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Chest drains: Oxford s approach

Conflicts of interest. Research funding; NIHR, HTA trials, MRC, UKCRN, CRUK, BLF, BHF, UKNCRIDrugs and matched placebos for clinical trials; Roche, Genentech, Boeringher, Lunamed, Syner-Med.Technical equipment for trials; Rocket Medical UK, ResMed, GE Medical, Embla systems.Trials unit funding; Roche, Syner-Med, GSKProduct design consultancy; Rocket Medical UK. IP; Lipoteichoic acid for pleurodesis, pneumothorax treatment system.

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Chest drains: Oxford s approach

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    1. Chest drains: Oxford’s approach? Robert JO Davies Professor of Respiratory Medicine Oxford Centre for Respiratory Medicine University of Oxford UK robert.davies@ndm.ox.ac.uk

    2. Conflicts of interest Research funding; NIHR, HTA trials, MRC, UKCRN, CRUK, BLF, BHF, UKNCRI Drugs and matched placebos for clinical trials; Roche, Genentech, Boeringher, Lunamed, Syner-Med. Technical equipment for trials; Rocket Medical UK, ResMed, GE Medical, Embla systems. Trials unit funding; Roche, Syner-Med, GSK Product design consultancy; Rocket Medical UK. IP; Lipoteichoic acid for pleurodesis, pneumothorax treatment system

    3. Drains: the problem Dangerous Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance

    4. Chest Drain Complications Oxford audit: image guided drains All image guided chest drains inserted over a 36 months 352 drains (273) patients Major complications in 4 (1.5%) Haemothorax 3 Empyema (post pleurodesis) 1 1 death (0.3%)

    5. Drains: the problem Dangerous Use is widespread Respiratory Medicine Paed respiratory medicine Cardiothoracic surgery Acute medicine A&E Adult ITU Paed ITU Neonatal ITU Radiology Oncology Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance

    6. Drains: the problem Dangerous Use is widespread Methods differ (appropriately) Pneumothorax Pleural Effusion Imaging Medicine CT surgery Paediatrics Neonatology Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance

    7. Drain insertion Strategy Quite a lot of work! Not amenable to a single strategy Solve at local level Key principles Drain only when really needed Only staff trained and active insert (applies to both drain insertion and ultrasound) Equipment should be good condition Image guidance where possible Audit trail needed Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance

    8. Thoracic US

    9. Solution strategy

    10. Solution strategy

    11. Solution strategy

    12. Solution strategy

    13. Solution strategy

    14. Solution strategy

    15. Solution strategy

    16. Drain insertion What happens at 2 am? Does the patient actually need a drain now? Will thoracentesis do? Is image guidance appropriate? Am I on the ultrasound register? Yes – next question! No – get help Am I on the drain insertion register? Yes – do it No – get help Who can help? Respiratory physician Paediatric respiratory physician Intensivist (including resus team/neonatology) Radiologist (two services) CT surgeon A&E staff Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance

    17. Drain insertion Summary Nominated leads Management algorithms Insertion form Training registries Drain insertion form Chest drain insertion kit ‘Large bore’ training video ‘Small bore’ training video Thorough dissemination of form and audit trail Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance Numbers and designs of each study Why biased – confounding factors Desrumaux – Isere district of France, 8 year study period, (1995-2003), compared 4 year periods and yyear on year increase on avaergae (poorly done) – 90 children only Munoz – 10 year prospective IPD study – associated decrased in pencillin resistance

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