagnostic benefit. This is in contrast to earlier retrospective and smaller prospective studies suggesting diagnosis was independent of volume (See Chest 2002;122:1913-7, Chest 2009; 135:999-1001)
PMID: 19741064
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Endotracheal intubation
Walz JM, Zayaruzny M, Heard SO. Airway management in critical illness. Chest 2007; 131:608-20. Concise review of the nuts and bolts of endotracheal intubation in critically-ill patients.
PMID: 17296669
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Percutaneous tracheostomies
Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 2006; 10:R55. Systematic review of 17 RCTs comparing elective percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in adult critically ill patients (17 RCTs involving 1,212 patients). The analysis concluded that PDT reduces the overall incidence of wound infection and may further reduce clinically relevant bleeding and mortality when compared with ST performed in the operating theatre.
PMID: 16606435
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Catheters, Central Venous
Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132:641-8. Study found a course on central venous catheter placement for residents emphasizing the use of full-size drapes reduced catheter-related infections. This article is a motivator to teach housestaff to do the job right when the unit gets busy and there is the temptation to cut corners.
PMID: 10766683
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Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for the management of intravascular catheter- related infections. Clin Infect Dis 2001;32:1249-72. Comprehensive, reader-friendly.
PMID: 11303260
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Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32. Large scale study of 103 ICUs in the state of Michigan demonstrated that implementation of an evidence based protocol lead to a significant and sustainable relative reduction of catheter-related infections by 66%. The protocol centered on 5 steps, comprising the now widely used “central line bundle” (see IHI.org), including hand hygiene, full-barrier precautions during line insertion, skin cleansing with chlorhexidine, avoiding the femoral site if possible, and removal of unnecessary catheters.
PMID: 17192537
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Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009; 301:12331-41. The recent loss of Medicare and Medicaid reimbursement for the cost of managing catheter-related bloodstream infections has made prevention of line infections an especially hot topic. This study is noteworthy for finding a low rate of catheter-related infections with standard therapy (1.3/1,000 catheter days) despite not using antiseptic or antibiotic-coated catheters when best practices for placement and maintenance were employed. Use of the chlorhexidine sponges was associated with a reduction in infection rate to 0.4/1,000 catheter days. Changing dressings q 7 days was equivalent to q 3 days as long as the site was unsoiled and free of leaks.
PMID: 19318651
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Procedure Videos
The New England Journal of Medicine has developed and published a series of Videos in Clinical Medicine, intended to facilitate teaching and learning of common procedural techniques. Videos and accompanying text provide an excellent review of indications, pertinent techniques, and potential complications. Links to those procedures most applicable to critical care medicine are provided below. Access requires subscription.
