|Year : 2020 | Volume
| Issue : 6 | Page : 303-304
Ultrasound-guided pigtail insertions: Do we need more evidences?
Department of Intensive Care, Mission Hospital, Durgapur, West Bengal, India
|Date of Submission||27-Aug-2020|
|Date of Acceptance||16-Sep-2020|
|Date of Web Publication||11-Nov-2020|
Dr. Mahammad Ali
Department of Intensive Care, Mission Hospital, Durgapur, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ali M. Ultrasound-guided pigtail insertions: Do we need more evidences?. J Pediatr Crit Care 2020;7:303-4
Medical Ultrasonography (USG) originated from Sound Navigation and Ranging principle, used in World War I (1914). The first medical sonography was performed for a human skull (1945) much earlier than the first USG machine was built (1950). Emergency and critical care use of USG started in the 1970s for the assessment of trauma victims. The technical advancement and sophistication of hardware and software systems have helped to build a portable USG machine with real-time imaging facility. This had begun a new era of bedside use of USG in the 1980s and became an important tool for emergency physicians for identifications of multiple life-threatening conditions without shifting the unstable patients to radiology department. The era of “Point-of-Care Ultrasound” (POCUS) was started in 2010, though the concept was imbibed in the 1990s as “USG Stethoscope.” The main purpose of POCUS in critical care is to confirm a clinically suspected life-threatening condition and that is why POCUS has become an integral part of systematic evaluation of a wide range of clinical problems such as acute respiratory failure (Bedside Lung Ultrasound in Emergency (BLUE) protocol-2008), shock (Rapid USG in Shock protocol-2009), and trauma (Focused Assessment with Sonography for Trauma [FAST]-1990/e-FAST protocol 2004). Evidences suggest that POCUS is rapid, is accurate, is repeatable, is nonexpensive, is noninvasive with no radiation risk, and can easily be performed by an intensivist.
Bedside USG has an established role in performing life-saving intervention. It decreases the time for intervention by early detection of problems, improved procedural success rate, and decreased procedure-related complications. USG-guided central line insertion was initiated in the clinical trial as early as 1986 and now it is considered the standard of care. Percutaneous image-guided catheter drainage of complicated pleural diseases was started in the 2000s. Current guideline for pleural effusion management recommends USG for diagnosis and for pigtail insertion. POCUS helps intensivists to identify the best site for pigtail insertion, allows real-time visualization of the underlying lung structures and the advancing needle, and thereby reduces the failure rate and procedure-related complications. Bedside USG can be used only for puncture site determination or as a step-by-step guide of the full procedure. Step-by-step guide is the best choice in case of localized or small collection to avoid misplacement or complication.
In the third world countries, till date, an intercostal drain (ICD) is inserted blindly in “the triangle of safety” to drain effusion, empyema, hemothorax, and pneumothorax, mainly due to the unavailability of bedside USG machine, expertise, and training facility. In the current issue of the Journal of Pediatric Critical Care, a study has been published on the safety and efficacy of USG-guided pigtail catheter insertion, which was done for the drainage of pleural and peritoneal fluids in a pediatric intensive care unit (PICU) in Karachi, Pakistan. The authors have found that USG-guided pigtail insertion (size 12–14 Fr) was highly effective with a procedural success rate of 92.5%. The procedure was very safe; pneumothorax (7.5%) was the only reported complication. I must appreciate the authors' efforts to conduct such an interventional study which involves the best practice guideline in a resource-poor country. This study has a simple methodology and has a clearly mentioned study objective. This study has given a detailed description of the procedure which will be helpful for the novice.
I would like to discuss some important issues of this study. First of all, this is not the first study showing that USG-guided pigtail insertion is better. Second, this a single-center, small-sample (n = 40) retrospective study. There were more than one pediatrics studies, and the largest one was from the UK, which enrolled 285 children with complicated parapneumonic effusion and empyema. They found that USG-guided pigtail insertion was safe and highly effective (98.2%). USG-guided pigtail was equally effective in treating simple parapneumonic effusion and empyema if fibrinolytic drug was used for the latter one. However, in this study, the authors have excluded empyema without proper justification. Finally, this study does not represent the patient profile of a general PICU in a third world country. In this study, 85% of cases had malignancy; only one had pneumonia; and no patient had dengue, scrub typhus, nephrotic syndrome, heart failure, or liver failure.
However, this study again has highlighted the importance of POCUS and bedside use of USG in PICU, especially while treating pleural and peritoneal effusions. Bedside USG-guided pleural-catheter placement had decreased both the cost of the total hospital stay and procedure-related risks. As compared to ICD, it is less time consuming, more patient friendly, and associated with less complications and probably early hospital discharge.,, The BTS 2010 guideline recommends that real-time bedside USG should be used while treating for pleural diseases (air, blood, and fluid). POCUS has now been recommended in pediatric emergency services and training curriculum by the American Academy of Paediatrics in 2015. Guidelines by the Society of Critical Care Medicine (2016) recommend that bedside USG assessment should be used as an extension of the intensivist's physical examination.
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