Talc pleurodesis; acute normovolemic hemodilution; laparoscopic cholecystectomy; blood ultrafiltration

AORN Journal,  Feb, 2007  by George Allen

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Pleurodesis using talc poudrage versus talc slurry

European Journal of Cardio-thoracic Surgery

December 2006

Malignant pleural effusion (MPE) is a disabling but common complication of advanced cancer. The goal of therapy for MPE is palliative, and treatment using chemical pleurodesis is widely accepted. Although numerous intrapleural sclerosing agents are available, including bleomycin, corticosteroids, Corynebacterium parvum, quinacrine, tetracycline, iodopovidone, and talc, numerous clinical studies have been published supporting the superior efficacy of talc compared to the other agents. The optimal route of talc administration, however, still is debated, and its safety for patients remains unclear. Thoracoscopically insuffiated talc (ie, talc poudrage) is often the preferred method of talc administration, but there are some who advocate that talc instillation through a chest tube (ie, talc slurry) is a simpler and equally effective technique. A recent phase III study showed no difference in efficacy of talc slurry compared to talc poudrage in the general population; however, when patients with lung or breast cancer were separately analyzed, talc poudrage was found to be superior to talc slurry. The purpose of this prospective study was to investigate the effectiveness and safety of intrapleural talc pleurodesis using talc poudrage and talc slurry in the treatment of MPE. (1)

From January 2000 through December 2005, all patients diagnosed with MPE with lung re-expansion after drainage were considered for talc pleurodesis. Each patient was evaluated by surgical and medical staff members together with the anesthesiologist to decide the appropriate mode of talc administration. Patients with acceptable performance status, less than three months' life expectancy, and the ability to undergo general anesthesia were selected to undergo videothorascopic talc poudrage. The remaining patients were given talc slurry at the bedside.

Both techniques were standardized before the study began. For talc poudrage, 6 g of sterile talc was insufflated and uniformly distributed onto the pleural surface using a disposable, gas-propelled atomizer. A 32-Fr chest tube was inserted, and a small-bore (eg, 10-Fr) catheter with a three-way stopcock was placed in the posterior cost-overtebral gutter. After 24 hours, the chest tube was removed and the patient was discharged with the small-bore catheter in place for outpatient management. Thoracentesis was performed through the catheter three, seven, 10, and 15 days after discharge, and chest x-rays were obtained seven and 15 days after discharge to evaluate the success of pleurodesis. If pleurodesis was achieved, the pleural catheter was removed, usually two weeks after the procedure.

Talc slurry was performed through a 20-Fr chest tube at the bedside, with 6 g of talc instilled as a slurry in a solution of 200 mL saline and 20 mL of 7.5% ropivacaine. After 24 hours, if hospital discharge was possible, the chest tube was removed and a 10-Fr catheter was inserted through the original chest tube site. Outpatient management was the same as for patients who received talc poudrage. All patients were regularly seen at ambulatory follow-up visits, and chest roentgenograms were obtained one month after the procedure and then monthly for three months. Common statistical procedures, including mean and standard deviation, chi-square tests, Fisher exact test, and t tests, were used to analyze the data.

Findings. One hundred nine patients completed the study, with 72 (66%) undergoing talc poudrage and 37 (34%) undergoing talc slurry. Sixty-three patients (87.5%) in the talc poudrage group and 27 patients (73%) in the talc slurry group had an immediately successful pleurodesis (P = .049). Adverse events were mild, with no significant differences between the groups. Of patients in the talc poudrage group, 36.1% experienced chest pain and 38.8% presented with a fever compared to 48.6% and 35.1%, respectively, in the talc slurry group. None of the patients developed acute respiratory failure or died as a result of the procedure.

Clinical implications. The results of this study revealed that talc poudrage was significantly more effective than talc slurry (P = .049) in the treatment of MPE. In addition, both talc poudrage and talc slurry were shown to be safe techniques for pleurodesis, but patients who underwent talc slurry had a higher incidence of thoracic pain during the procedure. Talc pleurodesis is widely recognized as the procedure of choice for the treatment of MPE, so perioperative nurses should be prepared to assist in these procedures.

Acute normovolemic hemodilution versus allogeneic transfusion

Transfusion July 2006

Allogeneic transfusion is associated with numerous risks, including transmission of viral or prion infections, transfusion mismatch, and immunomodulation. Consequently, autologous transfusion techniques, such as predonation, cell salvage, and acute normovolemic hemodilution (ANH), increasingly are being used to reduce the need for allogeneic transfusion in surgery. In ANH, the patient donates whole blood immediately before surgery and undergoes simultaneous intravenous colloid or crystalloid replacement to maintain normovolemia. The result is that blood lost during surgery is diluted, with reduced loss of hemoglobin and other blood components. In addition, as fresh, whole blood is returned at wound closure, fresh clotting factors and platelets are provided when hemostasis is needed most.