Decision making in ED

Pleural effusions in the ED may vary from being an incidental finding in an otherwise asymptomatic patient, to being the cause of life-threatening cardiovascular compromise. There are comprehensive national guidelines from the British Thoracic Society outlining investigation and management strategies of pleural diseases, including effusions. However, there is no national consensus on which patients should undergo diagnostic aspiration, therapeutic aspiration or drainage in the ED. It is important to take into account local guidelines and the condition of the patient when deciding to intervene in ED or refer onto the appropriate specialty service.

The BTS guidelines state that aspiration should not be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate unless there are atypical features or they fail to respond to therapy. If a transudate effusion if suspected, the focus should be on identifying and treating the underlying diagnosis [10].

The most common indication for drainage in ED is large effusion causing significant hypoxia or distress, particularly those associated with mediastinal shift.

If a patient requires aspiration or drainage [10]:

  • Unless the patient has significant cardiovascular or respiratory compromise, the procedure should not be performed overnight
  • Procedures should be carried out with full aseptic technique
  • Non-urgent interventions should be avoided in anticoagulated patients until the INR is <1.5 (note newer anticoagulants may still be effective despite a normal INR)
  • A recent chest radiograph should be reviewed prior to insertion
  • Bedside ultrasound should be used to increase likelihood of success and reduce risk of complications
  • A suitably trained practitioner should perform or directly supervise the procedure
  • Unless in an emergency, consent should be gained before any procedure. If a drain is being inserted, this should be in writing
  • There must be suitable and clearly organised follow up for investigations requested in the ED