A surgical needs assessment for airway rapid responses: A retrospective observational study.

BACKGROUND: Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS: A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS: A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION: Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. LEVEL OF EVIDENCE: Epidemiologic/prognostic, level III.

Inpatient mortality and its predictors after pericardiocentesis: An analysis from the Nationwide Inpatient Sample 2009-2013.

BACKGROUND: National registries have provided data on in-hospital outcomes for several cardiac procedures. The available data on in-hospital outcomes and its predictors after pericardiocentesis are mostly derived from single center studies. Furthermore, the outcomes after pericardiocentesis for iatrogenic pericardial effusion and the impact of procedural volume on in-hospital outcomes in the United States are largely unknown. METHODS: We used national inpatient database files for the years 2009-2013 to estimate the inpatient outcomes after pericardiocentesis in all-comers and in the subgroups with iatrogenic effusion. We also studied the impact of hospital procedural volume, among other predictors, on inpatient mortality. RESULTS: About 64,070 (95%CI 61 008-67 051) pericardiocentesis were performed in the United States during 2009-2013. Of these, 57.15% (56.02-58.26%) of the pericardiocentesis were in hemodynamically unstable patients. Percutaneous cardiac procedures were performed in 17.7% of patients (percutaneous coronary intervention (PCI) 4.02%, electrophysiologic procedures 13.58%, and structural heart intervention (SHI) 0.76%). Overall inpatient mortality was 12.30% (95%CI 11.66-12.96%). Inpatient mortality after PCI, electrophysiologic procedures, SHI and cardiac surgery were 27.67% (95%CI 24-31.67%), 7.8% (95%CI 6.67-9.31%), 22.36% (95%CI 15.06-31.85%) and 18.97% (95%CI 15.84-22.57%), respectively. There was an inverse association between hospital procedural volume and inpatient mortality, with a mortality of 14.01% (12.84-15.26%) at the lowest and 10.82% (9.44-12.37%) at highest quartile hospitals by procedure volume (ptrend = 0.001). CONCLUSION: The inpatient mortality after pericardiocentesis is high, particularly when associated with PCI and SHI.

Predictors and Outcome of Pericardial Effusion After Hematopoietic Stem Cell Transplantation in Children.

Pericardial Effusion (PE) is a potentially life-threatening complication of Hematopoietic Cell Transplantation (HCT). Our study aim was to identify incidence, risk factors, response to treatment, and outcome of PE after pediatric HCT. All patients after HCT at our tertiary center between 2005 and 2010 were included. Endpoints were PE development and overall survival. We analyzed patient factors, HCT details, and complications and used Cox proportional hazard regression modeling to identify predictors for PE. Twelve out of 129 patients (9.3%) developed PE. Multivariate analysis demonstrated that young age at HCT was a predictor for PE: expressed per year increase in age HR = 0.66 (95% CI 0.46-0.95, p = 0.03). PE had no impact on overall mortality of HCT. Mild respiratory symptoms and vomiting were presenting symptoms for PE. Discontinuation of calcineurin inhibitors-with or without pericardiocentesis-was the only effective treatment for PE, in contrast to diuretics or increased immunosuppression. Seven of 12 PE patients had pericardiocentesis, which was safe and effective in all. Pericardial effusion is not rare after HCT, and young age is the only significant risk factor. Calcineurin inhibitor toxicity appears to be the primary cause of PE after HCT, and discontinuation is effective in the reduction of PE. Pericardiocentesis for PE is a safe and effective procedure. Pericardial effusion did not have an impact on survival after HCT.

Relationship between hospital volume and major cardiac complications of rotational atherectomy: A nationwide retrospective cohort study in Japan.

BACKGROUND: Previous studies on life-threatening complications of rotational atherectomy (RA) were based on small sample sizes from a limited number of cardiovascular centers. No study has examined the relationship between hospital volume of RA and complications. METHODS: Using the Diagnosis Procedure Combination database in Japan, we identified inpatients aged ≥20 years who underwent RA. Hospital volume was defined as the annual number of patients undergoing RA at each hospital and eligible patients were categorized into hospital-volume tertile (low-, medium-, and high-volume) groups. The composite outcome consisted of cardiac complications requiring urgent procedures (covered stent implantation, coronary artery bypass grafting, or pericardiocentesis) or death on the day of RA. We examined the association between hospital-volume categories and the composite outcome by using a multivariable logistic regression model fitted with a generalized estimating equation. RESULTS: A total of 9970 patients (median age, 73 years; male, 69.8%) underwent RA in 309 hospitals. The 309 hospitals were categorized into 215 low-volume (≤15/year), 67 medium-volume (16-30/year), and 27 high-volume hospitals (≥31/year). Overall, the composite outcome occurred in 62 (0.62%) patients (36 covered stent implantation, 11 coronary artery bypass grafting, 9 pericardiocentesis, and 14 death). Patients in the high-volume group had a significantly lower rate of the composite outcome (0.29%) than those in the low-volume (0.72%, p=0.010) or medium-volume group (0.89%, p=0.001). With reference to the low-volume group, risk-adjusted odds ratios (95% confidence intervals) of the medium-volume and high-volume groups for the composite outcome were 1.10 (0.64-1.89) and 0.42 (0.20-0.88), respectively. CONCLUSIONS: This study showed that higher hospital volume was significantly associated with lower complication rates of RA. Our results also suggested that the major complication rates were low even in low-volume hospitals.

Percutaneous Pericardial Effusion Drainage under Ultrasonographic and Fluoroscopic Guidance for Symptomatic Pericardial Effusion: A Single-Center Experience in 93 Consecutive Patients.

PURPOSE: To evaluate the safety and efficacy of ultrasound-guided and fluoroscopically guided percutaneous pericardial effusion drainage as performed by interventional radiologists in patients with symptomatic pericardial effusion. MATERIALS AND METHODS: From July 2002 to December 2013, 93 patients were treated with percutaneous pericardial effusion drainage. Pericardial effusion drainage was performed via 3 routes: apical, subxiphoid, and transhepatic routes. After puncturing the pericardial sac with a 22-gauge needle under ultrasound guidance, a drainage catheter was inserted under fluoroscopic guidance. Pericardial effusion was categorized according to its distribution in the pericardial cavity: "circumferential even," "circumferential uneven" (predominant site specified), and "loculated." Technical success, recurrence, and complication rates were assessed. RESULTS: The technical success rate was 99%. Pericardial effusion drainage was performed via the subxiphoid approach in 54 procedures, transhepatic approach in 30 procedures, and apical approach in 13 procedures. The transhepatic approach was mainly performed in cases where the effusion was distributed posteriorly to the heart (80%). One patient died of uncontrolled hypotension without evidence of hemopericardium. CONCLUSIONS: Ultrasound-guided and fluoroscopically guided pericardial effusion drainage is a safe and effective procedure for patients with symptomatic pericardial effusion. The transhepatic approach may be preferable for posteriorly distributed pericardial effusion that would otherwise be inaccessible by a traditional subxiphoid or apical approach.

Pericardial effusions: do they all require pericardiocentesis?

Pericardial effusions are associated with multiple disorders, the causes of which are dependent on local epidemiologic and patient-specific factors. Pericardial effusions exhibit a broad spectrum of clinical presentations and may or may not be symptomatic. Echocardiographically guided pericardiocentesis should be reserved for patients with hemodynamic compromise, an intrathoracic mass effect, or an uncertain cause. Not all patients with pericardial effusions require pericardiocentesis, and an algorithmic approach to the decision to perform pericardiocentesis is recommended.

[Analysis of clinical, echocardiographic, microbiological and cytopathological characteristics of pericardial effusions in a tertiary hospital care]. / Análisis de las características clínicas, ecocardiográficas, microbiológicas y citopatológicas de derrames pericárdicos en un hospital de tercer nivel de atención.

OBJECTIVE: To determine the prevalence, etiology, clinical, echocardiographic, microbiological and cytopathological characteristics of patients with pericardial effusion. METHODS: Observational, retrospective, cross-sectional analytical study. We reviewed medical records of patients undergoing pericardiocentesis for a 5 years period. We used descriptive statistics, measures of central tendency and dispersion for analysis. RESULTS: The prevalence of pericardial effusion was 1.1%. Predominant in women (60.4%) and there was a mean age of 49 years. The main causes were neoplastic 32.1%, idiopathic 27.4% and rheumatological 10.4%. A percentage of 27.1 had cardiac tamponade whereas dyspnea and muffled heart sounds were the most common clinical data. The right atrial and ventricular collapse occurred in 84.9 and 75.5%, respectively. The pericardial fluid cytology yielded better in neoplastic causes a sensitivity of 54%, specificity 95%, positive predictive value 85% and negative predictive value 81%. CONCLUSIONS: The prevalence of pericardial effusion in a tertiary care hospital was 1.1%, the main cause was neoplastic. In the evaluation of moderate or severe pericardial effusion we found that right atrial and ventricular collapses were the most common echocardiographic findings. The cytopathological study had a high specificity for the diagnosis of neoplasia.

Causes of moderate to large pericardial effusion requiring pericardiocentesis in 140 Han Chinese patients.

BACKGROUND: Causes of pericardial effusion requiring pericardiocentesis are very complex; a summary of 140 patients, especially those having iatrogenic pericardial effusion, is rare. METHODS: We prospectively analyzed the clinical data and etiology of moderate to large pericardial effusion requiring pericardiocentesis and drainage in 140 consecutive Han Chinese patients from January 2007 to December 2009. RESULTS: Pericardiocentesis was successfully performed and effective in all patients. There were 9 cases with transudates, while the remaining 131 cases were diagnosed with exudates (neoplastic in 54 patients, tuberculous in 40 patients, 9 cases of connective tissue diseases, 12 cases undergoing cardiac catheterization, and 8 cases of acute myocardial infarction). Among the 54 malignancies, 30 patients had lung cancer, 7 had breast cancer, and 4 had liver cancer. No differences in the clinical characteristics and the results of routine and biochemistry studies in the pericardial fluid between tuberculous and malignant groups were found. Of the 12 patients undergoing cardiac catheterization, 6 cases had undergone catheter ablation for tachycardia and 4 cases had undergone percutaneous coronary intervention. The 6 patients undergoing catheter ablation were women and the ratio of pericardial effusion was higher in women (6/436) than in men (0/462; p<0.05). Pericardiocentesis and drainage was effective in the 6 patients who underwent catheter ablation, and the remaining 6 patients underwent surgical intervention after pericardiocentesis and drainage. All 8 patients with acute myocardial infarction died during hospitalization. CONCLUSION: In China, most moderate to large pericardial effusions requiring pericardiocentesis and drainage were exudates and bloody, which were mainly caused by malignancy and tuberculosis. However, the incidence of iatrogenic pericardial effusion has been increasing and should not be ignored. Pericardiocentesis and drainage were effective.

Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years.

OBJECTIVES: To evaluate consecutive therapeutic echocardiographically (echo)-guided pericardiocenteses performed at Mayo Clinic, Rochester, Minn, from 1979 to 2000 and to determine whether patient profiles, practice patterns, and outcomes have changed over time. PATIENTS AND METHODS: Consecutive echo-guided pericardiocenteses performed between February 1, 1979, and January 31, 2000, for treatment of clinically significant pericardial effusions were identified in the Mayo Clinic Echocardiographic-guided Pericardiocentesis Registry. The medical records of these patients were examined, and a follow-up survey was conducted. Clinical profiles, echocardiographic findings, procedural details, and outcomes were determined for 3 periods: February 1, 1979, through January 31, 1986; February 1, 1986, through January 31, 1993; and February 1, 1993, through January 31, 2000. RESULTS: During the 21-year study period, 1127 therapeutic echo-guided pericardiocenteses were performed in 977 patients. The mean +/- SD age at pericardiocentesis increased from 49+/-14 years in period 1 to 57+/-14 years in period 3. In recent years, cardiothoracic surgery replaced malignancy as the leading cause of an effusion requiring pericardiocentesis and together with malignancy and perforation from catheter-based procedures accounted for nearly 70% of all pericardiocenteses performed. The procedural success rate was 97% overall, with a total complication rate of 4.7% (major, 1.2%; minor, 3.5%). These rates did not change significantly over time. The use of a pericardial catheter for extended drainage increased from 23% in period 1 to 75% in period 3 (P<.001), whereas rates of effusion recurrence and pericardial surgery decreased significantly (P<.001). CONCLUSIONS: The profile of patients presenting with clinically significant pericardial effusion has changed over time. Increasing numbers of older patients and those who have undergone cardiothoracic surgery or catheter-based procedures develop effusions that can be rapidly, safely, and effectively managed with echo-guided pericardiocentesis. Extended drainage with use of a pericardial catheter has become standard practice, and concomitantly, recurrence rates and need for surgical management have decreased considerably.