Ultrasound-guided Thoracentesis Research Articles

An unexpected life-threatening persistent oxygen desaturation in a child after extubation.

Ureteroscopic nephrolithotripsy is now being preferred over percutaneous nephrolithotomy for removal of kidney stones in children. Here, in this report, we have discussed persistent oxygen desaturation immediately after extubation in a two-year-old child who underwent Ho-YAG (holmium-yttrium-aluminium garnet) laser ureteroscopic nephrolithotripsy. The child developed bilateral pleural effusion after nephrolithotripsy and required continuous oxygen supplementation to maintain oxygen saturation above 95%, followed by ultrasound-guided thoracentesis.

Re-expansion Pulmonary Edema (REPE) Following Thoracentesis: Is Large-Volume Thoracentesis Associated with Increased Incidence of REPE?

To determine the safety and efficacy associated with drainage volumes greater than 1,500mL in a single, unilateral thoracentesis without pleural manometry measurements. This retrospective, single-institution study included 872 patients (18years and older) who underwent ultrasound-guided thoracentesis. Patient and procedures data were collected including demographics, number of and laterality of thoracenteses, volume and consistency of fluid removed, and whether clinical or radiologic evidence of re-expansion pulmonary edema (REPE) developed within 24h of thoracentesis. Fisher's exact test was used to test the significance of the relationship between volume of fluid removed and evidence of REPE. A total of 1376 thoracenteses were performed among the patients included in the study. The mean volume of fluid removed among all procedures was 901.1mL (SD = 641.7mL), with 194 (14.1%) procedures involving the removal of ≥ 1,500mL of fluid. In total, six (0.7%) patients developed signs of REPE following thoracentesis, five of which were a first-time thoracentesis. No statistically significant difference in incidence of REPE was observed between those with ≥ 1,500mL of fluid removed compared to those with < 1,500mL of fluid removed (p-value = 0.599). Large-volume thoracentesis may safely improve patients' symptoms while preventing the need for repeat procedures.

Ultrasound-Assisted and Ultrasound-Guided Thoracentesis: An Educational Review.

Thoracentesis is one of the most important invasive procedures in the clinical setting. Particularly, thoracentesis can be relevant in the evaluation of a new diagnosed pleural effusion, thus allowing for the collection of pleural fluid so that laboratory tests essential to establish a diagnosis can be performed. Furthermore, thoracentesis is a maneuver that can have therapeutic and palliative purposes. Historically, the procedure was performed based on a physical examination. In recent years, the role of ultrasound has been established as a valuable tool for assistance and guidance in the thoracentesis procedure. The use of ultrasound increases success rates and significantly reduces complications. The aim of this educational review is to provide a detailed and sequential examination of the procedure, focusing on the two main modalities, the ultrasound-assisted and ultrasound-guided form.

Abstract PO5-20-09: LOCOREGIONAL MANAGEMENT OF DE NOVO STAGE IV HORMONE-POSITIVE BREAST CARCINOMA AFTER CDK 4/6 INHIBITOR TREATMENT

Abstract Systemic therapy remains the backbone for treatment of metastatic breast carcinoma. Locoregional treatment of the primary tumor remains controversial. While it has an established role in the palliative setting, its survival benefit remains unclear. The rationale behind locoregional approach is the reduction of tumor burden and the removal of cancer stem cells which may propagate the disease. In previous literature, hormone-positive breast cancer seems to be the best candidate for locoregional treatment in the presence of synchronous metastases. We present a case of a 43 year-old, female, with no known comorbidities, who sought consult due to note of a hard lump on her right breast. Core needle biopsy of the right breast mass was performed which showed invasive breast carcinoma, no special type, Nottingham histologic grade 2. On immunohistochemistry, tumor was ER +8, PR +8, Ki 67 90%, Her-2 neu negative. Baseline positron emission tomography/CT (PET/CT) scan showed hypermetabolic, heterogeneously-enhancing lobulated right breast mass, 3 × 6.7 × 7.7 cm, with smaller hypermetabolic adjacent nodules. There was also note of multiple enhancing, hypermetabolic lung and pleural nodules, and lymphadenopathies in the mediastinal, right axillary, right cardiophrenic and perigastric areas. Well-defined, hypermetabolic heterogeneously hypoenhancing masses were also seen in segments II and VII of the liver. There was also note of right-sided pleural effusion. Ultrasound-guided thoracentesis was done which turned positive for malignant cells on pleural fluid analysis. She underwent 4 cycles of chemotherapy with Doxorubicin and Paclitaxel. Reevaluation PET-CT scan revealed partial response. Patient was then started on Ribociclib plus Letrozole with ovarian function suppression for 18 months. On latest reevaluation PET/CT scan, there was no evidence of hypermetabolic metastatic disease, with demonstration of hypermetabolic activity only in the right breast. The patient then underwent right total mastectomy, with histopathologic findings of residual invasive carcinoma, Nottingham histologic grade 3, residual tumor size of 3.5 cm, with 95% tumor cellularity and lymphovascular invasion identified, ypT2. All surgical margins were negative for tumor. Currently, the patient has no evidence of disease, with ribociclib and letrozole continued until disease progression or unacceptable toxicity. In this case, surgery of the primary tumor was performed in the presence of a responsive metastatic disease, with the primary tumor being the only evidence of disease. With the advent of newer therapy options like cyclin-dependent kinase 4/6 inhibitors offering outstanding survival benefit for metastatic disease, a more aggressive and synergistic approach with locoregional therapy may be done to eradicate the tumor burden, translating to better long-term survival. Locoregional management of the primary tumor should be discussed in the context of a multidisciplinary team approach and should be individualized based on the individual patient’s need. Citation Format: Raye Angeli Abella, Rubi Li. LOCOREGIONAL MANAGEMENT OF DE NOVO STAGE IV HORMONE-POSITIVE BREAST CARCINOMA AFTER CDK 4/6 INHIBITOR TREATMENT [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-20-09.

Real-time ultrasound-guided thoracentesis simulation using an optical see-through head-mounted display: a proof-of-concept study.

This study aimed to examine the feasibility and potential benefits of an optical see-through head-mounted display (OST-HMD) during real-time ultrasound-guided thoracentesis simulations. Six physicians performed a thoracentesis simulation using an OST-HMD and a wireless image transmission system. The time required, puncture needle visibility, pleural fluid collection success rate, and head movement during the procedure using a smart glass equipped with an inertial measurement unit were all recorded and compared with and without the HMD. Study participants successfully extracted effusions in all procedures. The use of OST-HMD did not significantly affect the time of the procedure, but notably decreased the horizontal and vertical head movements during the procedure. The study demonstrated the feasibility of using an OST-HMD in a simulated real-time ultrasound-guided thoracentesis procedure and showed the potential of HMD in thoracentesis to improve ergonomics and accuracy. Further research is necessary to confirm these findings.

A tale of two effusions diagnosing and managing pleural and pericardial empyema

A male in his early 50s with no comorbidities presented with a weeklong history of left-sided chest pain, breathlessness, and cough with yellow–green expectoration. Over 4 months, he reported a 5 kg weight loss and decreased appetite. Investigations revealed mild anemia, electrolyte imbalances, elevated erythrocyte sedimentation rate, and alkaline phosphatase. An electrocardiogram showed low-voltage complexes, and an echocardiogram detected pericardial effusion. A chest X-ray showed bilateral pleural effusion. Ultrasound-guided thoracentesis indicated pleural and pericardial empyema. Sputum tests identified Proteus mirabilis and pericardial fluid grew Escherichia coli. After the therapeutic intervention, the patient initially improved but later worsened, requiring mechanical ventilation, and inotrope support. On the 5th day of admission, he suffered a cardiac arrest and expired despite resuscitative efforts.

Thoracentesis to alleviate pleural effusion in acute heart failure: study protocol for the multicentre, open-label, randomised controlled TAP-IT trial

IntroductionPleural effusion is present in half of the patients hospitalised with acute heart failure. The condition is treated with diuretics and/or therapeutic thoracentesis for larger effusions. No evidence from randomised...

RISK FACTORS AND INCIDENCE OF PNEUMOTHORAX AFTER ULTRASOUND-GUIDED THORACENTESIS

The retrospective study was conducted in tertiary care hospitals between June 2021 and June 2022 to evaluate the risk factors and occurrence of pneumothorax after ultrasound-guided thoracentesis. The study included subjects with pleural effusion in whom pre-procedural thoracentesis under ultrasound guidance was performed. Outcomes were recorded, including chest tube insertion, rate of re-expansion of lungs, length of hospital stay, ICU admission, and mortality rate. Results showed that 500 65 (13%) patients developed pneumothorax. The most frequent etiologies of pleural were congestive heart failure (21%) and malignancy (55%). Multivariate analysis showed an independent association between the volume of pleural fluid drained and the occurrence of thoracentesis-associated pneumothorax (Odds ratio 1.002, 95% Confidence interval 1–1.002; P=.042). It was concluded that pre-procedural thoracentesis under US guidance is associated with a relatively high incidence of pneumothorax. Drainage of a larger volume of pleural fluid is a significant risk factor for developing pneumothorax.

June 2023 Medical Image of the Month: Solitary Fibrous Tumor of the Pleura

No abstract available. Article truncated after 150 words. An 85-year-old man presented to our institution for a second opinion and for management of a recurrent left-sided pleural effusion. The patient has a history of CLL, which was diagnosed with a chest wall biopsy 4 years prior to presentation. Since that time, he has undergone chemotherapy and had a good response. In the past 18 months, the patient has had their left-sided pleural effusion drained 24 times. The patient also has a history of hypothyroidism and has had a cholecystectomy. The patient brought multiple outside imaging studies with him for review. An image capture from a recent ultrasound-guided left thoracentesis (Figure 1A) demonstrated, in retrospect, a pedunculated left lower lobe mass. An outside PET-CT (Figure 1B) was also available, confirming the presence of this mass, which had relatively uniform, low level FDG uptake such that it evade notice on first interpretation. A CT angiogram (Figure 2) demonstrated a large …

Preparing for the Unexpected: Recognizing a Tortuous Thoracic Aorta During Ultrasound-guided Thoracentesis

Preparing for the Unexpected: Recognizing a Tortuous Thoracic Aorta During Ultrasound-guided Thoracentesis

Milky fluid from where? You are about to find out…

Traumatic chylothorax most commonly occurs after thoracic surgeries with a few cases reported in patients after abdominal surgery. Effusions usually are caused by a pleural reaction during the postoperative period. However, this can also occur from disruption of the thoracic duct during the surgical procedure. The initial approach is conservative with supportive measures, including drainage by ultrasound-guided thoracentesis and diet modification, and surgery is rarely needed. Having a medical history preceding abdominal surgery is always important to consider the possibility of a pancreatic pleural fistula, which can be excluded by an abdominal computed tomography. Lymphangiography is considered the gold standard diagnostic tool, but its use is limited to cases unresponsive to conservative measures. In this patient, a lymphangiography or surgical intervention was not performed since the patient improved after initial management with no recurrent pleural effusion. A new pleural effusion after abdominal surgery must include chylothorax in the differential diagnosis.Keywords: Traumatic chylothorax, hiatal hernia repair, thoracic duct, lymphangiography, abdominal computed tomography

Stakeholder perspectives on current determinants of ultrasound-guided thoracentesis in resource limited settings: a qualitative study

ObjectivePreprocedure pleural fluid localization using bedside ultrasound has been shown to reduce complications related to thoracentesis and is now considered the standard of care. However, ultrasound-guided thoracentesis (USGT) has not...

Chinese expert consensus on diagnosis of pleural effusion

Pleural effusion(PE) is a common medical problem with various causes. The differential diagnosis for PE is often challenging. This consensus was generated by members of the academic group of the pleural and mediastinal diseases(preparatory) of Chinese Thoracic Society and some external experts. The members convened in virtual meetings and conducted an extensive literature investigation and assessed the quality of the evidence using a modified grading of recommendations assessment, development, and evaluation(GRADE) approach. This consensus included three chapters: the initial evaluation of PE, the diagnosis of PE with common causes, and the diagnosis of PE with uncommon causes.The main recommendations of Chapter Ⅰ were as follows:(1) For patients suspected of PE according to medical history and clinical manifestations, thoracic CT or ultrasound is recommended to confirm the presence or absence of PE.(2) Ultrasound-guided thoracentesis is recommended when available. Recommended tests for all sampled pleural effeusions include total protein, lactate dehydrogenase (LDH), adenosine deaminase (ADA), differential cell count, and cytological examination.(3) It is recommended to use Light's criteria to distinguish exudate and transudate. When PE is classified to be exudates with heart failure, it is recommended to detect N-terminal pro-brain natriuretic peptide of PE or serum-pleural fluid albumin gradient to assist the judgment.(4) Pleural biopsy is recommended for patients for whom the causes of PE cannot be identified by the detection of PE samples, and CT or ultrasound-guided pleural biopsy is more accurate. Thoracoscopy is recommended for patients whose etiology cannot be identified by laboratory tests of PE and/or pleural biopsy histopathology.The main recommendations of Chapter Ⅱ were as follows:(1)It is suggested to obtain more samples or use immunocytochemistry to assist the diagnosis and cell typing when initial cytopathology examination shows atypical cells, suspicious malignant or malignant cells. (2) Liquid medium for Mycobacterium tuberculosis culture is recommended to improve the positive rate. Molecular diagnosis (nucleic acid amplification or Xpert MTB/RIF) is recommended when tuberculous PE is suspected. For suspected tuberculous PE where the examination of PE is inconclusive. CT or ultrasound-guided pleural biopsy or thoracoscopy is recommended to obtain pleural tissue for acid-fast staining, Mycobacterium tuberculosis nucleic acid amplification and culture.(3)C-reactive protein (CRP) of PE is recommended to distinguish uncomplicated PPE from complicated PPE. It is suggested to inoculate pleural effusion into blood culture bottles or culturing specimens from ultrasound-guided pleural biopsy to increase the positive rate.The main recommendations of Chapter Ⅲ were as follows:(1) It is recommended to comprehensively analyze the patients' medical history, clinical manifestations, effusion characteristics, and biopsy pathological results to indentify uncommon causes.(2) It is recommended to detect the presence of chylomicrons or cholesterol crystals, with testing of the levels of triglyceride and cholesterol in PE for clinical suspicion of chylothorax or pseudochylothorax. (3) PE may be the result of a combination of various causes, and it is recommended to screen factors such as heart failure, hypoalbuminemia, and thoracic infection for critical patients.(4) For patients with PE whose cause has not been identified by thoracoscopic pleural biopsy, close follow-up for at least 2 years is recommended to exclude malignant diseases.

October 2022 Medical Image of the Month: Infected Dasatinib Induced Chylothorax-The First Reported Case

No abstract available. Manuscript truncated after 150 words. A 45-year-old man with chronic myeloid leukaemia (CML) on dasatinib presented to the emergency department with a 2-week history of dry cough, worsening shortness of breath and left-sided chest pain that had worsened on the day of presentation. On examination, oxygen saturation was 98% on 2 L nasal cannula, respiratory rate 22 bpm, pulse 77 bpm, blood pressure 117/90 mmHg and his temperature was 37.9° C (100.2 F). Examination of the left chest showed no air entry and stony dull percussion note. Laboratory results were significant for leucocytosis with a neutrophil count of 11.2, elevated CRP of 414, mildly elevated lactate of 1.1. Initial chest X-ray showed large left-sided pleural effusion and a small volume right effusion (Figure 1A). The patient was started on IV piperacillin /tazobactam, blood cultures were obtained and the dasatinib was held. Ultrasound-guided left thoracentesis and drain placement was performed, on ultrasound the effusion demonstrated several …

Effectiveness and Safety of Real-Time Transthoracic Ultrasound-Guided Thoracentesis.

Purpose: The purpose of the present study was to specifically evaluate the effectiveness and safety of real-time ultrasound-guided thoracentesis in a case series of pleural effusion. Patients and methods: An observational prospective study was conducted. From February 2018 to December 2019, a total of 361 consecutive real-time transthoracic ultrasound (TUS)-guided thoracentesis were performed in the Unit of Diagnostic and Interventional Ultrasound of the Research Hospital “Fondazione Casa Sollievo della Sofferenza” of San Giovanni Rotondo, Foggia, Italy. The primary indication for thoracentesis was therapeutic in all the cases (i.e., evacuation of persistent small/moderate pleural effusions to avoid super-infection; drainage of symptomatic moderate/massive effusions). For completeness, further diagnostic investigations (including chemical, microbiological, and cytological analysis) were conducted. All the procedures were performed by two internists with more than 30 years of experience in interventional ultrasound using a multifrequency convex probe (3–8 MHz). For pleural effusions with a depth of 2–3 cm measured at the level of the costo-phrenic sinus was employed a dedicated holed convex-array probe (5 MHz). Results: In all the cases, the attempts at thoracentesis were successful, allowing the achievement of the therapeutic purpose of the procedure (i.e., the complete drying of the pleural space or the withdrawal of fluid till a “safe” quantity [a mean of 1.5 L, max 2 L] producing relief from symptoms) regardless of the initial extent of the pleural effusion. There were only 3 cases of pneumothorax, for a prevalence rate of complications in this population of 0.83%. No statistical difference was recorded in the rate of pneumothorax according to the initial amount of pleural fluid in the effusion (p = 0.12). All the pleural effusions classified as transudates showed an anechoic TUS appearance. Only the exudative effusions showed a complex nonseptated or a hyperechoic TUS appearance. However, an anechoic TUS pattern was not unequivocally associated with transudates. Some chronic transudates have been classified as exudates by Light’s criteria, showing also a complex nonseptated TUS appearance. The cytological examination of the drained fluid allowed the detection of neoplastic cells in 15.89% cases. On the other hand, the microbiological examination of effusions yielded negative results in all the cases. Conclusions: Real-time TUS-guided thoracentesis is a therapeutically effective and safe procedure, despite the diagnostic yield of the cytological or microbiological examinations on the collected liquid being very low. Future blinded randomized studies are required to definitely clarify the actual benefit of the real-time TUS-guided procedure over percussion-guided and other ultrasound-based procedures.

CONCOMITANT TRANSUDATIVE AND EXUDATIVE PLEURAL EFFUSION: A CASE OF CONTARINI SYNDROME

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bilateral pleural effusion usually has a common etiology and a result of a systemic disease process. Contarini syndrome refers to bilateral pleural effusion with a separate etiology for both sides. We report a case of a patient with bilateral pleural effusion presenting as Contarini syndrome with one side with transudative and the other with exudative pleural effusion. CASE PRESENTATION: A 61-year-old female with a history of alpha-1-antitrypsin deficiency with emphysema and cirrhosis, Crohn's disease with ileostomy, and recurrent right-sided pleural effusion (with multiple thoracenteses) presented with worsening dyspnea on exertion, left-sided pleuritic chest pain, and hypoxia requiring 6L supplemental oxygen otherwise, hemodynamically stable without a fever. Initial laboratory evaluation showed leukocytosis of 26000 cells/mm3 with neutrophilia, macrocytic anemia with hemoglobin of 11 g/dL, and hematocrit of 32.4%. Additional workup showed elevated bilirubin (12 g/dL) with predominant indirect hyperbilirubinemia (8.7 g/dL). Initial chest x-ray showed bilateral pleural effusion with a subsequent computed tomography chest with intravenous contrast showed moderate to large right pleural effusion and moderately sized left pleural effusion with possible loculation. The patient was initially started on intravenous Piperacillin-Tazobactam later switched to Levofloxacin. She underwent ultrasound-guided thoracentesis of the left side with exudative effusion (via 2/3 Light's criteria) with 1L fluid removed. The oxygen requirements did not improve over the next 2 days, and a right-sided thoracentesis was performed with drainage of 1.6L cloudy orange fluid which was transudative via light's criteria. A 10-day course of antibiotics was completed. Her symptoms significantly improved, leukocytosis resolved, and was eventually discharged on 3L/min supplemental oxygen. A month later, she developed right-sided effusion and was drained (fluid not sent for analysis) and required 2L/min supplemental oxygen. DISCUSSION: Contarini syndrome, a rare yet distinct entity might be underdiagnosed. Bilateral thoracentesis is rarely justified however if imaging shows different morphology of effusions, unilateral parenchymal involvement with bilateral pleural effusion, failure of effusion resolution despite treatment, or if the patient is not improving clinically. Our patient's different effusion morphology and clinical status prompted for bilateral thoracentesis. The right-sided pleural effusion was likely due to liver cirrhosis while the left-sided probably a parapneumonic effusion. CONCLUSIONS: Bilateral pleural effusion due to two separate etiology is rare, but a distinctive entity. When clinically justified, a bilateral thoracentesis may be performed. This will help direct treatment, prevent repeat hospitalizations for patients, and direct prudent use of resources. REFERENCE #1: Porcel JM, Civit MC, Bielsa S, Light RW. Contarini's syndrome: bilateral pleural effusion, each side from different causes. J Hosp Med. 2012 Feb;7(2):164-5. doi: 10.1002/jhm.981. Epub 2011 Oct 31. PMID: 22042579. DISCLOSURES: No relevant relationships by Samir Jha, source=Web Response No relevant relationships by Sobia Nizami, source=Web Response No relevant relationships by Lintha Shah, source=Web Response

Limited Clinical Utility of Chest Radiography in Asymptomatic Patients after Interventional Radiology-Performed Ultrasound-Guided Thoracentesis: Analysis of 3,022 Consecutive Patients

Abstract Purpose The aim of this study was to report the utility of chest radiography following interventional radiology-performed ultrasound-guided thoracentesis. Materials and Methods A total of 3,998 patients underwent thoracentesis between 2003 and 2018 at two institutions. A total of 3,022 (75.6%) patients were older than 18 years old, underwent interventional radiology-performed ultrasound-guided thoracentesis, and had same-day post-procedure chest radiograph evaluation. Patient age (years), laterality of thoracentesis, procedural technical success, volume of fluid removed (mL), method of post-procedure chest imaging, absence or presence of pneumothorax, pneumothorax size (mm), pneumothorax management measures, and clinical outcomes were recorded. Technical success was defined as successful aspiration of pleural fluid. Post-procedure clinical outcomes included new patient-perceived dyspnea and hypoxia (oxygen saturations &lt; 90% on room air). Costs associated with radiographs were estimated using Medicare and Medicaid fee schedules. Results Mean age was 56.7 ± 15.5 years. Interventional radiology-performed ultrasound-guided thoracentesis was performed on the left (n = 1,531; 50.7%), right (n = 1,477; 48.9%), and bilaterally (n = 14; 0.5%) using 5-French catheters. Technical success was 100% (n = 3,022). Mean volume of 940 ± 550 mL of fluid was removed. Post-procedure imaging was performed in the form of posteroanterior (PA) (2.6%; 78/3,022), anteroposterior (AP) (17.0%; 513/3,022), PA and lateral (77.9%; 2,355/3,022), or PA, lateral, and left lateral decubitus (2.5%; 76/3,022) chest radiographs. Post-procedural pneumothorax was identified in 21 (0.69%) patients. Mean pneumothorax size, measured on chest radiograph as the longest distance from the chest wall to the lung, was 18.8 ± 10.2 mm (range: 5.0–35.0 mm). Of the 21 pneumothoraces, 7 (33.3%) were asymptomatic, resolved spontaneously, and had a mean size of 6.4 ± 2.4 mm. Fourteen pneumothoraces, of mean size 25.0 ± 5.8 mm, required management with a pleural drainage catheter (66.6%). The overall incidence of pneumothorax requiring pleural drainage catheter placement following interventional radiology-performed ultrasound-guided thoracentesis was 0.46% (14/3,022). Of the patients requiring drainage catheter placement, 12/14 (85.7%) and 13/14 (92.9%) had dyspnea and hypoxia, respectively. Potential costs to Medicare and Medicaid, for chest radiographs, in this study, were $27,547 and $10,581, respectively. Conclusion The incidence of clinically significant pneumothorax requiring catheter drainage following interventional radiology-operated ultrasound-guided thoracentesis is exceedingly low (0.46%), and routine post-procedure chest radiographs in asymptomatic patients provide little value. Reserving post-procedure chest radiographs for patients with post-procedure dyspnea or hypoxia will result in more efficient resource utilization and health care cost savings.

Mature Teratoma Revealed by an Encysted Pleural Effusion

A 32-year-old patient with no previous history was admitted for chest pain, dyspnea, appetite and weight loss. Chest X-ray revealed an opacity involving the lower two-thirds of the right hemithorax, suggestive of a pleural effusion. Because of the absence of fluid return even after ultrasound-guided thoracentesis, a Chest Computed tomography was required showing a heterogeneous anterior mediastinal mass with soft tissue, fat, fluid and calcifications associated with extensive encysted fluid collection in the right hemithorax. A video-assisted mini-thoracotomy revealed a mediastinal tumor firmly attached to the thymus with a cystic wall lined by squamous epithelium and sebaceous gland composed of respiratory tissue, adipose tissue, cartilage, smooth muscle fibers, and well-differentiated pancreatic tissue. These findings led to the diagnosis of a mature thymic teratoma. The patient was discharged 7 days after surgery, with no recurrence on follow-up.

NONTYPHOIDAL SALMONELLA EMPYEMA AS A COMPLICATION OF PRIMARY SALMONELLA ENTERITIDIS BACTEREMIA

TYPE: Abstract Publication TOPIC: Chest Infections PURPOSE: We present a case of Salmonella enteritidis empyema and bacteremia in the absence of enteric infection or known immunological dysfunction. METHODS: Clinical care and chart review of single patient. RESULTS: A 60-year-old female presented for evaluation of fever and dyspnea. She was febrile, tachycardic, and tachypneic. Chest X-ray revealed complete opacification of the left hemithorax [Figure 1 – panel A]. CT angiogram of the chest showed a large loculated left pleural effusion causing collapse of the left hemithorax [Figure 1 – panel B]. Blood cultures grew Salmonella enteritidis and the patient was treated for severe sepsis. Ultrasound-guided thoracentesis was performed and revealed frank pus consistent with acute suppurative empyema; pleural fluid cultures also grew Salmonella enteritidis. The patient underwent video-assisted thoracoscopic surgery with purulent fluid drainage and insertion of a chest tube. Despite aggressive medical treatment, she continued to deteriorate requiring transfer to the intensive care unit due to septic shock. Due to her exceptionally poor prognosis, the patient’s family ultimately elected to pursue comfort measures. CONCLUSIONS: Extraintestinal Salmonella infection due to primary bacteremia is exceedingly rare. Often, this can indicate underlying immunologic dysfunction due to HIV infection, malignancy, etc. In addition to prolonged antimicrobial therapy, surgical drainage or debridement is generally required, as with our case of empyema. CLINICAL IMPLICATIONS: A high index of suspicion is critical to early recognition, which can be difficult in non-endemic regions, particularly in the absence of enteric infection or underlying immunodeficiency. Despite our patient’s demise, early appropriate antibiotics and timely surgical intervention are crucial to improve future outcomes. DISCLOSURE: No significant relationships. KEYWORDS: Salmonella enteritidis, Empyema, VATS

Real-time ultrasound-guided thoracentesis in the intensive care unit: prevalence of mechanical complications

BackgroundThe use of thoracic ultrasound during thoracentesis reduces complications. The aim of this study was to determine the prevalence of complications for real-time ultrasound-guided thoracentesis performed by intensivists. As a secondary objective, the change in oxygenation before and after the procedure was evaluated.Patients and methodsAn observational prospective study was conducted. A total of 81 cases of real-time ultrasound-guided thoracentesis performed by intensivists in the intensive care unit (ICU) of Méderi Major University Hospital, Bogotá, Colombia, between August 2018 and August 2019 were analyzed. Thoracentesis performed by interventional radiologists and using techniques different from the focus of this study were excluded from the analysis.ResultsThere was one pneumothorax, for a prevalence rate of mechanical complications in this population of 1.2%. The mean partial oxygen pressure to inspired oxygen fraction ratio (PaO2/FiO2) prior to the procedure was 198.1 (95% CI 184.75–211.45), with a PaO2/FiO2 after the procedure of 224.6 (95% CI 213.08–226.12) (p < 0.05).ConclusionsReal-time ultrasound-guided thoracentesis performed by intensivists is a safe procedure and leads to a significant improvement in oxygenation rates. Future studies are required to determine the impact of these results on other outcomes, such as mortality, ICU stay, and days of mechanical ventilation.