Introduction The introduction of the European Working Time Directive has lead to concerns about reduction in exposure to practical procedures for junior doctors1.
Ultrasound is now considered essential for pleural aspiration and chest drain insertion2. Its use for LVP has also been suggested3.
Our aim was to assess the safety of LVP performed at our centre according to the clinical grade of the operator.
Methods We identified patients who had undergone LVP at our hospital during a 12 month period from October 2010 by reviewing the admission book of our department and by reviewing a list of all the ascitic fluid samples sent to our microbiology department. Case notes for these patients were reviewed and data were collected on patient demographics, method of insertion (blind vs. ultrasound guided), grade of operator, adequacy of albumin replacement and the occurrence of any complications.
Results 56 LVP were performed on 28 patients.
53 drains were successfully inserted blindly, 3 required ultrasound guidance.
2 drains were inserted by consultants (both ultrasound guided) and 9 by registrars. 15 were inserted by core training doctors (1 procedure was supervised) and 28 by foundation doctors (19 supervised).
Ascites was sent for white cell count after 53 (95%) procedures.
No major procedure related complications occurred; 1 patient required a stitch for a minor cutaneous bleed after drain removal.
6 received < 6 g albumin per litre of ascites drained. 3 LVP were carried out with no albumin replacement, in 2 of these the drain had been inserted under ultrasound guidance. For 2 procedures (performed on surgical wards) the drain was not removed after 6 hours.
Conclusion LVP can be safely performed without ultrasound guidance by adequately trained or supervised junior doctors. Some failings occurred with regard to albumin replacement, timely drain removal and request for ascitic white cell count. However, none of these would have been prevented by performing drain insertion under ultrasound guidance. Patients who had their drain inserted under ultrasound guidance were in fact more likely to receive sub-optimal post-procedure care.
Protocols are required for the management of ascitic drains and clear communication with nursing staff is essential.
Disclosure of Interest None Declared
Doctors’ training and the European Working Time Directive. Lancet 2010; 375(9732):2121.
Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and thoracic ultrasound British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii61–76.
Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomised study. Am J Emerg Med. 2005 May; 23(3):363–7.