|Year : 2020 | Volume
| Issue : 6 | Page : 311-315
Safety and efficacy of ultrasound-guided pigtail catheter insertion in pediatric intensive care unit: A single-center experience
Faiza Rahman, Abdul Rahim Ahmed, Anwarul Haque, Sadiq Mirza, Humaira Jurair
Department of Pediatric Intensive Care Unit, The Indus Hospital, Karachi, Pakistan
|Date of Submission||13-Jun-2020|
|Date of Decision||05-Aug-2020|
|Date of Acceptance||09-Aug-2020|
|Date of Web Publication||11-Nov-2020|
Dr. Abdul Rahim Ahmed
The Indus Hospital, Plot C-76, Sector 31/5, Korangi Crossing, Karachi 75140
Source of Support: None, Conflict of Interest: None
Objective: The study objective was to describe the safety and efficacy of ultrasound (US)-guided pigtail catheter (PC) (USGPC) placement at bedside for symptomatic pleural effusion and ascites in acute critically ill children in pediatric Intensive Care unit. and not critical care unit (PICU).
Design: This was a descriptive study.
Place: This study was conducted at the pediatric critical care unit (PICU) of The Indus Hospital, Karachi, Pakistan, from January 2018 to December 2019.
Subjects and Methods: We retrospectively reviewed the electronic medical records of critically ill children who underwent USGPC insertion for symptomatic pleural effusions and ascites on bedside. Demographic data, clinical indication, success rate, and complications of procedures were collected using a structured questionnaire approved by the institutional ethical committee. The PC of 10–14 French size was placed under US guidance, using Seldinger technique by a pediatric intensivist team on bedside with procedural sedation and analgesia.
Results: Forty patients (3.7% of the total admission) required PC insertion. The mean age of the patients was 8.3 years, and 55% (n = 22) were male. Nearly 85% (n = 34) of the patients had an underlying malignancy and presented as respiratory distress/failure secondary to either large pleural effusion and/or massive ascites. Indications were pleural effusions (n = 26, 65%) and ascites (n = 14, 35%). The procedure was successful in 92.5% of the patients. The mean duration of PC insertion was 13.9 days. Pneumothorax developed in three cases (7.5%) as a procedure-related complication, which resolved after chest tube insertion. None of the patients developed bleeding, or visceral injury. Resolution occurred in all cases.
Conclusion: USGPC placement at bedside by intensivists for percutaneous drainage in symptomatic pleural effusion and ascites is a simple, safe, and an effective modality for critically ill children.
Keywords: Ascites, critically ill children, effusion, pigtail catheter, ultrasound-guided
|How to cite this article:|
Rahman F, Ahmed AR, Haque A, Mirza S, Jurair H. Safety and efficacy of ultrasound-guided pigtail catheter insertion in pediatric intensive care unit: A single-center experience. J Pediatr Crit Care 2020;7:311-5
|How to cite this URL:|
Rahman F, Ahmed AR, Haque A, Mirza S, Jurair H. Safety and efficacy of ultrasound-guided pigtail catheter insertion in pediatric intensive care unit: A single-center experience. J Pediatr Crit Care [serial online] 2020 [cited 2020 Nov 27];7:311-5. Available from: http://www.jpcc.org.in/text.asp?2020/7/6/311/300589
| Introduction|| |
Serous cavity effusion (SCE) such as pleural effusion and ascites are common in critically ill patients. The pathophysiology of SCE is multifactorial such as cytokine storms, capillary leakage from endothelial damage, increased hydrostatic pressure and fluid overload due to severe sepsis, advanced malignancy, advanced stage of heart failure, renal failure, and miscellaneous. Large pleural effusion can cause respiratory deterioration and respiratory failure due to poor oxygenation. Similarly, intra-abdominal hypertension and abdominal compartment syndrome (ACS) can result from large ascites. Both are life-threatening conditions and need urgent intervention. Delay in recognition and initiation of appropriate treatment is associated with high morbidity and mortality as well as increased hospital stay. The insertion of pigtail catheter (PC) in these circumstances can be a lifesaving intervention, offering symptomatic relief, improvement in vital organ functions, and guidance in correct treatment for many conditions. The PC insertion is easy to perform, is less traumatic, has possibly fewer procedure-related complications, and is highly effective in treating many pleural and peritoneal diseases associated with large collection of fluid, causing symptoms. Its use in interventional radiology as well as in acute care settings such as emergency rooms and intensive care units is common and becoming the standard of care. Little is known about the experience of ultrasound (US)-guided PC (USGPC) insertion in pleural/peritoneal diseases of critically ill children by pediatric intensivists from pediatric intensive care unit (PICU) of underdeveloped countries like Pakistan. The objective of this study is to describe the safety, efficacy, and procedure-related complications of USGPC insertion in critically ill children by pediatric intensivists in PICU.
| Subjects and Methods|| |
We retrospectively reviewed the electronic medical records of all children admitted in the PICU, who underwent real-time USGPC catheter insertion from January 2018 to December 2019. All pediatric critical care medicine faculties have been trained in critical care point-of-care US on stimulators and patients in workshops and had performed at least twenty procedures under the supervision of an interventional radiologist before performing the procedures individually. We have a wide range of diagnostic and therapeutic applications of US on critically ill children in our PICUs. All procedures were performed under real-time US guidance with procedural sedation and analgesia if required and local anesthesia using modified Seldinger technique by either PICU consultants or pediatric critical care fellows under supervision on the bedside in PICU.
All children between the ages of 1 and 18 years who required PC insertion for nonseptated pleural effusion, pneumothorax, and ascites were identified through electronic medical records. The institutional review board approved the study protocol (IRD_IRB_2019_12_008). Patients with empyema and loculated effusions based on US findings by a radiologist and confirmed by computed tomography scan were excluded from the study, and the included patients were referred to surgery for video-assisted thoracoscopic surgery. Diagnosis was based on clinical examination as well as imaging modality (chest X-ray and US).
A detailed history and physical examination was done, and baseline hemoglobin, platelet count, and coagulation profile were checked for all patients. Chest X-rays and chest/abdomen US were done before the procedure for diagnosis and to mark the site of catheter insertion, respectively. A single-lumen, multi-hole, radiopaque, polyurethane, coiled PC of size 8–14 French was used (Medcomp®, Harleysville, PA, USA) in our cohort. The procedure for PC insertion was explained to the parents and informed parental consent was taken. The detail of the procedure was explained in the following paragraph and according to the standard protocol as explained in literature.
Patients were placed in supine position with head elevated to 30°–45° for pleural drainage and right or left lateral for ascites. After ensuring all aseptic precautions, the US 14 Hz linear-probe was placed perpendicular to the skin in the transverse plane and either in the fourth/fifth mid-postaxillary line over the top of the rib of the chest or at maximal collection of fluid in the abdomen; 2% lidocaine was infiltrated into the skin and deep tissue and pushed deeper with gentle aspiration under direct ultrasonographic visualization till the fluid was aspirated to confirm the presence of fluid in the space. A 20G angiocatheter over the needle with a 10-cc syringe was inserted with gentle suction through the same hole under direct visualization of the needle tip with the help of ultrasonographic guidance and as soon as the fluid started flowing freely, a soft plastic catheter was advanced smoothly into the space and the metal trocar with syringe was removed. A soft-tip, J-shaped guide wire was inserted through the angiocatheter into the space for an adequate length (usually >10 cm) effortlessly. Small incision with a scalpel was made into the skin and deeper tissue adjacent to the catheter. Holding the guide wire, the angiocatheter was removed and a stiff dilator over the wire was advanced into the space and stopped advancing as soon as a “sense of give-way” was noted. After removal of the dilator, a PC with trocar was advanced over the guide wire into the space, making sure that the last hole is in the cavity. The trocar with the guide wire was removed while holding the PC with the skin to avoid dislodgment. The PC was attached to an one-way valve with a drainage bag or a water-sealed drainage system. The PC was secured by suturing the PC with the chest/abdominal wall. A portable postprocedure Chest X-ray was obtained in cases of PC placement in the pleura. Then, the collected fluid was sent for appropriate analysis. The postcare of the procedure included daily assessment of system of drainage with dressing and daily amount of drainage along with re-expansion of pleura.
Success of the intervention was defined by either continuous free drainage of the fluid in the bag, and clinical improvement was confirmed by repeat imaging (chest X-ray or US). Failure of the intervention was defined as need of a second intervention due to the persistent fluid or development of complication such as pneumothorax. The PC was removed when there were clinical improvement, fluid drainage decreased to <10–15 mL/day, and disappearance of collection on imaging.
Data collected included demographic variables (age and gender); clinical data such as diagnosis, comorbidity, indication of PC insertion, patient's coagulation status, and size of the catheter used; and outcome data such as effective drainage and complications encountered. The data were entered into Statistical Package for Social Science (SPSS) Version 21 (IBM Corp., Armonk, NY), and descriptive statistics were applied.
| Results|| |
Of the total 1080 admissions in the PICU during the study period, 40 (3.7%) patients required PC insertion. Patient's characteristics are described in [Table 1]. Their mean age was 8.3 (interquartile range [IQR]: 5–12) years; 22 (55%) were male and 18 (35%) were female. Most of our patients (n = 34, 85%) had an underlying malignancy and presented with respiratory distress/failure either due to large pleural effusion and/or massive ascites. The indication of PC insertion was drainage of pleural effusion (n = 26, 65%) and ascites (n = 14, 35%).
|Table 1: Demographic, clinical data, and complications of patients having pigtail catheter insertion (n=40)|
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The mean duration of PC placement in our study was 13.9 (IQR: 12–17) days. Three patients with pleural effusion developed pneumothorax as a procedure-related complication (7.5%) with ineffective resolution which was resolved after chest tube insertion. None of the patients developed bleeding, visceral injury, or hemodynamic instability. Fluid specimen was sent for all diagnostic workup, including cultures, cytology, and flow-cytometry. All patients tolerated the procedure well. Resolution occurred in all cases [Table 1].
| Discussion|| |
Our data showed that real-time USGPC placement in critically ill children was simple, safe, and effective for drainage of symptomatic pleural effusion and ascites on bedside by pediatricians. This procedure was both diagnostic and therapeutic in all cases. In 1986, Fuhrman et al. published the first case series of 12 patients on PC insertion for drainage of pleural fluid in their PICU. Another report of 91 critically ill children had 133 PCs; most of them were related to heart failure (80%), their complication rates were 20%, and most of them were noted in under 5 kg category. The 113 critically ill adults had USGPC insertion by the intensivist for drainage of pleural effusion with 100% success and the complication rate was 18%, which was little higher than that of our report. In a study from UK, USGPC was used from from para-pneunomic effusion with success rate of 98%. Several studies ranging from neonatal age group to adult patients have shown that USGPC has been highly successful for pneumothorax instead of traditional chest tube thoracotomy. Conventionally, chest tube was used for pleural effusion and pneumothorax. The chest tube is large and stiff, needs muscle dissection for insertion, is painful, and needs more skill and time. The chest tube insertion has been associated with serious complications such as hemorrhage, visceral injury, diaphragm penetration, and impingement of neurovascular structure in the intercostal space, especially in small children. There was lower rate of complication and shorter hospital stay after PC insertion as compared to the conventional large-bore chest tube in a systemic review and meta-analysis. There were scarce data available on the use of PC insertion for relief of ACS due to massive ascites. ACS is a very serious complication and affects many organ systems, especially respiratory and renal systems. If ACS is not recognized and treated promptly, it results in mortality as high as 90%–100%. Liang et al. described safe and effective drainage of massive ascites in children with ACS. They have observed improvement in urine output as well as improvement in oxygenation status in their patients. We have similar findings in our cohort. Latenser et al. demonstrated that PC drainage is safe and effective as surgical decompressive laparotomy in patients with thermal injuries.
PC drainage is a life-saving intervention. However, it is a minimally invasive critical care procedure, which is easy to perform, with potential minimal complications. However, this invasive procedure is a part of advanced trauma life support course. The acquisition of knowledge and skill of this invasive critical care procedure can be easily done through simulation-based medical education, which has been demonstrated that it is a power tool to enhance effective training and patient safety.
We are aware of the limitations of the present study related to small sample size and single-centered and retrospective study design. There is a chance of incomplete data due to electronic medical records. The strength of this study is that the first publication found safe and effective PC insertion for drainage of pleural effusion and ascites in critically ill children from PICU of underdeveloped countries. Serous cavity effusions (SCE) are common in our region due to high prevalence of diseases like dengue shock with capillary leak and advance stage malignancies that not only cause massive fluid collections but compromise vital organ functions. In such scenarios USGPC can be a life-saving intervention which is performed in short time and is minimally invasive. This procedure has also proven to be helpful in neonates that present with severe distress due to tension pneumothorax instead of large-bore chest-tube insertion. It is crucial to educate postgraduate trainees and young pediatricians (frontline physicians) on lifesaving critical care procedures such as basic life support and pediatric advance life support courses.
| Conclusion|| |
Bedside USGPC insertion is a simple, safe, and effective modality of draining of symptomatic pleural effusion and ascites by pediatricians in acute critically ill children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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