Predictors of retained hemothorax after trauma and impact on patient outcomes

Outcomes of Video-assisted Thoracic Surgery-guided Early Evacuation of Traumatic Hemothorax: A Randomized Pilot Study at Level I Trauma Center

Introduction

Traumatic hemothorax is accounted for about 20% of traumatic chest injuries. Although majority can be managed with the timely placement of intercostal tube (ICT) drainage, the remaining pose a challenge owing to high complication rates associated with retained hemothorax. Although various treatment modalities including intrapleural instillation of fibrinolytics, radioimage guided drainage, VATS guided evacuation and thoractomy do exist to address the retained hemothorax, but indications along with timing to employ a specific treatment option is still unclear and ambiguous.

Methods

Patient with residual hemothorax (>200 mL) on ultrasonography after 48 h of indwelling ICT was randomized into either early video-assisted thoracic surgery (VATS) or conventional approach cohort. Early VATS cohort was subjected to video-assisted thoracoscopic evacuation of undrained blood along with normal saline irrigation and ICT placement. The conventional cohort underwent intrapleural thrombolytic instillation for 3 consecutive days. The outcome measures were the duration of indwelling ICT, removal rate of tube thoracostomy, length of hospital stay, duration of intensive care unit (ICU) monitoring, need for mechanical ventilation, incidence of pulmonary and pleural complications, and requirement of additional intervention to address undrained hemothorax and mortality rate.

Results

The early VATS cohort had shorter length of hospital stay (7.50 ± 0.85 vs. 9.50 ± 3.03, P = 0.060), reduced duration of indwelling ICT (6.70 ± 1.25 vs. 8.30 ± 2.91, P = 0.127) with higher rate of tube thoracostomy removal (70% vs. 30%, P = 0.003) and lesser need of additional interventions (0% vs. 30%, P = 0.105). Thoracotomy (3 patients) and image-guided drainage (4 patients) were additional interventions to address retained hemothorax in the conventional cohort. However, similar length of ventilator assistance (0.7 ± 0.48 vs. 0.60 ± 1.08, P = 0.791) and prolonged ICU monitoring (1.30 ± 1.06 vs. 0.90 ± 1.45, P = 0.490) was observed in early VATS cohort. Both the cohorts had no mortality.

Conclusion

VATS-guided early evacuation of traumatic hemothorax is associated with shorter length of hospital stay along with abbreviated indwelling ICT duration, reduced incidence of complications, lesser readmissions, and improved rate of tube thoracostomy removal. However, the duration of ventilator requirement, ICU stay, and mortality remain unchanged.

Continued Development and Testing of a Novel Steerable Chest Tube, Extendable Infusion Cannula, and Portable Suction-Infusion Pump for Use in Austere and Transport Environments to Prevent Retained Hemothorax

With blunt and penetrating trauma to the chest, warfighters frequently suffer from hemothorax. Optimal management requires the placement of a chest tube to evacuate the blood. Malposition of the tube may be a causative factor of inadequate drainage (retained hemothorax). As a potential solution, we developed a previously reported steerable chest tube allowing accurate placement into a desired location to enhance effectiveness. To provide assisted aspiration, we developed a portable, battery-operated suction device capable of simultaneous or sequential infusion. This report details the ongoing progress of this project. Updated steerable tube and pump prototypes were designed and produced. The tubes were tested for feasibility in two pigs and one cadaver by fluoroscopically comparing tip positions after insertion by a number of providers. Measured drainage volumes comparing standard vs. steerable tubes after pleural infusion of 1,000 mL of saline in two pigs were compared. Testing of the pump focused on the accuracy of suction and volume functions. The steerable tube prototype consists of sequentially bonded segments of differing flexibility and an ergonomic tensioning handle. The portable suction pump accurately provides up to 80 cmH2O of suction, an infusion capability of up to 10 mL/min, and a 950 mL removable reservoir canister. After minimal training, providers easily and repeatedly placed the tip of the steerable tube in the lateral diaphragmatic sulcus in animals and cadavers. Arc was limited to the distal segment. Compared to a standard tube, the steerable tube placed along the diaphragm improved pleural fluid drainage volumes by 17%, although this did not reach statistical significance in six trials. These new prototypes represent substantial improvements and were performed according to expectations. We believe that this steerable chest tube and portable suction-infusion pump can be effectively used for warfighters with chest injuries in austere environments.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis

BACKGROUND

Traumatic hemothorax is common, and management failure leads to worse outcomes. We sought to determine predictive factors and understand the role of trauma center performance in hemothorax management failure.

METHODS

We prospectively examined initial hemothorax management (observation, pleural drainage, surgery) and failure requiring secondary intervention in 17 trauma centers. We defined hemothorax management failure requiring secondary intervention as thrombolytic administration, tube thoracostomy, image-guided drainage, or surgery after failure of the initial management strategy at the discretion of the treating trauma surgeon. Patient-level predictors of hemothorax management failure requiring secondary intervention were identified for 2 subgroups: initial observation and immediate pleural drainage. Trauma centers were divided into quartiles by hemothorax management failure requiring secondary intervention rate and hierarchical logistic regression quantified variation.

RESULTS

Of 995 hemothoraces in 967 patients, 186 (19%) developed hemothorax management failure requiring secondary intervention. The frequency of hemothorax management failure requiring secondary intervention increased from observation to pleural drainage to surgical intervention (12%, 22%, and 35%, respectively). The number of ribs fractured (odds ratio 1.12 per fracture; 95% confidence interval 1.00-1.26) and pulmonary contusion (odds ratio 2.25, 95% confidence interval 1.03-4.91) predicted hemothorax management failure requiring secondary intervention in the observation subgroup, whereas chest injury severity (odds ratio 1.58; 95% confidence interval 1.17-2.12) and initial hemothorax volume evacuated (odds ratio 1.10 per 100 mL; 95% confidence interval 1.05-1.16) predicted hemothorax management failure requiring secondary intervention after pleural drainage. After adjusting for patient characteristics in the logistic regression model for hemothorax management failure requiring secondary intervention, patients treated at high hemothorax management failure requiring secondary intervention trauma centers were 6 times more likely to undergo an intervention after initial hemothorax management failure than patients treated in low hemothorax management failure requiring secondary intervention trauma centers (odds ratio 6.18, 95% confidence interval 3.41-11.21).

CONCLUSION

Failure of initial management of traumatic hemothorax is common and highly variable across trauma centers. Assessing patient selection for a given management strategy and center-level practices represent opportunities to improve outcomes from traumatic hemothorax.

Accurate identification of traumatic lung injury (TLI) by ATR-FTIR spectroscopy combined with chemometrics

Traumatic lung injury (TLI), which is a common mechanical injury, is receiving increasing attention because of its serious hazards. In forensic practices, accurately identifying TLI is of great importance for investigations and case trials. The main goal of this research was to identify TLI utilizing attenuated total reflection-Fourier transform infrared (ATR-FTIR) spectroscopy in combination with chemometrics. The macroscopic appearance of lung tissue showed that identifying TLI in lung tissue at the decomposition stage is not feasible by only visualization, and significant pulmonary hypostasis was observed in the lungs regardless of whether the lung tissue was injured. Average spectra and principal component analysis (PCA) suggested that the biochemical difference between injured lung tissue samples from the TLI group and noninjured lung tissue samples from the negative control group was mainly attributed to the different structures and contents of proteins. Partial least squares discriminant analysis (PLS-DA) was then utilized to identify TLI with an accuracy of 96.4% and 98.6% based on the training set and the test set, respectively. Next, we focused on samples that were misclassified in the model and proposed that the misclassification could be caused by the pulmonary hypostasis effect. Therefore, two additional PCA and PLS-DA models were created to identify the pulmonary hypostatic areas between the TLI group and the negative control group and the nonpulmonary hypostatic areas between the TLI group and the negative control group. The PCA results indicated that the biochemical difference between the two groups was still associated with proteins, and the two PLS-DA models achieved 100% accuracy based on both the training and test sets. This result indicated that when pulmonary hypostasis was considered and the lung tissue was divided into pulmonary hypostatic areas and nonpulmonary hypostatic areas for separate comparisons, TLI identification was achieved with a greater accuracy than that obtained when the two areas were combined. This research confirms that the combined application of ATR-FTIR spectroscopy and chemometrics can be utilized to accurately identify TLI.

Risk Factors for Retained Hemothorax after Trauma: A 10-Years Monocentric Experience from First Level Trauma Center in Italy

Thoracic trauma occurs in 20–25% of all trauma patients worldwide and represents the third cause of trauma-related mortality. Retained hemothorax (RH) is defined as a residual hematic pleural effusion larger than 500 mL after 72 h of treatment with a thoracic tube. The aim of this study is to investigate risk factors for the development of RH in thoracic trauma and predictors of surgery. A retrospective, observational, monocentric study was conducted in a Trauma Hub Hospital in Milan, recording thoracic trauma from January 2011 to December 2020. Pre-hospital peripheric oxygen saturation (SpO₂) was significantly lower in the RH group (94% vs. 97%, p = 0.018). Multivariable logistic regression analysis identified, as independent predictors of RH, sternum fracture (OR 7.96, 95% CI 1.16–54.79; p = 0.035), pre-admission desaturation (OR 0.96; 95% CI 0.77–0.96; p = 0.009) and the number of thoracic tube maintenance days (OR 1.22; 95% CI 1.09–1.37; p = 0.0005). The number of tubes placed and the 1° rib fracture were both significantly associated with the necessity of surgical treatment of RH (2 vs. 1, p = 0.004; 40% vs. 0%; p = 0.001). The risk of developing an RH in thoracic trauma should not be underestimated. Variables related to RH must be taken into account in order to schedule a proper follow-up after trauma.

Optimal time to thoracoscopy for trauma patients with retained hemothorax

BACKGROUND

Retained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set.

METHODS

Patients undergoing VATS for retained hemothorax within the first 14 days postinjury were identified from the Trauma Quality Improvement Program database over 5 years, ending in 2016. Demographics, mechanism, severity of injury, severity of shock, time to VATS, pulmonary morbidity, and mortality were recorded. Multivariable logistic regression analysis was performed to determine independent predictors of pulmonary morbidity. Youden's index was then used to identify the optimal time to VATS.

RESULTS

From the Trauma Quality Improvement Program database, 3,546 patients were identified. Of these, 2,355 (66%) suffered blunt injury. The majority were male (81%) with a median age and Injury Severity Score of 46 and 16, respectively. The median time to VATS was 134 hours. Both pulmonary morbidity (13 vs 17%, P = .004) and hospital length of stay (9 vs 12 days, P < .0001) were significantly reduced in patients undergoing VATS before 3.9 days. Multivariable logistic regression identified VATS during the first 7 days as the only modifiable risk factor significantly associated with reduced pulmonary morbidity (odds ratio 0.52; 95% confidence interval 0.43-0.63, P < .0001).

CONCLUSION

Patients undergoing VATS for retained hemothorax have significant morbidity and prolonged length of stay. VATS within the first week of admission results in fewer pulmonary complications and shorter length of stay. In fact, the optimal time to VATS was identified as 3.9 days and was the only modifiable risk factor associated with decreased pulmonary morbidity.

Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal

BACKGROUND

Traumatic hemothorax is a common injury that invites diagnostic and management strategy debates. Evidence-based management has been associated with improved care efficiency. However, the literature abounds with long-debated, re-emerging, and new questions. We aimed to consolidate up-to-date evidence on traumatic hemothoraces, focusing on clinical conundra debated in literature.

METHODS

We conducted a scoping review of 21 clinical conundra in traumatic hemothorax diagnosis and management according to PRISMA-ScR guidelines. Experimental and observational studies evaluating patients (aged ≥18 years) with traumatic hemothoraces were identified through database searches (PubMed, EMBASE, Web of Science, Cochrane Library; database inception to Sep, 26 2020) and bibliography reviews of selected articles. Three reviewers screened and selected articles using standardized forms.

RESULTS

We screened 1,440 articles for eligibility, of which 71 met criteria for synthesis. The review comprises 6 sections: (1) Presumptive antibiotics before tube thoracostomy; (2) Initial diagnostic and intervention decisions; (3) Chest tubes; (4) Retained hemothoraces; (5) Delayed hemothoraces; and (6) Chest tube removal). The 21 conundra across these sections follow the format of a question, our recommendation based on interpretation of available evidence, and succinct rationale. Rationale sections detail knowledge gaps and opportunities for future research.

CONCLUSION

Even practices engrained into surgical dogma, such as obtaining chest x-rays after inserting or removing chest tubes and mandating operation for patients who develop chest tube output above a certain threshold, deserve re-evaluation. Some knowledge gaps require rigorous future investigation; sound clinical judgment can likely supplement others.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Timing to perform VATS for traumatic-retained hemothorax (a systematic review and meta-analysis)

PURPOSE

In this systematic review, we analyzed the optimal time range to evacuate traumatic-retained hemothorax using video-assisted thoracoscopic surgery (VATS).

METHODS

We searched PubMed, EMBASE, the Cochrane Register of Controlled Trials, Google Scholar, and the U.S. National Library of Medicine clinical trials database up to February 2019. Randomized controlled trials (RCTs) and observational studies with relevant data were included. Data were extracted from studies that reported the success, mortality, or length of hospital stay (LOS) after using VATS during at least two out of three of our time-ranges of interest: days 1-3 (group A), days 4-6 (group B), and day 7 or later (group C).

RESULTS

Six cohort studies with 476 total participants were included in the meta-analysis. The patients in group A had a significantly higher success rate than those in group C (RR = 0.42; 95% CI = 0.21-0.84, p = 0.01). The total LOS for patients whose retained hemothorax was evacuated in group A was 4.7 days shorter than that for those in group B (95% CI =  - 5.6 to  - 3.8, p = 0.006). Likewise, group B patients were discharged 18.1 days earlier than group C patients (95% CI =  - 22.3 to  - 14, p < 0.001). Short-term mortality was not decreased by early VATS.

CONCLUSIONS

Our results indicate that VATS should be considered within the first three days of admission if this intervention is the clinician's choice to evacuate a traumatic-retained hemothorax. Protocol registration number in PROSPERO: CRD42017046856.

Management of post-traumatic retained hemothorax

Introduction

Chest injuries occur in a significant portion of trauma patients and hemothorax is a common result. While the initial management of traumatic hemothorax is most commonly treated with tube thoracostomy, the management of retained hemothorax is a subject of debate. Recent literature has proposed different methods for treating or preventing retained hemothorax, yet the approach to this pathology is not straightforward.

Methods

The literature was reviewed for relevant studies regarding the prevention and management of post-traumatic retained hemothorax. What follows is a review of the recent literature and an algorithm for the approach to treating a traumatic retained hemothorax.

Results

Identifying a traumatic retained hemothorax and preventing subsequent complications such as pneumonia, empyema, and fibrothorax are significant issues faced by surgeons. Studies for preventing retained hemothorax have focused on initial chest tube size, location, and peri-procedural placement conditions, as well as thoracic lavage. Several treatment modalities exist, including second drainage procedure and intra-pleural fibrinolytic drug instillation, but video-assisted thoracoscopic surgery is the most common and successful approach. Regardless of the approach to evacuation, early intervention is paramount.

Conclusion

Further studies will help characterize appropriate candidates, timing, treatment modalities, and guide therapy for retained hemothorax.

Role of biomarkers in acute traumatic lung injury

In severely injured patients severe thoracic trauma is common and can significantly influence the outcome of these critically ill patients by increased rates of mainly pulmonary complications. Furthermore, patients who sustained thoracic trauma are at increased risk for Acute Lung Injury (ALI) or Adult Respiratory Distress Syndrome (ARDS). Therapeutic options are limited, basically consisting of prophylactic antibiotic therapy and changing patient's positions. It is known, that ALI and ARDS differ clinically and pathobiologically from ALI/ARDS caused by other reasons, but the exact pathology remains elusive. Due to that no reliable predictive or surveillance biomarkers could be established for clinical diagnosis and identification of patients at high risk for acute traumatic lung injury. Nevertheless, there are plenty of promising markers that need to be further elucidated in larger case numbers and multicenter studies. This article sums up the recent status of those promising clinical biomarkers.