368 Sonographic Assessment of Inadvertent Vascular Puncture During Paracentesis Using the Traditional Landmark Approach

Abstract

with ICD-9 codes for pneumonia. In the pre-retirement group, 145/152, or 95.4% (95% CI: 90-95%), of patients were given the correct antibiotics. The most common fallouts included administering azithromycin without ceftriaxone (3/152, 2%, 95% CI: 0.7-5%). These patients also had COPD; however, they were diagnosed as having pneumonia, not a COPD flare or bacterial bronchitis. The second source of errors included ICU patients (3/152, 2%, 95% CI:0.7-5%). These patients often received vancomycin and cefepime (2/ 152, 1%, 0.6-3%) rather than cipro/cefepime/vanco to adequately cover for pseudomonas, with 1/152 (0.3%, 95% CI 0.2-2%) receiving vancomycin and piperacillin/tazobactam. Lastly, an ESRD requiring dialysis was incorrectly classified and treated as having CAP (1/152, 0.3%, 95% CI 0.2-2%). After core measures were retired, 114/117 (97.4%), 95% CI 93-99%)patients were given the correct antibiotic. The fallouts included one patient receiving ceftriaxone and sulfamethoxazole/trimethoprim, another cefepime and vancomycin, and the third vancomycin, rocephin, and moxifloxacin.Conclusion: Compliance with Pneumonia Core Measure was not affected by retirement of this core measure. Based on this pilot data, we believe that these treatment strategies are hardwired into ED clinical culture.

Bedside ultrasonography prior to abdominal paracentesis is associated with low complication and high success rate: Experience in a National Health Service District General Hospital in the United Kingdom from 2013 to 2019

“…34,35 To the contrary, our data, similar to other articles, support the use of bedside ultrasound-assisted paracentesis leading to a high success rate for diagnostic aspirations and drain insertions. 12,[14][15][16][17][19][20][21][22][23]35 Regarding the analysis of procedure activity, unfortunately coding data were not reliably reflecting the activity in 2019. This is not necessarily surprising, since a lack of accurate procedure activity documentation by the coding process in NHS trusts has been demonstrated in other studies.…”

“…[15][16][17][18][19] Many articles support the use of ultrasound prior or during abdominal paracentesis for detection of ascites to reduce failed paracentesis attempts and identify the safest site for needle insertion. [15][16][17][20][21][22] Furthermore, in several countries, guidelines supporting the use of ultrasoundassisted abdominal paracentesis have been published. [23][24][25][26] The authors present their 7-year experience of using bedside ultrasound prior to diagnostic and therapeutic abdominal paracentesis, on hospital wards and an Ambulatory Care Unit (ACU) and compare the results with previous studies.…”

“…15–19 Many articles support the use of ultrasound prior or during abdominal paracentesis for detection of ascites to reduce failed paracentesis attempts and identify the safest site for needle insertion. 15–17,20–22 Furthermore, in several countries, guidelines supporting the use of ultrasound-assisted abdominal paracentesis have been published. 23–26…”

Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine

“…One study showed that 43% of patients had a vascular structure present at one or more of the three traditional landmark paracentesis sites. 78 Another study directly compared bleeding rates between an approach utilizing a low-frequency transducer to identify the largest collection of fluid only versus a two-transducer approach utilizing both low and high-frequency transducers to identify the largest collection of fluid and evaluate for any superficial blood vessels. In this study, which included 5,777 paracenteses, paracentesis-related minor bleeding rates were similar in both groups, but major bleeding rates were less in the group utilizing color flow Doppler to evaluate for superficial vessels (0.3% vs 0.08%); differences found between groups, however, did not reach statistical significance (P = .07).…”

“…13,16,53 Therefore, if the patient changes position or there is a delay between marking the needle insertion site and performing the procedure, the patient should be reevaluated with ultrasound to ensure that the marked needle insertion site is still safe for paracentesis. 78 After marking the needle insertion site, the skin surface should be wiped completely clean of gel, and the probe should be removed from the area before sterilizing the skin surface. 9.…”