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Aryan N, Nahmias J, Grigorian A, Hsiao Z, Bhullar A, Dolich M, Jebbia M, Patel F, Hemingway J, Silver E, Schubl S. Effects of post rib plating tube thoracostomy output on the need for thoracic re-intervention: Does the volume matter? Injury 2024:111910. [PMID: 39384499 DOI: 10.1016/j.injury.2024.111910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 08/09/2024] [Accepted: 09/15/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) has been demonstrated to improve early clinical outcomes. Tube thoracostomy (TT) is commonly performed with SSRF, however there is a paucity of data regarding when removal of TT following SSRF should occur. This study aimed to compare patients undergoing thoracic reinterventions (reintubation, reinsertion of TT/pigtail, or video-assisted thoracic surgery) to those not following SSRF+TT, hypothesizing increased TT output prior to removal would be associated with thoracic reintervention. METHODS We performed a single center retrospective (2018-2023) analysis of blunt trauma patients ≥ 18 years-old undergoing SSRF+TT. The primary outcome was thoracic reinterventions. Patients undergoing thoracic reintervention ((+)thoracic reinterventions) after TT removal were compared to those who did not ((-)thoracic reintervention). Secondary outcomes included TT duration and outputs prior to removal. RESULTS From 133 blunt trauma patients undergoing SSRF+TT, 23 (17.3 %) required thoracic reinterventions. Both groups were of comparable age. The (+)thoracic reintervention group had an increased injury severity score (median: 29 vs. 17, p = 0.035) and TT duration (median: 4 vs. 3 days, p < 0.001) following SSRF. However, there were no differences in median TT outputs between both cohorts post-SSRF day 1 (165 mL vs. 160 mL, p = 0.88) as well as within 24 h (60 mL vs. 70 mL, p = 0.93) prior to TT removal. CONCLUSION This study demonstrated over 17 % of SSRF+TT patients required a thoracic reintervention. There was no association between thoracic reintervention and the TT output prior to removal. Future studies are needed to confirm these findings, which suggest no absolute threshold for TT output should be utilized regarding when to pull TT following SSRF.
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Affiliation(s)
- Negaar Aryan
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Zoe Hsiao
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Avneet Bhullar
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Matthew Dolich
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Mallory Jebbia
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Falak Patel
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Jacquelyn Hemingway
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Elliot Silver
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
| | - Sebastian Schubl
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care.
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Shah A, Naselsky W, Dave S, Young BA, Bittle G, Tabatabai A, Friedberg J, Krause E. Pneumothorax in acute respiratory distress syndrome on extracorporeal membrane oxygenation support. Perfusion 2024; 39:776-783. [PMID: 36877783 DOI: 10.1177/02676591231159559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
INTRODUCTION Pneumothorax is associated with poor prognosis in patients with acute respiratory distress syndrome (ARDS). We sought to examine the outcomes of patients who are supported on veno-venous extracorporeal membrane oxygenation (VV ECMO) and develop a pneumothorax. METHODS We retrospectively reviewed all adult VV ECMO patients supported for ARDS between 8/2014-7/2020 at our institution, excluding patients with recent lung resection and trauma. Clinical outcomes were compared between patients with a pneumothorax to those without a pneumothorax. RESULTS Two hundred eighty patients with ARDS on VV ECMO were analyzed. Of those, 213 did not have a pneumothorax and 67 did. Patients with a pneumothorax had a longer duration of ECMO support (30 days [16-55] versus 12 [7-22], p < 0.001) and hospital length of stay (51 days [27-93] versus 29 [18-49], p < 0.001), and lower survival-to-discharge (58.2% versus 77.5%, p = 0.002) compared to patients without a pneumothorax. Controlling for age, BMI, sex, RESP score and pre-ECMO ventilator days, the odds ratio of survival-to-discharge was 0.41 (95% CI 0.22-0.78) in patients with a pneumothorax compared to those without. There was a lower incidence of significant bleeding when chest tubes were placed by proceduralist services (2.4% versus 16.2%, p = 0.03). Removal of the chest tube prior to ECMO decannulation compared to removal after decannulation was associated with need for replacement (14.3% versus 0%, p = 0.01). CONCLUSION Patients who develop a pneumothorax and are supported with VV ECMO for ARDS have longer duration on ECMO and decreased survival. Further studies are needed to assess risk factors for development of pneumothorax in this patient population.
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Affiliation(s)
- Aakash Shah
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Warren Naselsky
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sagar Dave
- Department of Emergency Medicine and Anesthesia, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Bree Ann Young
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Bittle
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Tabatabai
- Department of Medicine, Division of Pulmonary and Critical Care, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph Friedberg
- Department of Surgery, Division of Thoracic Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Eric Krause
- Department of Cardiac Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Sweet AAR, Kobes T, Houwert RM, Leenen LPH, de Jong PA, Veldhuis WB, IJpma FFA, van Baal MCPM. The value of chest radiography after chest tube removal in nonventilated trauma patients: A post hoc analysis of a multicenter prospective cohort study. J Trauma Acute Care Surg 2024; 96:623-627. [PMID: 37480167 DOI: 10.1097/ta.0000000000004105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND Chest tubes are commonly placed in trauma care to treat life-threatening intrathoracic injuries by evacuating blood or air from the pleural cavity. Currently, it is common practice to routinely obtain chest radiographs between 1 to 8 hours after chest tube removal, while the necessity of it has been questioned. This study describes the "ins-and-outs" of chest tubes and evaluates the value of routine postremoval chest radiography in nonventilated trauma patients. METHODS A post hoc analysis of a multicenter observational prospective cohort study was performed in blunt chest trauma patients admitted with multiple rib fractures to two level 1 trauma centers between January 2018 and March 2021 and treated with one or more chest tubes. Exclusion criteria were mechanical ventilation during chest tube removal, missing reports of postremoval chest radiography, transfer to another hospital, or mortality before chest tube removal. Descriptive analyses were performed to calculate the number of findings on postremoval chest radiographs and reinterventions. RESULTS A total of 207 patients were included for analysis of whom 14 underwent bilateral chest tube placement, resulting in 221 chest tube removals investigated in this study. The mean ± SD age was 58 ± 17 years, 71% were male, 73% had American Society of Anesthesiologists scores of 1 or 2, and the median Injury Severity Score was 19 (interquartile range, 14-29). In 68 of 221 chest tube removals (31%), postremoval chest radiography showed increased or recurrent intrathoracic pathology (i.e., 13% pneumothorax, 18% pleural fluid, and 8% atelectasis). Only two (3%) of these patients underwent a same-day reintervention based on these findings, of whom one had signs or symptoms of recurrent pathology and one was asymptomatic. CONCLUSION It seems safe to omit routine use of postremoval chest radiography in nonventilated blunt chest trauma patients and to selectively use imaging in those patients presenting with clinical signs or symptoms after chest tube removal. LEVEL OF EVIDENCE Diagnostic Tests/Criteria; Level IV.
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Affiliation(s)
- Arthur A R Sweet
- From the Department of Surgery (A.A.R.S., T.K., R.M.H., L.P.H.L., M.C.P.M.v.B.) and Department of Radiology (A.A.R.S., T.K., P.A.d.J., W.B.V.), University Medical Center Utrecht, Utrecht; Department of Surgery (F.F.A.I.), University Medical Center Groningen, Groningen, the Netherlands
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Korda T, Baillie-Stanton T, Goldstein LN. An observational simulation-based study of the accuracy of intercostal drain placement and factors influencing placement. Afr J Emerg Med 2022; 12:473-477. [DOI: 10.1016/j.afjem.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 08/22/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022] Open
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Butts CC, Cline D, Pariyadath M, Avery MD, Nunn AM, Miller PR. Diagnostic Inaccuracies Using Extended Focused Assessment With Sonography in Trauma for Traumatic Pneumothorax. Am Surg 2022:31348221087926. [PMID: 35435007 DOI: 10.1177/00031348221087926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Traumatic pneumothorax (PTX) can be deadly, and rapid diagnosis is vital. Ultrasound (US) is rapidly gaining acceptance as an accurate bedside diagnostic tool. While making the diagnosis is important, not all PTX require tube thoracostomy. Our goal was to evaluate the predictive ability of ultrasound in identifying clinically significant PTX. METHODS Over 13 months, data was collected on patients undergoing evaluation for trauma. Patients were included if they underwent US, radiograph chest X-ray (CXR), and computed tomography of the chest. Predictive ability of ultrasound was evaluated in identifying clinically significant PTX. RESULTS Ninety-four patients received evaluation by all 3 modalities. Of these, 32% were diagnosed with PTX. Sixteen patients (17%) had a clinically significant PTX. Chest X-ray and US both had a sensitivity of 75%; however, US had more than twice as many false positives, resulting in a much lower positive predictive value (63% vs 80%). CONCLUSIONS While US can reliably rule out PTX, it may be overly sensitive diagnosing clinically significant PTX. Ultrasound alone should not be used in determining the need for tube thoracostomy as many patients will not require acute intervention.
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Affiliation(s)
- C Caleb Butts
- Department of Surgery, Division of Trauma, Acute Care Surgery, & Burns, 12214University of South Alabama College of Medicine, Mobile, AL, USA
| | - David Cline
- Department of Surgery, Division of Acute Care Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Manoj Pariyadath
- Department of Surgery, Division of Acute Care Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Martin D Avery
- Department of Emergency Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew M Nunn
- Department of Emergency Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Preston R Miller
- Department of Emergency Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Beattie G, Cohan CM, Tang A, Chen JY, Victorino GP. Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement. J Trauma Acute Care Surg 2022; 92:177-184. [PMID: 34538828 DOI: 10.1097/ta.0000000000003415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management. METHODS Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression. RESULTS Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05). CONCLUSION The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients. LEVEL OF EVIDENCE Prognostic, level IV.
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Affiliation(s)
- Genna Beattie
- From the Department of Surgery (G.B., C.M.C., A.T., G.P.V.), University of California, San Francisco, East Bay, Oakland; Chemical Sciences Division (J.Y.C.), Lawrence Berkeley National Laboratory, Berkeley, California
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Smith TA, Gage D, Quencer KB. Narrative review of vascular iatrogenic trauma and endovascular treatment. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1199. [PMID: 34430640 PMCID: PMC8350708 DOI: 10.21037/atm-20-4332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/12/2020] [Indexed: 11/29/2022]
Abstract
Iatrogenic injury is unfortunately a leading cause of morbidity and mortality for patients worldwide. The etiology of iatrogenic injury is broad, and can be seen with both diagnostic and therapeutic interventions. While steps can be taken to reduce the occurrence of iatrogenic injury, it is often not completely avoidable. Once iatrogenic injury has occurred, prompt recognition and appropriate management can help reduce further harm. The objective of this narrative review it to help reader better understand the risk factors associated with, and treatment options for a broad range of potential iatrogenic injuries by presenting a series of iatrogenic injury cases. This review also discusses rates, risk factors, as well as imaging and clinical signs of iatrogenic injury with an emphasis on endovascular and minimally invasive treatments. While iatrogenic vascular injury once required surgical intervention, now minimally invasive endovascular treatment is a potential option for certain patients. Further research is needed to help identify patients that are at the highest risk for iatrogenic injury, allowing patients and providers to reconsider or avoid interventions where the risk of iatrogenic injury may outweigh the benefit. Further research is also needed to better define outcomes for patients with iatrogenic vascular injury treated with minimally invasive endovascular techniques verses conservative management or surgical intervention.
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Affiliation(s)
- Tyler Andrew Smith
- Department of Interventional Radiology, University of Utah, Salt Lake City, UT, USA
| | - David Gage
- Department of Medicine, Intermountain Healthcare, Murray, UT, USA
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Beyond the tube: Can we reduce chest tube complications in trauma patients? Am J Surg 2021; 222:1023-1028. [PMID: 33941358 DOI: 10.1016/j.amjsurg.2021.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/05/2021] [Accepted: 04/10/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT). METHODS Retrospective review of all trauma patients undergoing TT from 6/30/2016-6/30/2019. Multivariable logistic regression identified independent predictors of complications. RESULTS Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m2 were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%-53.5%), and early complication increased the likelihood of late complication (4.3%-13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication. CONCLUSION TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m2. We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes.
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Williams OD, Penn M. Can patients with traumatic pneumothorax be managed without insertion of an intercostal drain? TRAUMA-ENGLAND 2021. [DOI: 10.1177/1460408620946261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Michael Penn
- ST1 Emergency Medicine, University Hospital of North Tees
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10
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Menegozzo CAM, Utiyama EM. Ultrasound Should Be Routinely Incorporated as an Adjunct to Tube Thoracostomies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 40:2225-2226. [PMID: 33289150 DOI: 10.1002/jum.15585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 06/12/2023]
Affiliation(s)
| | - Edivaldo Massazo Utiyama
- Department of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, São Paulo, Brazil
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Fonseca AZ, Kunizaki E, Waisberg J, Ribeiro MAF. Managing tube thoracostomy with thoracic ultrasound: results from a randomized pilot study. Eur J Trauma Emerg Surg 2020; 48:973-979. [PMID: 33244615 DOI: 10.1007/s00068-020-01554-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/10/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Tube thoracostomy (TT) is a simple and a life-saving procedure; nevertheless, it carries morbidity, even after its removal. Currently, TT is managed and removed by chest X-ray (CXR) evaluation. There are limitations and these are directly linked to complications. The use of thoracic ultrasound (US) has already been established in the diagnosis of pneumothorax (PTX) and hemothorax (HTX); its use, in substitution of CXR can lead to improvement in care. Our aim is to evaluate the efficiency and safety of US in the management of TT. METHODS Prospective and randomized study with patients requiring TT. They were divided in groups according to their thoracic injuries (PTX and HTX) and randomized into two groups according to TT management: US and CXR. Data collected included gender, age, mechanism of injury, days to TT removal, complications after TT removal and presence of mechanical ventilation. RESULTS Sixty-one patients were randomized, of which 68.8% were male. The most frequent diagnosis was PTX, present in 37 cases. Median time for TT removal was 2.5 days in the US group and 4.9 in the control group (p = 0.009). The complication rate was 6.6%, with no morbidity in the US group. TT removal in patients with mechanical ventilation did not increase the incidence of complications. CONCLUSIONS The use of US in the management is efficient and safe. It allows early TT removal regardless the cause of the thoracic injury.
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Affiliation(s)
- Alexandre Zanchenko Fonseca
- Programa de Pós-Graduação Do Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Av. Ibirapuera, 981 - 2º andar, Vila Clementino, São Paulo, SP, 04029-000, Brazil.
| | - Eric Kunizaki
- Programa de Pós-Graduação Do Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Av. Ibirapuera, 981 - 2º andar, Vila Clementino, São Paulo, SP, 04029-000, Brazil
| | - Jaques Waisberg
- Programa de Pós-Graduação Do Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Av. Ibirapuera, 981 - 2º andar, Vila Clementino, São Paulo, SP, 04029-000, Brazil
| | - Marcelo Augusto Fontenelle Ribeiro
- Programa de Pós-Graduação Do Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Av. Ibirapuera, 981 - 2º andar, Vila Clementino, São Paulo, SP, 04029-000, Brazil
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Beattie G, Cohan CM, Chomsky-Higgins K, Tang A, Senekjian L, Victorino GP. Is a chest radiograph after thoracostomy tube removal necessary? A cost-effective analysis. Injury 2020; 51:2493-2499. [PMID: 32747140 DOI: 10.1016/j.injury.2020.07.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/24/2020] [Accepted: 07/25/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Following placement of tube thoracostomy (TT) for evacuation of traumatic hemopneumothorax (HPTX), controversy persists over the need for routine post-TT removal chest radiograph (CXR). Current research demonstrates routine CXR may offer no advantage over clinical observation alone while simultaneously increasing hospital resource utilization. As such, we hypothesized that in resolved traumatic HPTXs routine post-TT removal CXR to assess recurrent PTX compared to clinical observation is not cost-effective. METHODS We performed a decision-analytic model to evaluate the cost-effectiveness of routine CXR compared to clinical observation following TT removal. Our base case was a patient that sustained thoracic trauma with radiographic and clinical resolution of HPTX following TT evacuation. Cost, utility and probability estimates were generated from published literature, with costs represented in 2019 US dollars and utilities in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed. RESULTS Decision-analytic model identified that clinical observation after TT removal was the dominant strategy with increased benefit at less cost, when compared to routine CXR, with a net cost of $194.92, QALYs of 0.44. In comparison, routine CXR demonstrated an increase of $821.42 in cost with 0.43 QALYs. On probabilistic sensitivity analysis the clinical observation strategy was found cost-effective in 99.5% of 10,000 iterations. CONCLUSION In trauma patients with clinical and radiographic evidence of a resolved HPTX, the adoption of clinical observation in lieu of post-TT removal CXR is cost-effective. Routine CXR following TT removal accrues more cost without additional benefit. The practice of routinely obtaining a CXR following TT removal should be scrutinized.
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Affiliation(s)
- Genna Beattie
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Caitlin M Cohan
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Kathryn Chomsky-Higgins
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Annie Tang
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Lara Senekjian
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Gregory P Victorino
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
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Observing pneumothoraces: The 35-millimeter rule is safe for both blunt and penetrating chest trauma. J Trauma Acute Care Surg 2020; 86:557-564. [PMID: 30629009 DOI: 10.1097/ta.0000000000002192] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As more pneumothoraxes (PTX) are being identified on chest computed tomography (CT), the empiric trigger for tube thoracostomy (TT) versus observation remains unclear. We hypothesized that PTX measuring 35 mm or less on chest CT can be safely observed in both penetrating and blunt trauma mechanisms. METHODS A retrospective review was conducted of all patients diagnosed with PTX by chest CT between January 2011 and December 2016. Patients were excluded if they had an associated hemothorax, an immediate TT (TT placed before the initial chest CT), or if they were on mechanical ventilation. Size of PTX was quantified by measuring the radial distance between the parietal and visceral pleura/mediastinum in a line perpendicular to the chest wall on axial imaging of the largest air pocket. Based on previous work, a cutoff of 35 mm on the initial CT was used to dichotomize the groups. Failure of observation was defined as the need for a delayed TT during the first week. A univariate analysis was performed to identify predictors of failure in both groups, and multivariate analysis was constructed to assess the independent impact of PTX measurement on the failure of observation while controlling for demographics and chest injuries. RESULTS Of the 1,767 chest trauma patients screened, 832 (47%) had PTX, and of those meeting inclusion criteria, 257 (89.0%) were successfully observed until discharge. Of those successfully observed, 247 (96%) patients had a measurement of 35 mm or less. The positive predictive value for 35 mm as a cutoff was 90.8% to predict successful observation. In the univariant analyses, rib fractures (p = 0.048), Glasgow Coma Scale (p = 0.012), and size of the PTX (≤35 mm or >35 mm) (P < 0.0001) were associated with failed observation. In multivariate analysis, PTX measuring 35 mm or less was an independent predictor of successful observation (odds ratio, 0.142; 95% confidence interval, 0.047-0.428)] for the combined blunt and penetrating trauma patients. CONCLUSION A 35-mm cutoff is safe as a general guide with only 9% of stable patients failing initial observation regardless of mechanism. LEVEL OF EVIDENCE Therapeutic, level III.
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Bedawi EO, Talwar A, Hassan M, McCracken DJ, Asciak R, Mercer RM, Kanellakis NI, Gleeson FV, Hallifax RJ, Wrightson JM, Rahman NM. Intercostal vessel screening prior to pleural interventions by the respiratory physician: a prospective study of real world practice. Eur Respir J 2020; 55:13993003.02245-2019. [PMID: 32139459 DOI: 10.1183/13993003.02245-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/01/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The rising incidence of pleural disease is seeing an international growth of pleural services, with physicians performing an ever-increasing volume of pleural interventions. These are frequently conducted at sites without immediate access to thoracic surgery or interventional radiology and serious complications such as pleural bleeding are likely to be under-reported. AIM To assess whether intercostal vessel screening can be performed by respiratory physicians at the time of pleural intervention, as an additional step that could potentially enhance safe practice. METHODS This was a prospective, observational study of 596 ultrasound-guided pleural procedures conducted by respiratory physicians and trainees in a tertiary centre. Operators did not have additional formal radiology training. Intercostal vessel screening was performed using a low frequency probe and the colour Doppler feature. RESULTS The intercostal vessels were screened in 95% of procedures and the intercostal artery (ICA) was successfully identified in 53% of cases. Screening resulted in an overall site alteration rate of 16% in all procedures, which increased to 30% when the ICA was successfully identified. This resulted in procedure abandonment in 2% of cases due to absence of a suitable entry site. Intercostal vessel screening was shown to be of particular value in the context of image-guided pleural biopsy. CONCLUSION Intercostal vessel screening is a simple and potentially important additional step that can be performed by respiratory physicians at the time of pleural intervention without advanced ultrasound expertise. Whether the widespread use of this technique can improve safety requires further evaluation in a multi-centre setting with a robust prospective study.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Ambika Talwar
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,Chest Diseases Dept, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - David J McCracken
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, University of Oxford, Oxford, UK.,Laboratory of Pleural Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Fergus V Gleeson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Dept of Radiology, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rob J Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, University of Oxford, Oxford, UK.,Laboratory of Pleural Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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15
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Cook A, Hu C, Ward J, Schultz S, Moore Iii FO, Funk G, Juern J, Turay D, Ahmad S, Pieri P, Allen S, Berne J. Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study. Trauma Surg Acute Care Open 2019; 4:e000356. [PMID: 31799417 PMCID: PMC6861092 DOI: 10.1136/tsaco-2019-000356] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022] Open
Abstract
Background Thoracic injuries are common in trauma. Approximately one-third will develop a pneumothorax, hemothorax, or hemopneumothorax (HPTX), usually with concomitant rib fractures. Tube thoracostomy (TT) is the standard of care for these conditions, though TTs expose the patient to the risk of infectious complications. The controversy regarding antibiotic prophylaxis at the time of TT placement remains unresolved. This multicenter study sought to reconcile divergent evidence regarding the effectiveness of antibiotics given as prophylaxis with TT placement. Methods The primary outcome measures of in-hospital empyema and pneumonia were evaluated in this prospective, observational, and American Association for the Surgery of Trauma multicenter study. Patients were grouped according to treatment status (ABX and NoABX). A 1:1 nearest neighbor method matched the ABX patients with NoABX controls. Multilevel models with random effects for matched pairs and trauma centers were fit for binary and count outcomes using logistic and negative binomial regression models, respectively. Results TTs for HPTX were placed in 1887 patients among 23 trauma centers. The ABX and NoABX groups accounted for 14% and 86% of the patients, respectively. Cefazolin was the most frequent of 14 antibiotics prescribed. No difference in the incidence of pneumonia and empyema was observed between groups (2.2% vs 1.5%, p=0.75). Antibiotic treatment demonstrated a positive but non-significant association with risk of pneumonia (OR 1.61; 95% CI: 0.86~3.03; p=0.14) or empyema (OR 1.51; 95% CI: 0.42~5.42; p=0.53). Conclusion There is no evidence to support the routine use of presumptive antibiotics for post-traumatic TT to decrease the incidence of pneumonia or empyema. More investigation is necessary to balance optimal patient outcomes and antibiotic stewardship. Level of evidence II Prospective comparative study
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Affiliation(s)
- Alan Cook
- Department of Surgery, University of Texas Health Science Center at Tyler, Tyler, Texas, USA
| | - Chengcheng Hu
- Department of Epidemiology and Biostatistics, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona, USA
| | - Jeanette Ward
- Department of Trauma, HonorHealth, Scottsdale, Arizona, USA
| | - Susan Schultz
- Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | | | - Geoffrey Funk
- Department of Surgery, Baylor Scott and White Health, Dallas, Texas, USA
| | - Jeremy Juern
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David Turay
- Department of Surgery, Loma Linda University, Loma Linda, California, USA
| | - Salman Ahmad
- Department of Surgery, University of Missouri Hospital & Clinics, Columbia, Missouri, USA
| | - Paola Pieri
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona, USA
| | - Steven Allen
- Department of Surgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - John Berne
- Department of Surgery, Broward Health, Fort Lauderdale, Florida, USA
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16
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Patel BH, Lew CO, Dall T, Anderson CL, Rodriguez R, Langdorf MI. Chest tube output, duration, and length of stay are similar for pneumothorax and hemothorax seen only on computed tomography vs. chest radiograph. Eur J Trauma Emerg Surg 2019; 47:939-947. [DOI: 10.1007/s00068-019-01198-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
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17
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Can ultrasound be used as an adjunct for tube thoracostomy? A systematic review of potential application to reduce procedure-related complications. Int J Surg 2019; 68:85-90. [DOI: 10.1016/j.ijsu.2019.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/10/2019] [Accepted: 06/18/2019] [Indexed: 11/23/2022]
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18
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Complications Associated With Placement of Chest Tubes: A Trauma System Perspective. J Surg Res 2019; 239:98-102. [DOI: 10.1016/j.jss.2019.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 11/19/2018] [Accepted: 01/04/2019] [Indexed: 11/23/2022]
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19
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Abstract
BACKGROUND Tube thoracostomy (TT) complications and their reported rates are highly variable (1-40%) and inconsistently classified. Consistent TT complication classification must be applied to compare reported literature to standardize TT placement. We aim to determine the overall TT-related complication rates in patients receiving TT for traumatic indications using uniform definitions. METHODS Systematic review and meta-analysis was performed assessing TT-related complications. Comprehensive search of several databases (1975-2015) was conducted. We included studies that reported on bedside TT insertion (≥22 Fr) in trauma patients. Data were abstracted from eligible articles by independent reviewers with discrepancies reconciled by a third. Analyses were based on complication category subtypes: insertional, positional, removal, infection/immunologic/education, and malfunction. RESULTS Database search resulted in 478 studies; after applying criteria 29 studies were analyzed representing 4,981 TTs. Injury mechanisms included blunt 60% (49-71), stab 27% (17-34), and gunshot 13% (7.8-10). Overall, median complication rate was 19% (95% confidence interval, 14-24.3). Complication subtypes included insertional (15.3%), positional (53.1%), removal (16.2%), infection/immunologic (14.8%), and malfunction (0.6%). Complication rates did not change significantly over time for insertional, immunologic, or removal p = 0.8. Over time, there was a decrease in infectious TT-related complications as well as an increase in positional TT complications. CONCLUSION Generation of evidence-based approaches to improve TT insertion outcomes is difficult because a variety of complication classifications has been used. This meta-analysis of complications after TT insertion in trauma patients suggests that complications have not changed over time remaining stable at 19% over the past three decades. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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20
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Using cable ties to connect thoracostomy tubes to drainage devices decreases frequency of unplanned disconnection. Eur J Trauma Emerg Surg 2018; 46:621-626. [PMID: 30386866 DOI: 10.1007/s00068-018-1044-2] [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: 08/14/2018] [Accepted: 10/28/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Thoracostomy tube (TT) connection to drainage device (DD) may be unintentionally disconnected, potentiating complications. Tape may strengthen this connection despite minimal data informing optimal practice. Our goal was to analyze the utility of cable ties for TT to DD connection. METHODS On April 1, 2015, our trauma center supplanted use of tape or nothing with cable ties for securing TT to DD connection. We abstracted trauma registry patients with TTs placed from March 1, 2014 to May 31, 2016 and dichotomized as prior ("BEFORE") and subsequent ("AFTER") to the cable tie practice pattern change. We analyzed demographics, TT-specific details and outcomes. Primary outcome was TT to DD disconnection. Secondary outcomes included TT dislodgement from the chest, complications, length of stay (LOS), mortality, number of TTs placed and TT days. RESULTS 121 (83.4% of abstracted) patients were analyzed. Demographics, indications for TT and operative rate were similar for BEFORE and AFTER cohorts. ISS was lower BEFORE (14.12 ± 2.35 vs 18.21 ± 2.71, p = 0.022); however, RTS and AIS for chest were similar (p = 0.155 and 0.409, respectively). TT to DD disconnections per TT days were significantly higher in the BEFORE cohort [6 (2.8%) vs. 1 (0.19%), p = 0.003], and dislodgements were statistically similar [0 vs 3 (0.57%), p = 0.36]. LOS, initial TTs placed and days per TT were similar, and median and mode of days per TT were the same. CONCLUSIONS Cable ties secure connections between TT and DDs with higher fidelity compared to tape or nothing but may increase rates of TT dislodgement from the chest.
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21
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The Benefit of Ultrasound in Deciding Between Tube Thoracostomy and Observative Management in Hemothorax Resulting from Blunt Chest Trauma. World J Surg 2018; 42:2054-2060. [PMID: 29305713 DOI: 10.1007/s00268-017-4417-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hemothorax is most commonly resulted from a closed chest trauma, while a tube thoracostomy (TT) is usually the first procedure attempted to treat it. However, TT may lead to unexpected results and complications in some cases. The advantage of thoracic ultrasound (TUS) over a physical examination combined with chest radiograph (CXR) for diagnosing hemothorax1 has been proposed previously. However, its benefits in terms of avoiding non-therapeutic TT have not yet been confirmed. Therefore, this study is aimed to evaluate the severity of hemothorax in blunt chest trauma patients by using TUS in order to avoid non-therapeutic TT in stable cases. METHODS The data from 46,036 consecutive patient visits to our trauma center over a four-year period were collected, and those with blunt chest trauma were identified. Patients who met any of the following criteria were excluded: transferred from another facility, with an abbreviated injury scale (AIS) score ≥ 2 for any region except the chest region, with a documented finding of tension pneumothorax or pneumothorax >10%, younger than 16 years old and with indications requiring any non-thoracic major operation. The decision to perform TT for those patients in the non-TUS group was made on the basis of CXR findings and clinical symptoms. The continuous data were analyzed by using the two-tailed Student's t test, and the discrete data were analyzed by Chi-square test. RESULTS A total of 84 patients met the criteria for inclusion in the final analysis, with TT having been performed on 42 (50%) of those patients. The mean volume of the drainage amount was 860 ml after TT. The TT drainage was less than 500 ml in 12 patients in the non-TUS group (40%), while none was less than 500 ml in the TUS group (p = 0.036, Fisher's exact test). In terms of the positive rate of subsequent effective TT, the sensitivity of TUS was 90% and the specificity was 100%. There were 3 patients with delayed hemothorax: 2 of the 58 (3.6%) in the non-TUS group and 1 of 26 (4.5%) in the TUS group (p > 0.05, Fisher's exact test). The hospital length of stay in the non-TUS group with non-therapeutic TT was significantly longer than in the TUS group without TT (8.2 vs. 5.4 days, p = 0.018). There were no other major complications or deaths in either group during the 90-day follow-up period. CONCLUSION In the case of blunt trauma, TUS can rapidly and accurately evaluate hemothorax to avoid TT in patients who may not benefit much from it. As a result, the rate of non-therapeutic TT can be decreased, and the influence on shortening hospital length of stay may be further evaluated with prospective controlled study.
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22
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Abstract
BACKGROUND Tube thoracostomy (TT) is a commonly performed procedure which is associated with significant complication rates. Currently, there is no validated taxonomy to classify and compare TT complications across different populations. This study aims to validate such TT complication taxonomy in a cohort of South African trauma patients. METHODS Post hoc analysis of a prospectively collected trauma database from Pietermaritzburg Metropolitan Trauma Service (PMTS) in South Africa was performed for the period January 2010 to December 2013. Baseline demographics, mechanism of injury and complications were collected and categorized according to published classification protocols. All patients requiring bedside TT were included in the study. Patients who necessitated operatively placed or image-guided TT insertion were excluded. Summary and univariate analyses were performed. RESULTS A total of 1010 patients underwent TT. The mean age was (±SD) of 26 ± 8 years. Unilateral TTs were inserted in n = 966 (96%) and bilateral in n = 44 (4%). Complications developed in 162 (16%) patients. Penetrating injury was associated with lower complication rate (11%) than blunt injury (26%), p = 0.0001. Higher complication rate was seen in TT placed by interns (17%) compared to TT placed by residents (7%), p = 0.0001. Complications were classified as: insertional (38%), positional (44%), removal (9%), infective/immunologic (9%), and instructional, educational or equipment related (0%). CONCLUSIONS Despite being developed in the USA, this classification system is robust and was able to comprehensively assign and categorize all the complications of TT in this South African trauma cohort. A universal standardized definition and classification system permits equitable comparisons of complication rates. The use of this classification taxonomy may help develop strategies to improve TT placement techniques and reduce the complications associated with the procedure. LEVEL OF EVIDENCE V. STUDY TYPE Single Institution Retrospective review.
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23
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Menegozzo CAM, Utiyama EM. Steering the wheel towards the standard of care: Proposal of a step-by-step ultrasound-guided emergency chest tube drainage and literature review. Int J Surg 2018; 56:315-319. [DOI: 10.1016/j.ijsu.2018.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/20/2018] [Accepted: 07/03/2018] [Indexed: 11/16/2022]
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24
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Struck MF, Ewens S, Fakler JKM, Hempel G, Beilicke A, Bernhard M, Stumpp P, Josten C, Stehr SN, Wrigge H, Krämer S. Clinical consequences of chest tube malposition in trauma resuscitation: single-center experience. Eur J Trauma Emerg Surg 2018; 45:687-695. [PMID: 29855668 DOI: 10.1007/s00068-018-0966-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/28/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Evaluation of trauma patients with chest tube malposition using initial emergency computed tomography (CT) and assessment of outcomes and the need for chest tube replacement. METHODS Patients with an injury severity score > 15, admitted directly from the scene, and requiring chest tube insertion prior to initial emergency CT were retrospectively reviewed. Injury severity, outcomes, and the positions of chest tubes were analyzed with respect to the need for replacement after CT. RESULTS One hundred seven chest tubes of 78 patients met the inclusion criteria. Chest tubes were in the pleural space in 58% of cases. Malposition included intrafissural positions (27%), intraparenchymal positions (11%) and extrapleural positions (4%). Injury severity and outcomes were comparable in patients with and without malposition. Replacement due to malfunction was required at similar rates when comparing intrapleural positions with both intrafissural or intraparenchymal positions (11 vs. 23%, p = 0.072). Chest tubes not reaching the target position (e.g., pneumothorax) required replacement more often than targeted tubes (75 vs. 45%, p = 0.027). Out-of-hospital insertions required higher replacement rates than resuscitation room insertions (29 vs. 10%, p = 0.016). Body mass index, chest wall thickness, injury severity, insertion side and intercostal space did not predict the need for replacement. CONCLUSIONS Patients with malposition of emergency chest tubes according to CT were not associated with worse outcomes compared to patients with correctly positioned tubes. Early emergency chest CT in the initial evaluation of severely injured patients allows precise detection of possible malposition of chest tubes that may require immediate intervention.
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Affiliation(s)
- Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Sebastian Ewens
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Johannes K M Fakler
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - André Beilicke
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Patrick Stumpp
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Sebastian N Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Sebastian Krämer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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Tube Thoracostomy Complications: More to Learn. World J Surg 2017; 42:310. [PMID: 28744594 DOI: 10.1007/s00268-017-4154-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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