Background:

Ultrasonography (US) has improved the yield of bedside invasive procedures over the last decade; however, unsuccessful procedures still occur. As benchmarks for the yield of procedures using US are limited, we aimed to quantify and review unsuccessful procedures done by the hospitalist procedure service (HPS) at the University of California, San Francisco, in its first 2 years.

Methods:

The HPS began offering procedure services for paracentesis, thoracentesis, lumbar puncture, and arthrocentesis in November 2008. Interns perform nearly all procedures during a 2‐week rotation supervised by an attending hospitalist with additional US and procedural training. All paracenteses and thoracenteses are performed under US guidance, and US is used for lumbar puncture as needed. Unsuccessful procedures were defined as those that were deemed to be safe by examination, imaging, and ultrasound, but where no fluid was obtained. We queried our database for attempted procedures in which little to no fluid was removed to screen for unsuccessful procedures and then performed a detailed chart analysis to determine the reasons for failure and patient outcomes.

Results:

Of the 1005 procedures performed by the service in the first 2 years, 76 (7.6%) were unsuccessful [4 of 409 paracenteses (1%), 16 of 278 thoracenteses (5.8%), and 56 of 290 lumbar punctures (19.3%)]. All unsuccessful paracenteses occurred in the presence of an abdominal wall > 5 cm in thickness, and all had ascitic fluid on formal US. Patients with a high suspicion for SBP (3, 75%) were treated empirically. Of the 16 patients who had an unsuccessful thoracentesis, 2 procedures obtained fluid, but the procedure was aborted because of the bloody nature of the fluid. Eight patients (50%) demonstrated loculated fluid on ultrasound or CT chest. Interventional radiology (IR) attempted a thoracentesis in 9 patients and was successful in 6 (66.7%), using CT guidance for 3 procedures and placing a chest tube in 2. Of the 56 failed lumbar punctures, 24 (43%) had resolution of or an alternative explanation of their symptoms that initially prompted the lumbar puncture, and further attempts were not pursued. Of the lumbar punctures eventually performed, 28 (50%) were performed by neuro IR, and 6 (11%) were later performed by other providers. Of those done by neuro IR, 8 (14%) required CT guidance. The most commonly cited reasons for difficulty were body habitus 16 (28.6%) and challenging spinal anatomy 13 (28.2%). Twenty patients (36%) with unsuccessful lumbar punctures had a BMI > 30, and 15 (28%) had abnormal lumbar anatomy on imaging.

Conclusions:

Our data provide new benchmarking for procedures performed by hospitalists with bedside ultrasound. Better understanding of unsuccessful procedures attempted by a bedside procedure service provides an opportunity to both improve practice where possible and refer procedures directly to interventional radiology to improve procedure efficiency.

Disclosures:

M. Mourad ‐ none; D. Sliwka ‐ none