Real-Time Ultrasound-Guided Versus Ultrasound-Assisted (non–Real-Time) Pigtail Catheter Insertion for Pleural Effusion Drainage in the Intensive Care Unit: A Retrospective Cohort Study

Pleural effusion is common in critically ill adults, and bedside pigtail catheter drainage is often required; insertion without continuous imaging may lead to pneumothorax or catheter malposition. We conducted a single-center retrospective cohort study of adult intensive care unit pigtail pleural drainage procedures (28 December 2020-2018 March 2025) comparing real-time ultrasound-guided insertion with ultrasound-assisted insertion using preprocedure localization/skin marking only (no real-time needle tracking). The primary outcome was procedure-related mechanical complications (pneumothorax or catheter malposition); between-group comparisons used exact tests, and relative risks (RRs) with 95% confidence intervals (CIs) were reported. Among 175 procedures in 145 patients, 89 were real-time ultrasound-guided and 86 were ultrasound-assisted without real-time guidance. Mechanical complications occurred in 0/89 (0.0%) versus 10/86 (11.6%) procedures, respectively (RR 0.05, 95% CI 0.00-0.77; p < 0.001), driven by catheter malposition (0/89 vs 7/86 (8.1%); RR 0.06, 95% CI 0.00-1.11; p = 0.006) and pneumothorax (0/89 vs 3/86 (3.5%); RR 0.14, 95% CI 0.01-2.63; p = 0.117). Median catheter dwell time was 11.0 (8.0-20.0) versus 9.0 (6.0-15.0) days (p = 0.031). Real-time ultrasound guidance was associated with fewer observed mechanical complications in this cohort; given the retrospective design and baseline differences between groups, prospective risk-adjusted validation is warranted.