Discuss current evidence based capabilities of percutaneous drainage (PCD) for spaceflight

Antonsen, Erik L.

Guehl, Allen

Kerstman, Eric L.

Reyes, David P.

NASA Technical Reports Server

Percutaneous Drainage Capability 
for Deep Space Exploration
89th Annual Scientific Meeting of the Aerospace Medical Association
Allen Guehl, MD, DPM, MS
David P. Reyes, MD, MPH, MS
Eric L. Kerstman, MD, MPH
Erik L. Antonsen, MD, PhD
National Aeronautics and Space Administration
WWW.NASA.GOV
https://ntrs.nasa.gov/search.jsp?R=20180003969 2019-08-31T15:58:05+00:00Z
Disclosure Information
AsMA 89th Annual Scientific Meeting
• We have no financial relationships to disclose
• We will not discuss off-label use or investigational uses
Percutaneous DrainageNational Aeronautics and Space Administration
Objectives
• Discuss current evidence based capabilities of 
percutaneous drainage (PCD) for spaceflight
National Aeronautics and Space Administration Percutaneous Drainage
Exploration Medical Capabilities (ExMC)
• Expanding capability 
beyond LEO
• New challenges
– No evacuation
– Communication delays
– Mass/volume constraints
• Need robust autonomous 
capabilities“Evidence Report: Risk of Adverse Health 
Outcomes and Decrements in Performance 
due to In-Flight Medical Conditions,” 2017
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Percutaneous Drainage
• Drainage of fluid, abscess or air
• Needle or catheter placement 
• Often with image guidance
• Benefits
– Preferred for many conditions
– Simple
– Repeatable 
– Minimally invasive
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Percutaneous Drainage
Equipment
• Low mass and volume
• Alternate medical/non-medical uses
• Ultrasound Imaging likely imaging modality
• Ongoing development
– Flow is reduced at 0G compared to 1G1
1L. Brown, Personal Communication, October, 
23,2017
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Equipment
National Aeronautics and Space Administration Percutaneous Drainage
Training and Currency: MicroG
• Standard sterile technique
• Tubing and equipment tethering
• Altered fluid mechanics 
• Abdomen tends to “circularize”1
• Parabolic flight tests
– Successful aspiration of intra-peritoneal fluid
– No more demanding than 1-G rehearsals
– Fluid collections more distinct from surrounding viscera2
1Surgical Capabilities for Exploration 
and Colonization Space Flight,” 2015.
2A W Kirkpatrick et al., 2002
National Aeronautics and Space Administration Percutaneous Drainage
Training and Currency: Deep Space
• Non-physician versus physician astronaut
• Emergency Physicians (ACEP) training guidelines: 
– Sixteen to twenty four hours1
• ISS FAST exam trial: successful exam with
– three hours of familiarization
– two hours hands on training2
– Non medical crew
• Augmented reality computer based simulations3
– May provide ongoing review and training on mission
1Emergency Ultrasound Guidelines,2009
2Sargsyan et al.,2005
3Magee et al., 2007
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Percutaneous Drainage
• Integrated Medical Model (IMM) conditions:
• Appendicitis
• Acute Cholecystitis
• Chest Injury
• Abdominal Injury
• Urinary Retention
• Hydronephrosis (kidney stone)
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Appendicitis
• Percutaneous drainage
– Only intervention available in ExMC
– Ruptured appendix and intra-abdominal abscess
– 64% success rate with US guided drainage1
• Recent meta-analysis: 
– Antibiotic treatment comparable to appendectomy
– 72% antibiotic success rate2
– 14.2 to 20% subsequent surgical appendectomy3
• Modification of success rates needed
– Healthy crew
– Quick treatment and no surgical option
1Fagenholz et al., 2016 
2Zhi-Hua Liu, 2014 
3Flum, 2015
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National Aeronautics and Space Administration Percutaneous Drainage
Acute Cholecystitis
• Drainage via perc. transhepatic cholecystostomy
• Can be definitive procedure
• 94 % technical success rate 
• 86 % procedural success rate
• US lower complication /death rate versus fluoroscopy
Wagner et al., 2017
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Hemothorax/Pneumothorax
• 100 % Success with pneumothorax
• 80 %   Success with loculated pleural effusions1
• Successful with different pleural fluids
• Studies found minimal complications
• Significant clinical improvement2
1Bediwy & Amer, 2012; Liu et al., 2010
2Aziz, Penupolu, & Flores, 2012
National Aeronautics and Space Administration Percutaneous Drainage
Abdominal Compartment Syndrome
• Intra-abdominal pressure >12 mm hg
• Possible etiologies in spaceflight1
• Abdominal trauma
• Hemorrhage 
• Intestinal obstruction
• Large Burns
• Percutaneous drainage preferred over laporotomy2
• PCD is safe and effective in preventing ACS in burn patients3
1Backer, 1999
2Kirkpatrick et al., 2013
3Latenser et al., 2002
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Urinary Retention
• Suprapubic catheterization safely performed in remote 
areas by non-physicians1
• Study showed suprapubic catheterization to be:
– Quick procedure
– High success rate
– Minimal complications
– Recommended after 2 or 3 failed transurethral attempts2
1Gujral, Kirkwood, Hinchliffe, & Gujral, 1999 
2 Bilehjani E & Fakhari S, 2017 
National Aeronautics and Space Administration Percutaneous Drainage
Hydronephrosis
• Kidney stone usual cause
• Found in 89 % of suspected stone1
• US guided placement success rate 96%2
• Complete urinary obstruction
– One week-complete recovery of kidney function
– Twelve weeks- Non recoverable kidney damage
1Song et al., 2016
2Lodh et al., 2014
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Complications
• Infection
• Bleeding
• Nephrostomy complication rate 10% 1
• Abdominal PCD complications < 5%
• Bowel puncture with 21 g needle “inconsequential” 
in most cases2
1Pabon-Ramos et al., 2016
2Lorenz & Thomas, 2006
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Further Research
• Risk mitigation
– Guidance and training
– Physician-astronaut utilization
• Optimal catheter size and materials
• 3D printing of supplies
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PCD Conclusions
• Achievable skill by physician and non-physician
• Small overall resource burden
• Treat surgical conditions that can occur in spaceflight
• Many advantages of a robust procedural capability
• Decreases mission risk
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Thank You
National Aeronautics and Space Administration Percutaneous Drainage
References
• Aziz, F., Penupolu, S., & Flores, D. (2012). Efficacy of percutaneous pigtail catheters for thoracostomy at bedside. Journal of 
Thoracic Disease, 4(3), 292–295. https://doi.org/10.3978/j.issn.2072-1439.2011.12.01
• Backer, D. D. (1999). Abdominal compartment syndrome. Critical Care, 3(6), R103–R104. https://doi.org/10.1186/cc373
• Bediwy, A. S., & Amer, H. G. (2012). Pigtail Catheter Use for Draining Pleural Effusions of Various Etiologies [Research article]. 
https://doi.org/10.5402/2012/143295
• Bilehjani E, & Fakhari S. (2017). Using central venous catheter for suprapubic catheterization in cardiac surgery. Research and 
Reports in Urology, Vol Volume 9, Pp 1-4 (2017), 1.
• Emergency Ultrasound Guidelines. (2009). Annals of Emergency Medicine, 53(4), 550–570. 
https://doi.org/10.1016/j.annemergmed.2008.12.013
• Fagenholz, P. J., Peev, M. P., Thabet, A., Michailidou, M., Chang, Y., Mueller, P. R., … Velmahos, G. C. (2016). Abscess due to 
perforated appendicitis: factors associated with successful percutaneous drainage. American Journal of Surgery, 212(4), 
794–798. https://doi.org/10.1016/j.amjsurg.2015.07.017
• Flum, D. R. (2015). Acute Appendicitis — Appendectomy or the “Antibiotics First” Strategy. New England Journal of Medicine, 
372(20), 1937–1943. https://doi.org/10.1056/NEJMcp1215006
• Gujral, Kirkwood, Hinchliffe, & Gujral. (1999). Suprapubic catheterization: a suitable procedure for clinical nurse specialists in 
selected patients. BJU International, 83(9), 954–956. https://doi.org/10.1046/j.1464-410X.1999.00051.x
• Kirkpatrick, A W, Nicolaou, S., Campbell, M. R., Sargsyan, A. E., Dulchavsky, S. A., Melton, S., … Hamilton, D. R. (2002). 
Percutaneous aspiration of fluid for management of peritonitis in space. Aviation, Space, And Environmental Medicine, 73(9), 
925–930.
• Kirkpatrick, Andrew W., Roberts, D. J., De Waele, J., Jaeschke, R., Malbrain, M. L. N. G., De Keulenaer, B., … Olvera, C. (2013). 
Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical 
practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Medicine, 39(7), 1190–
1206. https://doi.org/10.1007/s00134-013-2906-z
National Aeronautics and Space Administration Percutaneous Drainage
References
• Latenser, B. A., Kowal-Vern, A., Kimball, D., Chakrin, A., & Dujovny, N. (2002). A pilot study comparing percutaneous 
decompression with decompressive laparotomy for acute abdominal compartment syndrome in thermal injury. The Journal 
Of Burn Care & Rehabilitation, 23(3), 190–195.
• Liu, Y.-H., Lin, Y.-C., Liang, S.-J., Tu, C.-Y., Chen, C.-H., Chen, H.-J., … Hsu, W.-H. (2010). Ultrasound-guided pigtail catheters for 
drainage of various pleural diseases. The American Journal of Emergency Medicine, 28, 915–921. 
https://doi.org/10.1016/j.ajem.2009.04.041
• Lorenz, J., & Thomas, J. L. (2006). Complications of Percutaneous Fluid Drainage. Seminars in Interventional Radiology, 23(2), 
194–204. https://doi.org/10.1055/s-2006-941450
• Magee, D., Zhu, Y., Ratnalingam, R., Gardner, P., & Kessel, D. (2007). An augmented reality simulator for ultrasound guided 
needle placement training. Medical & Biological Engineering & Computing, 45(10), 957–967. 
https://doi.org/10.1007/s11517-007-0231-9
• Pabon-Ramos, W. M., Dariushnia, S. R., Walker, T. G., Janne d’Othée, B., Ganguli, S., Midia, M., … Nikolic, B. (2016). Quality 
Improvement Guidelines for Percutaneous Nephrostomy. Journal of Vascular and Interventional Radiology, 27, 410–414. 
https://doi.org/10.1016/j.jvir.2015.11.045
• Sargsyan, A. E., Hamilton, D. R., Jones, J. A., Melton, S., Whitson, P. A., Kirkpatrick, A. W., … Dulchavsky, S. A. (2005). FAST at 
MACH 20: Clinical ultrasound aboard the International Space Station. Journal of Trauma-Injury Infection and Critical Care, 
58(1), 35–39. https://doi.org/10.1097/01.TA.0000145083.47032.78
• Song, Y., Hernandez, N., Gee, M. S., Noble, V. E., & Eisner, B. H. (2016). Can ureteral stones cause pain without causing 
hydronephrosis? World Journal Of Urology, 34(9), 1285–1288. https://doi.org/10.1007/s00345-015-1748-4
• Surgical Capabilities for Exploration and Colonization Space Flight. (2015). Retrieved October 13, 2017, from 
https://ston.jsc.nasa.gov/collections/TRS/_techrep/TP-2016-219281.pdf
• Wagner, A., Mayr, C., Kiesslich, T., Berr, F., Friesenbichler, P., & Wolkersdörfer, G. W. (2017). Reduced complication rates of 
percutaneous transhepatic biliary drainage with ultrasound guidance. Journal of Clinical Ultrasound: JCU, 45(7), 400–407. 
https://doi.org/10.1002/jcu.22461
• Zhi-Hua Liu, Chao Li, Xing-Wei Zhang, Liang Kang, & Jian-Ping Wang. (2014). Meta-analysis of the therapeutic effects of 
antibiotic versus appendicectomy for the treatment of acute appendicitis. Experimental & Therapeutic Medicine, 7(5), 1181–
1186. https://doi.org/10.3892/etm.2014.1584
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Percutaneous Drainage


Percutaneous Drainage Capability for Deep Space Exploration

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