Royal Columbian Hospital

Although thoracentesis has traditionally been performed with anatomic landmarking, ultrasound guidance is increasingly used. The primary objective of this systematic review and meta-analysis is to determine the difference in success rates between ultrasound guidance versus anatomic landmark technique. Secondary outcomes include assessing the effects of ultrasound guidance on complication rates.

MEDLINE, Embase, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, LILACS, Web of Science Core Collection, Google Scholar, and the grey literature were searched for prospective randomized trials or cluster randomized trials comparing the success rate of ultrasound-guided to anatomic landmark thoracentesis in patients of all ages from inception to February 2024. Two investigators independently completed study screening, data extraction, and quality evaluations using the Cochrane Risk of Bias and GRADE tools. Outcomes were analyzed using random effects meta-analysis using generalized linear mixed effects models and corresponding 95 % confidence intervals (CI).

Three papers met inclusion criteria (n = 417 patients). Overall, ultrasound-guided thoracentesis was successful in 195 of 202 patients (96.5 %), and anatomic landmark thoracentesis was successful in 189 of 215 patients (87.9 %). Ultrasound-guidance trended towards higher success rates (OR 3.99, 95 % CI 0.60-26.50) and lower complication rates (OR 0.18, 95 % CI 0.01-3.07). Only two of the three studies evaluated post-procedure pneumothorax: in sum, 1/99 of the ultrasound group versus 20/113 in the anatomic landmark group were complicated by pneumothorax.

This systematic review and meta-analysis of randomized trials found that ultrasound guidance for thoracentesis trended towards increased success and lower complication rates compared to anatomic landmark technique.

Rationale: Diaphragm inactivity during invasive mechanical ventilation may predispose the lung and diaphragm to injury and is associated with adverse clinical outcomes. Objectives: Assess the feasibility of continuous on-demand diaphragm neurostimulation-assisted mechanical ventilation to maintain diaphragm activity in the absence of respiratory drive for at least 24 hours of mechanical ventilation. Methods: In a single-center phase 1 clinical trial, patients receiving invasive mechanical ventilation for acute hypoxemic respiratory failure or after thoracic surgery underwent transvenous diaphragm neurostimulation delivered in synchrony with mechanical ventilation. Diaphragm neurostimulation was delivered when breaths were initiated by the ventilator and not by the patient until a successful spontaneous breathing trial was performed or for up to 7 days. The coprimary outcomes were safety and feasibility of maintaining diaphragm activity over the first 24 hours of intervention. Measurements and Main Results: Twenty participants were enrolled and 19 underwent study procedures. Diaphragm neurostimulation was successfully initiated in all 19 patients (100%), and on-target diaphragm activity was maintained for ⩾50% of hours of passive mechanical ventilation over the initial 24-hour period in 18/19 (95%) patients. Diaphragm neurostimulation was well tolerated; one pneumothorax unrelated to the device occurred after subclavian catheter placement before surgery. Over the 7-day study period, diaphragm activity was maintained during a median of 100% (interquartile range, 95-100%) hours with absent respiratory drive. Conclusions: Continuous on-demand diaphragm neurostimulation-assisted mechanical ventilation is feasible and can prevent diaphragm inactivity during mechanical ventilation. Clinical Trial registered with www.clinicaltrials.gov (NCT05465083).

Anesthesia contributes up to 25% of operating room (OR) waste. We sought to conduct a quality improvement project to initiate soft plastic recycling, aiming to recycle 1,000 g per day of soft plastic.

In this single-centre, anesthesiology resident-led quality improvement initiative in British Columbia, Canada, we started a soft plastics recycling collection program in a single operating room (OR) and expanded it to 12 ORs through a series of Plan-Do-Study-Act cycles. The outcome measure was the daily weight of soft plastics recycled. We tracked the number of mistakes as a balancing measure. We collected data eight months after the conclusion of the project to assess sustained changes. We visualized data with Shewhart control charts.

One OR resulted in a mean (standard deviation [SD]) of 194 (157) g of soft plastics collected daily. Once we expanded to all ORs, a mean (SD) of 1,524 (708) g of waste was collected daily. A mean (SD) of 1,284 (613) g was recycled daily during the eight-month follow-up. There was a median [interquartile range (IQR)] of 0 [0-2] mistakes per day with only one OR, which increased to a median [IQR] of 2 [1-4] mistakes per day upon expansion, and remained low at eight months, with a median [IQR] of 1 [0-3] mistake per day. E-mail reminders and signage improved the error rate.

We successfully introduced and sustained a soft plastics collection program in our centre's OR suite with the aim to stream it for recycling. Monitoring and education were helpful in growing the program and reducing errors.