We write to congratulate the authors on writing an excellent piece of work that GP trainees on general medical rotations should find very helpful.1
Although the article provides good advice on commonly encountered medical problems, we would like to highlight issues relating to pleural problems (point 20: ‘Never let the sun go down on an empyema’).
Pleural intervention (including thoracocentesis and drain insertion) is associated with a range of potential complications, and each procedure should be performed by competent (or supervised) medical staff. These procedures are best avoided out of hours. We recommend that in most situations you can ‘let the sun set’ and defer the intervention until the next day.
The authors suggest that everyone with pneumonia-associated pleural effusion needs a pleural tap. Diagnostic pleural tap should be guided by clinical need. Up to 40% of pneumonias have associated para-pneumonic effusion (the most common cause of exudative pleural effusion in young patients)2 and the vast majority will settle with antibiotic treatment. Pleural tap should be considered in the context of persistent sepsis despite antibiotics.
While we agree that pleural fluid pH <7.2 or aspiration of frank pus requires drainage of pleural cavity, we wish to point out that, in the majority of cases, this can be done safely by ‘specialist teams’ within working hours and does not require urgent out-of-hours chest drain insertions.3
The National Patient Safety Agency 2008 rapid response entitled Risk of chest drain insertion highlights the potential and sometimes fatal complications from implantable cardioverter defibrillator insertion.4 The current practice in most hospitals is to insert chest drains for pleural effusions using real-time pleural ultrasound guidance during normal working hours.
By highlighting the points above, we hope to emphasise the importance of patient safety in pleural intervention.
- © British Journal of General Practice 2012
