Respiratory complications are a major contributing factor to postoperative morbidity and mortality in pediatric liver transplantation.

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1 Real-time ultrasound-guided pigtail catheter placement in supine position for drainage of symptomatic pleural effusions in paediatric patients who underwent liver transplantation Poster No.: B-0163 Congress: ECR 2015 Type: Authors: Keywords: DOI: Scientific Paper M. D'Amico, R. Miraglia, L. Maruzzelli, G. Gallo, A. Luca; Palermo/ IT Pediatric, Thorax, Interventional non-vascular, Ultrasound, Drainage, Transplantation /ecr2015/B-0163 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 11

2 Purpose Respiratory complications are a major contributing factor to postoperative morbidity and mortality in pediatric liver transplantation. Pleural effusion is a common clinical entity in the early postoperative period, with a reported incidence of up to 76% in the first postoperative week, and a reported incidence of 25% considering only persistent pleural effusion. Image-guided percutaneous pigtail catheter placement is a less-invasive alternative to the large-bore chest tube, especially for pediatric patients. Ultrasound guidance enables visualization of the needle insertion for wire-guided drainage placement, and is associated with decreased risk of pneumothorax. However, most studies in this field have been done out on adults. The aims of this study were report the technical success and complication rate observed during real-time US-guided thoracic pigtail catheter placement in the supine position, and at bedside, in pediatric liver transplant recipients with symptomatic pleural effusion. Methods and materials At our institute, a comprehensive transplant center, it is standard practice for all pediatric thoracic pigtail placement procedures to be referred to our Radiology Service. From May, 2006 to June, 2014, a total of 41 real-time US-guided thoracic pigtail catheter placements in the supine position, at bedside, were done in 25 pediatric patients with symptomatic pleural effusion in the post liver transplant period. The procedures were all performed at the bedside with the patient in the supine position. The complete real-time US visualization of each operating phase did not require significant mobilization and/or decubitus change in procedures done in the intensive care unit with or without mechanical ventilation. For procedures performed in monitored anesthesia care with spontaneous respiration, the supine position facilitated airway control by the anesthesiologist during the procedure. Ultrasound confirmation of pleural effusion was made prior to skin disinfection. Page 2 of 11

3 The ultrasonic appearances were classified as -stage 1 with simple clear anechoic effusion; -stage 2 with complex effusion appearing as cloudyhypoechoic fluid with floating fibrin strands; -stage 3 with complex effusion appearing asseptated ormultiloculatedhypoechoic fluid partitioned by fibrin strands with no clear demarcation between the lung and pleural components. A semi-quantitative ultrasound evaluation of pleural effusion was also done, and the effusions were classified as large, medium, or small. Pigtail catheters were inserted with the Seldinger technique. The procedure was performed with a percutaneous intercostal approach, approximately at the level of the midaxillary line. Local anesthesia was administered under real-time US guidance, with 1% lidocaine, using a 25 gauge spinal needle. The pleural space puncture was made with an 18 gauge Chiba needle (Biopsybell, Modena, Italy) advanced under real-time US guidance using a 6 to 15 MHz linear transducer or a 3.5MHz sectorial transducer. In all procedures a sterile disposable needle guide was placed over a sterile cover-probe on the specific transducer bracket. The needle was followed, by the operator, according to the US-screen software guidelines. A inch Starter guidewire was advanced over the needle. After needle removal, a small skin incision with a scalpel was made at the access point, and dilatation of the access point was achieved with a vascular dilator. A pigtail catheter was then placed over the wire. The catheter was sutured in situ. The typical pigtail size varied from 5Fr to 8.5 Fr. A routine post-procedural chest radiograph was not performed in the absence of valid clinical indications Page 3 of 11

4 Images for this section: Fig. 1: Chest x-ray shows large right pleural effusion in a 7-month-old patient, weighing 6.5 kg, who underwent left lateral split liver transplant for biliary atresia. Post-operative day 3. Platelet count mm³, INR 2.2. Procedure performed in the intensive care unit. Page 4 of 11

5 Fig. 2: Pleural space puncture performed under real-time US guidance with intercostal approach. Seldinger technique. Page 5 of 11

6 Fig. 3: Ultrasound confirmation of correct placement of 6F pigtail catheter. Page 6 of 11

7 Fig. 4: Chest x-ray performed the day after the procedure; of note is marked reduction of pleural effusion, no pneumothorax. Page 7 of 11

8 Results Thirty-eight of the 41 catheters were placed in the right pleural space. Eleven procedures were done in 7 patients weighing less than 10 kg. Twenty-four procedures were performed in our institute's Radiology Service, 17 procedures were done in the intensive care unit, and 8 procedures in patients under mechanical ventilation. Twelve of the 41 procedures were done in patients with altered hemostasis (platelets <50,000 mm³ and/or INR> 1.5) after infusion of platelets and/or fresh frozen plasma one hour prior to the procedure. The semi-quantitative ultrasound evaluation of pleural effusion, before pigtail placement, showed 15 effusions classified as large (36%), 24 as medium (59%), and 2 as small (5%). The ultrasonic appearances of the pleural effusion were classified as stage 1 in 36 cases (87%), and stage 2 in 5 cases (13%). 11 patients required repeated pigtail insertions over prolonged hospitalizations. Four of these repeated procedures were performed to replace an accidentally dislodged drain in a period of 3 to 10 days after the first procedure, with an overall incidence of 9% of premature dislodgement. The other cases were for recurrence of the original condition on a separate occasion. Technical success was obtained in all procedures, without complications, and no patient developed pneumothorax and/or significant bleeding. No pigtail drainage was stopped for onset of complications. Limitations. Because it is a retrospective study, some minor complications may have been missed in the clinical records. In addition, the absence of major technical complications could conceivably be explained by the relatively low number of procedures in our cohort of patients compared with other studies done in adult patients. However, large cohorts of patients are difficult to amass in the pediatric population. Page 8 of 11

9 Another important consideration is that all procedures in our study were performed by two staff-level interventional radiologists, with no procedures being performed by supervised fellows or residents. We have no direct comparison with conventional chest tubes. However, those are now not placed outside the operating room at our institute in the pediatric population. Images for this section: Table 1: Patient characteristics. Page 9 of 11

10 Conclusion In our experience, in pediatric patients, real time US-guided pleural space puncture in the supine position, at bedside, followed by pigtail placement is a safe procedure with a high technical success rate. Unlike conventional chest tubes, pigtail catheters are easily compressed, and this is why the entry site of the catheter at the level of the midaxillary line and not the standard posterior approach results in a reduced likelihood of catheter dysfunction secondary to kinking or compression, and should be, in our opinion, preferred. Personal information References Hasegawa S, Mori K, Inomata Y, Murakawa M, Yamaoka Y, Tanaka K. (1996) Factors associated with postoperative respiratory complications in pediatric liver transplantation from living-related donors. Transplantation. Oct 15;62(7): Mack CL, Millis JM, Whitington PF, Alonso EM. (2000) Pulmonary complications following liver transplantation in pediatric patients. Pediatr Transplant. Feb;4(1): Mercaldi JC, Lanes SF. (2013) Ultrasound Guidance Decreases Complications and Improves the Cost of Care Among Patients Undergoing Thoracentesis and Paracentesis. Chest; 143(2): Heidecker J, Huggins JT, Sahn SA, Doelken P. (2006) Pathophysiology of Pneumothorax Following Ultrasound-Guided Thoracentesis. Chest; 130: Soldati G, Smargiassi A, Inchingolo R, Sher S, Valente S, CorboGM. (2013) Ultrasoundguided pleural puncture in supine or recumbent lateral position - feasibility study. Multidisciplinary Respiratory Medicine, 8:18 Horsley A, Jones L, White J, Henry M. (2006) Efficacy and Complications of Small- Bore, Wire-Guided Chest Drains. Chest; 130: Page 10 of 11

11 Kim OH, Kim WS, Kim MJ, Jung JY, Suh JH. (2000) US in the diagnosis of pediatric chest diseases. Radiographics; 20: Roberts JS, Bratton SL, Brogan TV. (1998) Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients. Chest. Oct;114(4): K. Martin, S Emil, S Zavalkoff, A. Lo, M Ganey, R Baird et al. (2013) Transitioning from Stiff Chest Tubes to Soft Pleural Catheters: Prospective Assessment of a Practice Change. Eur J Pediatr Surg; 23(05): Page 11 of 11