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Priyadarshi A, Gupta S, Priyadarshini P, Kumar A, Alam J, Bagaria D, Choudhary N, Sagar S, Gupta A, Mishra B, Pandey S, Kumar S. Role of low-pressure negative pleural suction in patients with thoracic trauma - a randomized controlled trial. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02565-0. [PMID: 38874624 DOI: 10.1007/s00068-024-02565-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/26/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function. It is a simple and life-saving procedure; nevertheless, it carries morbidity, even after its removal. Efforts have been made continuously to shorten the duration of ICD, but mostly in non-trauma patients. In this study, we evaluated the impact of negative pleural suction over the duration of ICD. METHODS This study was a prospective randomized controlled interventional trial conducted at Level 1 Trauma Centre. Thoracic trauma patients with ICD, who met the inclusion criteria (sample size 70) were randomized into two groups, the first group with negative pleural suction up to -20 cm H2O, and the second group as conventional, i.e. ICD connected to underwater seal container only. The primary objective was to compare the duration of ICDs and the secondary objectives were the length of hospital stay and various complications of thoracic trauma. RESULTS Duration of ICD was measured in median days with minimum & maximum days. For the negative suction group, it was 4 days (2-16 days); for the conventional group, it was also 4 days (2-17 days). There was also no significant difference among both groups in length of hospital stay. CONCLUSION The beneficial effect of negative pleural suction to ICD could not be demonstrated over the duration of ICD and hospital stay. In both groups, there was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema. LEVEL OF EVIDENCE Therapeutic Study, Level II TRIAL REGISTRATION: This trial was registered with the Clinical Trial Registry of India (CTRI) with registration no. REF/2020/11/038403.
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Affiliation(s)
- Amit Priyadarshi
- Department of Trauma & Emergency Medicine, All India Institute of Medical Sciences, Bhopal, India
| | - Sahil Gupta
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Pratyusha Priyadarshini
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Abhinav Kumar
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Junaid Alam
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Narendra Choudhary
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Biplab Mishra
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Shivam Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
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Yap JA, Gummalla KM, H'ng MWC. High-Vacuum Drainage System in Percutaneous Image-Guided Thoracocentesis for Complex Pleural Effusions. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2023. [DOI: 10.1055/s-0043-1761629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
Abstract
Purpose Our retrospective study is aimed to analyze the efficacy and outcomes between high-vacuum suction drain (HVSD) over passive drainage in the setting of percutaneous image-guided thoracocentesis, with a secondary aim to determine if preprocedural computed tomography (CT) can aid decision-making.
Materials and Methods Clinical and imaging details of patients using HVSD between November 2012 and October 2018, who had a preceding CT within a month before drainage, were collated. The control group was selected from patients who had thoracocentesis with passive drainage performed between November 2017 and October 2018. Cases where HVSD was the sole device were compared with those using only a chest bottle.
Results The HVSD was the only device in 17 cases compared to chest bottle in 47 cases. Mean duration being on a drain for these two arms were 5.5 and 7.3 days, respectively (p = 0.170). Fewer from the HVSD arm needed a repeat procedure (p = 0.424). Patients in the HVSD arm had significantly smaller volumes (p = 0.013) of higher density (p = 0.016), associated with a more encapsulating wall (p = 0.013) but not septations (p = 0.922). Density of contents on CT was useful in distinguishing between straw-colored effusion versus hemoserous fluid or pus (p = 0.008).
Conclusions HVSD was not inferior to the chest bottle in the setting of thoracocentesis. Considering its potential adjunctive benefits, it should be an option for draining smaller volume complex effusions. Due to poor correlation with preprocedural CT, decision to insert a HVSD should be made by the procedurist at the time of thoracentesis.
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Affiliation(s)
- Jiawei Alexander Yap
- Department of Diagnostic Imaging, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore
| | - Krishna Mohan Gummalla
- Department of Diagnostic Imaging, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore
| | - Martin Weng Chin H'ng
- Department of Diagnostic Imaging, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore
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Wu CJ, Liu YY, Tarng YW, Huang FD, Chou YP, Chuang JF. It is Time to Replace Large Drains with Small Ones After Fixation of Rib Fractures: A Prospective Observational Study. Adv Ther 2022; 39:3668-3677. [PMID: 35723830 PMCID: PMC9309127 DOI: 10.1007/s12325-022-02182-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022]
Abstract
Introduction Large-bore chest tubes are usually applied after thoracic surgery. Recently, small-bore tubes have been increasingly considered owing to the extensive use of video-assisted thoracoscopic surgery (VATS). This study assessed the differences in outcomes between large-bore and small-caliber drainage tubes in patients undergoing surgical stabilization of rib fractures (SSRF) with VATS. Methods Overall, 131 patients undergoing SSRF with VATS were prospectively enrolled, including 65 patients receiving 32-Fr chest tubes (group 1) and 66 patients receiving 14-Fr pigtail catheters (group 2) for postoperative drainage. The clinical characteristics and perioperative outcomes of the patients were compared. Results All patients underwent SSRF with VATS within 4 days after trauma. After the operation, the mean duration of chest tubes was longer than that of pigtail catheters, with statistical significance (5.08 ± 2.47 vs 3.11 ± 1.31, P = 0.001). Length of stay (LOS) was also longer in group 1 (10.38 ± 2.90 vs 8.18 ± 2.44, P = 0.001). After multivariate logistic regression, the only independent factors between the two groups were duration of postoperative drainage (adjusted odds ratio [AOR] 1.746; 95% confidence interval [CI] 0.171–10.583, P = 0.001) and hospital LOS (AOR 1.272; 95% CI 0.109–4.888, P = 0.027). Conclusion After reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS.
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Affiliation(s)
- Chieh-Jen Wu
- Division of Cardiac Surgery, Department of Surgery, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan.,Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Yuan-Yuarn Liu
- Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung, 813, Taiwan
| | - Yih-Wen Tarng
- Department of Medical Education and Research, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Fong-Dee Huang
- Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung, 813, Taiwan
| | - Yi-Pin Chou
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan.,Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung, 813, Taiwan
| | - Jung-Fang Chuang
- Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung, 813, Taiwan.
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Anderson D, Chen SA, Godoy LA, Brown LM, Cooke DT. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg 2022; 157:269-274. [PMID: 35080596 DOI: 10.1001/jamasurg.2021.7050] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Thoracostomy, or chest tube placement, is used in a variety of clinical indications and can be lifesaving in certain circumstances. There have been developments and modifications to thoracostomy tubes, or chest tubes, over time, but they continue to be a staple in the thoracic surgeon's toolbox as well as adjacent specialties in medicine. This review will provide the nonexpert clinician a comprehensive understanding of the types of chest tubes, indications for their effective use, and key management details for ideal patient outcomes. Observations This review describes the types of chest tubes, indications for use, techniques for placement, common anatomical landmarks that are encountered with placement and management, and an overview of complications that may arise with tube thoracostomy. In addition, the future direction of chest tubes is explored, as well as the management of chest tubes during the COVID-19 pandemic. Conclusions and Relevance Chest tube management is subjective, but the compilation of data can inform best practices and safe application to successfully manage the pleural space and ameliorate acquired pleural space disease.
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Affiliation(s)
- Devon Anderson
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
| | - Sarah A Chen
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
| | - Luis A Godoy
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
| | - Lisa M Brown
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
| | - David T Cooke
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento
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Mortality rate and factors associated with death in traumatic chest injury patients: A retrospective study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Choi J, Villarreal J, Andersen W, Min JG, Touponse G, Wong C, Spain DA, Forrester JD. Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal. Surgery 2021; 170:1260-1267. [PMID: 33888318 DOI: 10.1016/j.surg.2021.03.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/01/2021] [Accepted: 03/11/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA.
| | - Joshua Villarreal
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - Wyatt Andersen
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Jung Gi Min
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Gavin Touponse
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Connie Wong
- Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA
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Improved outcomes utilizing a novel pectin-based pleural sealant following acute lung injury. J Trauma Acute Care Surg 2020; 89:915-919. [PMID: 33108138 DOI: 10.1097/ta.0000000000002754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Persistent air leaks after thoracic trauma are associated with significant morbidity. To evaluate a novel pectin sealant in a swine model of traumatic air leaks, we compared a pectin biopolymer with standard surgical and fibrin-based interventions. METHODS A standardized lung injury was created in male Yorkshire swine. Interventions were randomized to stapled wedge resection (n = 5), topical fibrin glue (n = 5), fibrin patch (n = 5), and a pectin sealant (n = 6). Baseline, preintervention and postintervention tidal volumes (TV) were recorded. Early success was defined as the return to near-normal TV (>95% of baseline). Late success was defined as no detectable air leak in the chest tube after chest closure. RESULTS There were no differences in injury severity between groups (mean TV loss, 62 ± 17 mL, p = 0.2). Early success was appreciated in 100% (n = 6) of the pectin interventions which was significantly better than the fibrin sealant (20%, n = 1), fibrin patch (20%, n = 1), and stapled groups (80%, n = 4, p = 0.01). The percent of return to baseline TV after sealant intervention was significantly increased in the pectin (98%) and staple arms (97%) compared with the fibrin sealant (91%) and fibrin patch arms (90%) (p = 0.02; p = 0.03). Late success was also improved with the pectin sealant: no air leak was detected in 83% of the pectin group compared with 40% in the stapled group (p = 0.008)-90% of the fibrin-based interventions resulted in continuous air leaks (p = 0.001). CONCLUSION Pectin-based bioadhesives effectively seal traumatic air leaks upon application in a porcine model. Further testing is warranted as they may provide a superior parenchymal-sparing treatment option for traumatic air leaks.
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Abstract
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.
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Bertoglio P, Guerrera F, Viti A, Terzi AC, Ruffini E, Lyberis P, Filosso PL. Chest drain and thoracotomy for chest trauma. J Thorac Dis 2019; 11:S186-S191. [PMID: 30906584 DOI: 10.21037/jtd.2019.01.53] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Traumas are the leading cause of death in the first four decades of life. Nevertheless, thoracic traumas only seldom require invasive procedures. In particular, chest drain placement is required in case of pleural disruption causing haemothorax, pneumothorax or haemopneumothorax. Although large-bore chest drains have been traditionally used in case of haemothorax, recent evidences seem to question this routine, showing good performances of small-bore and pig tail drains. Although it is a common procedures, experience and training is needed to avoid complications which might be even lethal. Surgical exploration after thoracic trauma is rare, accounting for less than 3% of traumas. Penetrating traumas more likely require surgical exploration compared to blunt trauma. Anterolateral thoracotomy is usually performed in this setting, but also clamshell or hemi-clamshell approach can be used. In selected patients, minimally invasive techniques can be performed. Large randomized trials are still needed to assess and standardized the role of new tools and procedures in the thoracic trauma setting.
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Affiliation(s)
- Pietro Bertoglio
- Division of Thoracic Surgery, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Francesco Guerrera
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Andrea Viti
- Division of Thoracic Surgery, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Alberto Claudio Terzi
- Division of Thoracic Surgery, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy
| | - Enrico Ruffini
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Paraskevas Lyberis
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pier Luigi Filosso
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Torino, Torino, Italy
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Leenen LPH. Penetrating trauma and invasive management of thorax trauma. Eur J Trauma Emerg Surg 2018; 44:803-804. [PMID: 30456417 DOI: 10.1007/s00068-018-1052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- L P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands.
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