Elective paracentesis

[Groove]

Do you guys do many of these in the ED? I just find them so annoying. It's probably my least favorite procedure. They are rarely indicated emergently, take forever, and this patient population is usually extremely vocal about not receiving it in the ED. It's usually someone who has skipped several appointments with IR and is screaming over the phone with their GI office and directed to the ED on a Friday night. I've gotten to the point where I just flat out refuse to do them in the ED. I'd honestly rather deal with drug seekers than positively reinforce this pt population to abuse the ED.

I've started to think that I might be out of touch. What's everyone else's practice?

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[valianteffort]

I work in a single coverage ER at times/sometimes double during peak hours. Its really not fathomable to stop seeing patients to do this. I change my practice at night however and will do it if theres not much going on. However, for the most part I agree its really not indicated nor should the precedence be set to come through the ER for this

 

[Dr Mantis Toboggan]

Do you guys do many of these in the ED? I just find them so annoying. It's probably my least favorite procedure. They are rarely indicated emergently, take forever, and this patient population is usually extremely vocal about not receiving it in the ED. It's usually someone who has skipped several appointments with IR and is screaming over the phone with their GI office and directed to the ED on a Friday night. I've gotten to the point where I just flat out refuse to do them in the ED. I'd honestly rather deal with drug seekers than positively reinforce this pt population to abuse the ED.

I've started to think that I might be out of touch. What's everyone else's practice?

Take off 10 cc of fluid to r/o bacterial peritonitis. The patients love this.

 

[hoot504]

During the day these patients go to IR. At night, it's DC vs. put them in obs. There's a tacit understanding between us and the hospitalists that we don't do these. It's cumbersome at best, and a huge time suck.

 

[Mount Asclepius]

Anymore I primarily just perform diagnostic paracentesis on septic patients with ascites to help the inpatient teams rule out SBP. My overall rates for paracentesis have decreased over the years in similar fashion to my LP rates. I'll occasionally perform elective paracentesis if the patient volume is low at night, I can generate income, and it helps the patient symptomatically. Often I make patients wait until the end of my shift when I'm finishing up charting as long as not tying up a room I need to actively see incoming patients. I no longer sit in the room waiting for bottles to collect. I also don't remove significant amounts requiring Albumin replacement. I do have mixed feelings on this practice, as I don't like the concept of positively reinforcing the ED as a location where elective paracentesis is performed. Unfortunately due to GI and IR availability, in addition to patient compliance and motivation, it is difficult to plug these patients into the right outpatient location.

 

[Groove]

I don't like poking them because they are all coagulopaths and come back within 24 hours complaining of oozing or increasing abdominal pain (because now they are bleeding into the ascitic fluid). If I think it's SBP, it's actually an easier disposition because I just admit them and I'm done with it. If I tell them that we don't do elective paracentesis, inevitably the very next thing out of their mouth is "WELL, I HAD IT DONE IN THE ER LAST TIME!".

And for the love of God if nursing tells me one more time that we don't have vacuum bottles and instead hands me one of those 60cc syringe, 3-way stopcock/one way valve pumping kits...I'll scream.

Sorry, I'm just paracentesis triggered today apparently.

 

[pkwraith]

We don't even do diagnostic parancentesis at my current shops. If I tried to do one, I would get blank stares from the nurses and I would have to walk them through every step of the process.

 

[GonnaBeADoc2222]

Nah I don't do em. Not my prob you drank a liter a day for 10 years and then didn't go to your outpatient appointment

 

[BoardingDoc]

Do you guys do many of these in the ED? I just find them so annoying. It's probably my least favorite procedure. They are rarely indicated emergently, take forever, and this patient population is usually extremely vocal about not receiving it in the ED. It's usually someone who has skipped several appointments with IR and is screaming over the phone with their GI office and directed to the ED on a Friday night. I've gotten to the point where I just flat out refuse to do them in the ED. I'd honestly rather deal with drug seekers than positively reinforce this pt population to abuse the ED.

I've started to think that I might be out of touch. What's everyone else's practice?

Therapeutic? No. There's no emergent indication to do so. Diagnostic? Sure. Takes like 30 seconds.

 

[RustedFox]

Absolutely not.

 

[ShockIndex]

When I worked in the ED, I almost never did therapeutic paras. However, you cannot escape them in the ICU. It is here that I learned a little trick to turn a 45 min ordeal into a quick, 10 min procedure. Rather than using the vacuum bottles that take forever, simply use the wall suction and 3-4 suction canisters. It’s simple - just hook the tubing in the para kit up to some sterile suction tubing that is connected to the wall suction. The large diameter of the suction tubing plus continuous wall suction fills up a 1.5L suction container in about 2 minutes. The suction bottles are much slower because of the resistance created by that 18G needle in the bottle cap; the smallest diameter in the wall suction method is your 7-9F para cath which is much wider than an 18G needle.

The nurse just needs to be in the room to switch out the canisters to the wall suction as each one fills. While I wouldn’t to this for a thora since -20-40 is about the limit of safe pleural pressure (hence the need for a 3-bottle system or Atrium to regulate vaccume), the peritoneum has no problem with this level of section and your not going to hurt the bowel. It really is a 10-15 min procedure to take off 4-5 liters once you get set-up and find a pocket of fluid.

 

[Mount Asclepius]

Would some of you that say no to elective therapeutic paracentesis in the ED reconsider if you knew you could bill ~$300-400 for each paracentesis (depending on use of imaging guidance)? If not, what dollar amount would make you consider performing?

A paracentesis is roughly equivalent to a charge for a level 4 encounter, which makes up about 1/3rd of the patients you see in the ED.

From a purely financial standpoint, if the procedural time for a paracentesis is less than the patient LOS and physician time involved of seeing a level 4 patient then it makes sense to perform.

Or is it the principle that if it's not emergently indicated then it shouldn't be done in the ED? Do you also perform medical screening exams for the majority of ED visits given most aren't for emergent conditions? Playing devil's advocate a little for discussion.

Edit: Clarification that charge for paracentesis ~$300-400 although collection typically less. Still in line with level 4 E/M encounter. Thanks to BoardingDoc for pointing out.

 

[NITRAS]

When I worked in the ED, I almost never did therapeutic paras. However, you cannot escape them in the ICU. It is here that I learned a little trick to turn a 45 min ordeal into a quick, 10 min procedure. Rather than using the vacuum bottles that take forever, simply use the wall suction and 3-4 suction canisters. It’s simple - just hook the tubing in the para kit up to some sterile suction tubing that is connected to the wall suction. The large diameter of the suction tubing plus continuous wall suction fills up a 1.5L suction container in about 2 minutes. The suction bottles are much slower because of the resistance created by that 18G needle in the bottle cap; the smallest diameter in the wall suction method is your 7-9F para cath which is much wider than an 18G needle.

The nurse just needs to be in the room to switch out the canisters to the wall suction as each one fills. While I wouldn’t to this for a thora since -20-40 is about the limit of safe pleural pressure (hence the need for a 3-bottle system or Atrium to regulate vaccume), the peritoneum has no problem with this level of section and your not going to hurt the bowel. It really is a 10-15 min procedure to take off 4-5 liters once you get set-up and find a pocket of fluid.

If you can find the 3 L suction canisters, it is better than the 1.2ish L canisters they carry on the floor. But wall suction is way better than vacuum canisters.

 

[skougess]

Therapeutic? No. There's no emergent indication to do so. Diagnostic? Sure. Takes like 30 seconds.

End thread.

If it’s a first time ascites who is in a fair amount of discomfort I’ll work with them to figure out a plan that still almost never involves me doing them. That’s the only exception. Otherwise it’s “Sorry, I don’t do those. I don’t care that you’ve had this done here before. I don’t do those.”

 

[Porfirio]

No.

 

[GonnaBeADoc2222]

Would some of you that say no to elective therapeutic paracentesis in the ED reconsider if you knew you were directly paid ~$300-400 for each paracentesis (depending on use of imaging guidance)? If not, what dollar amount would make you consider performing?

A paracentesis is roughly equivalent to a charge for a level 4 encounter, which makes up about 1/3rd of the patients you see in the ED.

From a purely financial standpoint, if the procedural time for a paracentesis is less than the patient LOS and physician time involved of seeing a level 4 patient then it makes sense to perform.

Or is it the principle that if it's not emergently indicated then it shouldn't be done in the ED? Do you also perform medical screening exams for the majority of ED visits given most aren't for emergent conditions? Playing devil's advocate a little for discussion.

Most people in EM are W2/1099 employed by a hospital system or CMG and aren't directly paid squat.

I agree if you are with an SDG it may make sense to do.

 

[hoot504]

Here’s a more interesting question (to me). Do you guys do thoras?

 

[Groove]

Here’s a more interesting question (to me). Do you guys do thoras?

I haven't done a thoracentesis since residency.

 

[NYEMMED]

I don’t do them. They can have it done through IR or after hours obs for IR the next day.
Too much time and complications.

 

[NYEMMED]

Here’s a more interesting question (to me). Do you guys do thoras?

No

 

[Interpolfanclub]

Here’s a more interesting question (to me). Do you guys do thoras?

Year 14 as attending, think I’ve done two maybe three on people that were about to die. One did. Like others said, these almost never need to be done emergently. Paras I’ll do pretty often if they’re distressed and I can just discharge. I don’t do them if I’m busy. Admit.

 

[Fox800]

Absolutely not. IR does these.

I'll take 10-20 mL off for a diagnostic para to r/o SBP.

 

[hoot504]

Year 14 as attending, think I’ve done two maybe three on people that were about to die. One did. Like others said, these almost never need to be done emergently. Paras I’ll do pretty often if they’re distressed and I can just discharge. I don’t do them if I’m busy. Admit.

This is close to my experience. I learned how and did some in residency but now I really don’t feel comfortable with them given the potential for complications and their overall rarity. The thing is I do have a patient every once in a blue moon trying to die on me who might benefit from one. I usually patch something together with either IR or pulm. On one occasion I’ve just put a chest tube in on a patient that was actively crumping.

 

[JacobMcCandles]

Pretty much elective anything gets a number to the appropriate department to call when they’re discharged.

 

[Porfirio]

Here’s a more interesting question (to me). Do you guys do thoras?

No.

 

[BoardingDoc]

Would some of you that say no to elective therapeutic paracentesis in the ED reconsider if you knew you were directly paid ~$300-400 for each paracentesis (depending on use of imaging guidance)? If not, what dollar amount would make you consider performing?

A paracentesis is roughly equivalent to a charge for a level 4 encounter, which makes up about 1/3rd of the patients you see in the ED.

From a purely financial standpoint, if the procedural time for a paracentesis is less than the patient LOS and physician time involved of seeing a level 4 patient then it makes sense to perform.

Or is it the principle that if it's not emergently indicated then it shouldn't be done in the ED? Do you also perform medical screening exams for the majority of ED visits given most aren't for emergent conditions? Playing devil's advocate a little for discussion.

What? Where are you getting this? My understanding is that a para pays the same for both diagnostic and therapeutic and that both are worth 2 rvus. The former is worth your time ( and sometimes indicated) the latter is not on either count.

 

[emergentmd]

What? Where are you getting this? My understanding is that a para pays the same for both diagnostic and therapeutic and that both are worth 2 rvus. The former is worth your time ( and sometimes indicated) the latter is not on either count.

You are going down a path you do not want to. You better be ready for some subjective made up data to prove some annoying point.

 

[emergentmd]

Thora in residency, great learning times. But never as an attending. No one dying that can’t wait for interventional to do.

 

[Mount Asclepius]

What? Where are you getting this? My understanding is that a para pays the same for both diagnostic and therapeutic and that both are worth 2 rvus. The former is worth your time ( and sometimes indicated) the latter is not on either count.

Based upon fee schedule for CPT codes 49082 and 49083.

 

[southerndoc]

Like almost all of you, I don't do them except for diagnostic purposes. Sure, if somebody is hypoxemic from inability to breathe, I'll take it off. 99% of the ones I see just want it taken off because it's uncomfortable. For those, it's an elective procedure.

 

[GonnaBeADoc2222]

You are going down a path you do not want to. You better be ready for some subjective made up data to prove some annoying point.

I am just so happy that someone finally called this guy out. Thank you from us all.

 

[WorkNoteEmergency]

I did more paracenteses in the ED in medical school (20+ years ago) than I did in my career. It was pretty routine then but I maybe did one or two as an attending, early career before I knew better. Interestingly at my last rural shop, the solo GI doc, a very good one, didn’t/doesn‘t do those in the office and they get farmed to the mother ship radiology dept. I guess takes away from scope time.

Same on thoracentesis, don’t think I’ve ever done one in the ED. Hospitalist called me up to the floor to help her do one not all that long ago and I went up, looked at the patient and told her to stop and wait for a pro to do it in the morning.

 

[CoolDoc1729]

I did more paracenteses in the ED in medical school (20+ years ago) than I did in my career. It was pretty routine then but I maybe did one or two as an attending, early career before I knew better. Interestingly at my last rural shop, the solo GI doc, a very good one, didn’t/doesn‘t do those in the office and they get farmed to the mother ship radiology dept. I guess takes away from scope time.

Same on thoracentesis, don’t think I’ve ever done one in the ED. Hospitalist called me up to the floor to help her do one not all that long ago and I went up, looked at the patient and told her to stop and wait for a pro to do it in the morning.

What was it about the thoracentesis patient that made you hesitant ? Habitus, agitation? Just curious, I haven’t done one since residency.

I have done a couple para for a patient with respiratory embarrassment/ desats. For me to do a non urgent therapeutic para it would have to be a situation of me being bored , near but not too near the end of my shift, and the patient being endearing in some way - apparently the combination is very rare 😉.

 

[TooMuchResearch]

Twice I've prevented intubation with emergent thoracentesis. Those are the only two I've done since residency.

 

[BoardingDoc]

Here’s a more interesting question (to me). Do you guys do thoras?

I do maybe 1 thora a year. Stupid easy, but time consuming. Almost never emergently indicated. I'll do one if someone is having enough increased WOB that they might need to go to the ICU, but could go to the floor if the fluid is off... and I have a completely full ICU. Obviously a very niche case, but it's generally easier in that case to do the thora and admit rather than try to transfer.

 

[thegenius]

I don't like poking them because they are all coagulopaths and come back within 24 hours complaining of oozing or increasing abdominal pain (because now they are bleeding into the ascitic fluid). If I think it's SBP, it's actually an easier disposition because I just admit them and I'm done with it. If I tell them that we don't do elective paracentesis, inevitably the very next thing out of their mouth is "WELL, I HAD IT DONE IN THE ER LAST TIME!".

LOL you can thank your colleagues for that one.

I try very hard not to do them anymore. And I don't buy that 25% of all ascites walking around has SBP in it, as that one study suggested.

 

[BoardingDoc]

And I don't buy that 25% of all ascites walking around has SBP in it, as that one study suggested.

I'm not familiar with that paper but that's definitely wrong. I did residency at a hospital with a huge hepatology department. We had TONS of liver patients roll through the ED. I would estimate VERY conservatively, that I did between 200 and 300 diagnostic paras during residency. I diagnosed SBP maybe 20 times as a resident. Tops.

 

[Brigade4Radiant]

Would some of you that say no to elective therapeutic paracentesis in the ED reconsider if you knew you were directly paid ~$300-400 for each paracentesis (depending on use of imaging guidance)? If not, what dollar amount would make you consider performing?

A paracentesis is roughly equivalent to a charge for a level 4 encounter, which makes up about 1/3rd of the patients you see in the ED.

From a purely financial standpoint, if the procedural time for a paracentesis is less than the patient LOS and physician time involved of seeing a level 4 patient then it makes sense to perform.

Or is it the principle that if it's not emergently indicated then it shouldn't be done in the ED? Do you also perform medical screening exams for the majority of ED visits given most aren't for emergent conditions? Playing devil's advocate a little for discussion.

A paracentesis takes way too much time to set up you can see three level 4s in that time you can’t just do the paracentesis you also have to give the albumin

 

[gruemd]

No. I haven't even done a diagnostic para in the last 3 years. Same with thora, haven't since residency.

 

[Fox800]

LOL you can thank your colleagues for that one.

I try very hard not to do them anymore. And I don't buy that 25% of all ascites walking around has SBP in it, as that one study suggested.

Yep, this is learned behavior. Stop doing them, and they stop coming to the ED and go to their IR appointments.

 

[LChristmas]

I'll do maybe 2 or 3 of each per year. I'm lucky to work in a place that IR and pulm are available during business hours, so that takes more burden off me. I also did way more when I worked at a CAH.

Paras: I'm sympathetic to the cancer patients and will go out of my way to take some fluid off if they're in pain or having trouble breathing. Even more likely if I see they're going to all their scheduled outpatient IR appts. Alcoholics get a referral for elective IR and IV lasix. But even the cancer patients get the spiel that "I'm only doing this because it's a slow day and I have time. Any other day you would have to wait for your scheduled appointment."

Thoras: More likely to do them if it's a resident shift or if they're in respiratory distress. If I'm admitting I'll just put in a pigtail since it's basically the same procedure. I think I've only done one diagnostic in the past 2 years, and that was to expedite a cancer work up.

Most of the time though it's just too busy for me and they either get admitted or discharged for somebody else to do it.

 

[Rendar5]

Thoracentesis:
I’m 11 years out of residency and have done a total of 3 as an attending. 1 was an effusion that I needed to determine if it was a hemothorax or not my first year out (that was a chest tube that doubled as a thoracentesis. The other 2 were true thoracentesis last year in the same week. One was emergent (n=1 for my career, couldn’t maintain sats on bipap) the other was just for teaching residents on a super slow shift.

Para: therapeutic are not worth my time. IR can do these. Diagnostic are a 60cc syringe stuck in one time.

I did do a ton in residency because they were fun. I stuck an 18g angiocath in and setup a siphon system (like you do when getting gasoline out of a car but with a syringe to initiate it as opposed to your mouth) with iv tubing and let them just drain out into a large plastic tub or a foley bag. No need for vacutainers, just drains to gravity. Only issue is you need to make sure it doesn’t overflow because it’ll just keep going and going if you don’t stop it.

 

[WorkNoteEmergency]

What was it about the thoracentesis patient that made you hesitant ? Habitus, agitation? Just curious, I haven’t done one since residency.

I have done a couple para for a patient with respiratory embarrassment/ desats. For me to do a non urgent therapeutic para it would have to be a situation of me being bored , near but not too near the end of my shift, and the patient being endearing in some way - apparently the combination is very rare 😉.

Patient didn’t need it right away. She was ultrasounding and it looked like loculations to me and, even though I don’t recall why she thought she needed to do it, the patient seemed OK and I told her I’m not sticking a needle in any of that and just wait for daylight. I had a single coverage ED to get back to. Same hospitalist group, but different hospitalist, that called me away from a burning down ED because “someone needed a chest tube stat” and I go up there and after sorting through the mess, turns out it was a right mainstem intubation. Pull the tube back 3 cm and go back to work.

 

[carbonizedeyesockets]

I do diagnostic paras fairly frequently, a little annoying but also pretty quick compared to many other things we do. If you are only doing it when someone is septic, you will miss it when they're not septic. But I do not do therapeutic paras. DC to f/u with IR on an output basis, or admitted to observation.

 

[CajunMedic]

I have only done 1 as an attending. It was at the end of my shift at the CAH I work at, the night doc was in already (I was on a mid-shift) and I had the time

 

[InternistDO]

I did more paracenteses in the ED in medical school (20+ years ago) than I did in my career. It was pretty routine then but I maybe did one or two as an attending, early career before I knew better. Interestingly at my last rural shop, the solo GI doc, a very good one, didn’t/doesn‘t do those in the office and they get farmed to the mother ship radiology dept. I guess takes away from scope time.

Same on thoracentesis, don’t think I’ve ever done one in the ED. Hospitalist called me up to the floor to help her do one not all that long ago and I went up, looked at the patient and told her to stop and wait for a pro to do it in the morning.

I think our GI fellows were lucky if they got the 5 paras needed to be certified before graduation, and I trained at a transplant center. Our GI attendings very explicitly did not do or supervise them. I think there were only 3 or so medicine residents including myself (out of 100 or so) signed off on them--IR did the vast majority.

Our ED did not do therapeutics, they were admitted if some vague reason could be found (pretty easy with advanced cirrhosis) or DCed with IR follow up.

 

[Janders]

Diagnostic all the time.

Theraputic perhaps 1 or 2 per year. I do have a heart, and its usually some sob story about weekend, holiday, ovarian cancer, can't get to see so-and-so, whatever. Radiology already home for the day, GI doesn't come in, Hospitalist doesn't do procedures. Not for recurrent bounce-backs or minimal ascites.

Certainly the RVU isn't worth it per unit time.

Once upon a time when we had PA students around I suddenly did them frequently, as I had a friendly body to switch bottles and learn a procedure.

I set them up for the end of the shift, and bring a computer on wheels in the room and do a backlog of a dozen charts while draining the fluid... not the WORST use of time.

 

[clibby]

We do paras regularly in the ED. IM will never admit these for IR because it could take more than 24 hours for IR to get to scheduling it. Our boarding is also so bad that all they would do is sit in an ED bed for 10 hours before clogging another inpatient obs bed for 20 hours before IR got to them. Or, I can go in the room after the tech set everything up, spend 5 min to place the catheter, connect it to the wall, and come back when the tech has filled up 2-6 L depending on the patient. Now they can be DCed and free up another bed in less of my time than a decent laceration repair. It doesn’t work as well if your kits don’t have a catheter or your techs can’t help with the containers.

As for thoras, I have done more as an attending than in residency largely because we didn’t really do any in residency other than chest tubes and pigtails that stayed in. Our IM docs and even PCCM folks, unless the patient is in extremis, don’t do these bedside, so it falls on IR whenever they can be scheduled during bankers hours. Definitely not common for me to do them, but maybe handful a year. It doesn’t take much time if your staff can set everything up and can make a significant difference in the patients comfort for the next 24-72 hours, so I’ll occasionally offer to do one to those with tachypnea or new O2 needs . We also have a large and complicated heart failure population, so my numbers here may be higher.

 

[ShockIndex]

Most EPs are not going to sit on a PTX that is causing respiratory distress. I humbly suggest that we should give the same priority to a moderate to large pleural effusion that is causing respiratory distress. Tension physiology can happen with these too.

Sometimes, I think that people are afraid that they will be criticized for putting a pigtail in a pleural effusion. In reality, we under drain and sample these effusions and your aggressive EP instincts to just put a damn tube in it are correct.

 

[skougess]

Most EPs are not going to sit on a PTX that is causing respiratory distress. I humbly suggest that we should give the same priority to a moderate to large pleural effusion that is causing respiratory distress. Tension physiology can happen with these too.

Sometimes, I think that people are afraid that they will be criticized for putting a pigtail in a pleural effusion. In reality, we under drain and sample these effusions and your aggressive EP instincts to just put a damn tube in it are correct.

It’s not as straight forward as a PTX though. Plenty of effusions really should not be drained and can only do harm. That’s not really true with a large pneumo. Add this to the fact that it’s rare for someone with an effusion to not have other good reasons for dyspnea when presenting, and you can see the reluctance.