Tuberculosis and Respiratory Diseases

The Korean Academy of Tuberculosis and Respiratory Diseases (대한결핵및호흡기학회)
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Diagnostic Approach to a Patient with a Pleural Effusion Including Ultrasound-guided Paracentesis Performed by a Medical Resident

내과 전공의가 시행한 초음파 이용 흉수천자를 포함한 흉수의 진단적 접근

  • Lee, Yun Young (Department of Internal Medicine, National Police Hospital) ;
  • Choi, Won Je (Department of Internal Medicine, National Police Hospital) ;
  • Yu, Chang Min (Department of Internal Medicine, National Police Hospital) ;
  • Suh, Seong O (Department of Internal Medicine, National Police Hospital) ;
  • Kim, Eun Sil (Department of Internal Medicine, National Police Hospital) ;
  • Ahn, Seok- in (Department of Internal Medicine, National Police Hospital) ;
  • Chung, Jun-Oh (Department of Internal Medicine, National Police Hospital) ;
  • Park, Sang Joon (Department of Internal Medicine, National Police Hospital) ;
  • Kim, Yun Kwon (Department of Internal Medicine, National Police Hospital) ;
  • Kim, Soyon (Department of Internal Medicine, National Police Hospital) ;
  • Kim, Young Jung (Department of Internal Medicine, National Police Hospital) ;
  • Lee, Se Han (Department of Internal Medicine, National Police Hospital) ;
  • Heo, Heon (Department of Radiology, National Police Hospital)
  • Received : 2008.02.23
  • Accepted : 2008.06.11
  • Published : 2008.06.30
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Abstract

Background: A patient with a pleural effusion that is difficult to safely drain by a "blind" thoracentesis procedure is generally referred to a radiologist for ultrasound-guided thoracentesis. But such a referral increases the cost and the patient's inconvenience, and it causes delay in the diagnostic procedures. If ultrasound-guided thoracentesis is performed as a bedside procedure by a medical resident, then this will reduce the previously mentioned problems. So these patients with pleural effusions were treated by medical residents at our medical center, and the procedures included bedside ultrasound-guided thoracenteses. Methods: We studied 89 cases of pleural effusions from March 2003 to June 2005. A "blind" thoracentesis was performed if the amount of pleural effusion was moderate or large. Bedside ultrasound-guided thoracentesis was performed for small or loculated effusions or for the cases that failed with performing a "blind" thoracentesis. Results: "Blind" thoracenteses were performed in 79 cases that had a moderate or large amount of uncomplicated pleural effusions and the success rate was 93.7% (74/79 cases). Ultrasound-guided thoracentesis by the medical residents was performed in 15 cases and the success rate was 66.7% (10/15 cases). The 5 failedcases included all 3 cases with loculated effusions and 2 cases with a small amount of pleural effusion. All the failed cases were referred to one radiologist and they were then successfully treated. If we exclude the 3 cases with loculated pleural effusions, the success rate of ultrasound-guided thoracentesis by the medical residents increased up to 83% (10/12cases). Two cases of complications (1 pneumothorax, 1 hydrohemothorax) occurred during ultrasound-guided thoracentesis. Conclusion: Ultrasound-guided thoracentesis performed as a bedside procedure by a medical resident may be relatively effective and safe. If a patient has a loculated effusion, then it would be better to first refer the patient to a radiologist.

연구배경: 일반적으로 고식적 흉수천자가 어렵다고 판단되는 경우 초음파를 이용한 흉수천자를 영상의학과에 의뢰해 왔다. 영상의학과에 의뢰할 경우 검사를 위해 환자가 직접 이동해야 된다는 불편함과 영상의학과 스케줄에 따라 검사가 지연되거나 비용이 많이 드는 단점이 있다. 이에 저자들은 병실에서 내과 전공의들이 직접 초음파를 이용해서 흉수천자를 시행하는 단계를 포함해서 흉수가 있는 환자에게 접근해보았다. 방 법: 2003년 3월부터 2005년 6월까지 입원한 환자중 흉수가 확인된 환자들을 대상으로 하였고, 흉수의 양이 중등도 이상일 경우에는 고식적 천자를, 흉수의 양이 소량 이거나 소방이 형성된 경우 또는 고식적 천자를 실패 하였을 때에는 초음파를 이용한 천자를 시행하였다. 결 과: 총 89예의 연구대상 가운데 소방의 형성이 없으며 흉수의 양이 대량과 중등도의 양인 79예에서 고식적 흉수천자를 시행하여 74예에서 성공하였다. 고식적 흉수 천자가 실패한 5예와 흉수의 양이 소량인 7예 그리고 소방형성이 있는 3예를 합한 15예에서 초음파를 이용해서 흉수천자를 시행하였고 10예에서 성공하였다(66.7%). 소방이 형성된 3예는 모두 실패하였다. 이 3예를 제외하면 12예 중 10예에서 성공하여 83%의 성공률을 보였다. 2예(기흉 1예, 혈기흉 1예)에서 합병증이 발생하였다(13.3%). 결 론: 고식적 흉수천자가 실패하였거나 흉수의 양이 소량인 경우, 병실에서 내과 전공의가 초음파를 이용하여 흉수천자를 시행하는 것이 비교적 효과적이고 안전할 것으로 사료된다. 그러나 소방이 형성된 경우에는 영상의학과에 먼저 의뢰하는 것이 좋을 것으로 판단된다.

Keywords

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