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Beyer CA, Byrne JP, Moore SA, McLauchlan NR, Rezende-Neto JB, Schroeppel TJ, Dodgion C, Inaba K, Seamon MJ, Cannon JW. Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis. Surgery 2023; 174:1063-1070. [PMID: 37500410 DOI: 10.1016/j.surg.2023.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/23/2023] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Carl A Beyer
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James P Byrne
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD. https://twitter.com/DctrJByrne
| | - Sarah A Moore
- Division of Acute Care Surgery, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM. https://twitter.com/AnnieMooreMD
| | - Nathaniel R McLauchlan
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joao B Rezende-Neto
- Department of Trauma and Acute Care Surgery, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Thomas J Schroeppel
- Department of Surgery, University of Colorado School of Medicine, UCHealth Memorial Hospital, Colorado Springs, CO
| | - Christopher Dodgion
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. https://twitter.com/ChrisDodgion
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, Los Angeles, CA
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. https://twitter.com/MarkSeamonMD
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Becker L, Schulz-Drost S, Schreyer C, Lindner S. [Chest Tube in Thoracic Trauma - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU)]. Zentralbl Chir 2023; 148:57-66. [PMID: 36849110 DOI: 10.1055/a-1975-0243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH2O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.
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Affiliation(s)
- Lars Becker
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Stefan Schulz-Drost
- Klinik für Unfallchirurgie und Traumatologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Christof Schreyer
- Allgemein-/Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Koblenz, Deutschland
| | - Sebastian Lindner
- Klinik für Thoraxchirurgie und thorakale Endoskopie, HELIOS Klinikum Erfurt, Erfurt, Deutschland
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Freeman JJ, Asfaw SH, Vatsaas CJ, Yorkgitis BK, Haines KL, Burns JB, Kim D, Loomis EA, Kerwin AJ, McDonald A, Agarwal, S, Fox N, Haut ER, Crandall ML, Como JJ, Kasotakis G. Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open 2022; 7:e000886. [PMID: 36312819 PMCID: PMC9608538 DOI: 10.1136/tsaco-2022-000886] [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: 01/12/2022] [Accepted: 10/02/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. METHODS Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. RESULTS Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. DISCUSSION In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO REGISTRATION NUMBER CRD42018088759.
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Affiliation(s)
- Jennifer J Freeman
- Surgery, Texas Christian University Burnett School of Medicine, Fort Worth, Texas, USA
| | - Sofya H Asfaw
- General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cory J Vatsaas
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian K Yorkgitis
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Krista L Haines
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - J Bracken Burns
- Surgery, East Tennessee State University, Johnson City, Tennessee, USA
| | - Dennis Kim
- Surgical Critical Care, Los Angeles County Harbor–UCLA Medical Center, Torrance, California, USA
| | | | - Andy J Kerwin
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Amy McDonald
- Surgery, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Suresh Agarwal,
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nicole Fox
- Surgery, Cooper University Health Care, Camden, New Jersey, USA
| | | | - Marie L Crandall
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - John J Como
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - George Kasotakis
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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The Volume of Thoracic Irrigation Is Associated With Length of Stay in Patients With Traumatic Hemothorax. J Surg Res 2022; 279:62-71. [PMID: 35724544 DOI: 10.1016/j.jss.2022.05.031] [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: 12/03/2021] [Revised: 04/15/2022] [Accepted: 05/21/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Irrigation of the thoracic cavity at tube thoracostomy (TT) placement may decrease the rate of a retained hemothorax (RHTX); however, other resource utilization outcomes have not yet been quantified. This study evaluated the association of thoracic irrigation during TT with the length of stay and outcomes in patients with traumatic hemothorax (HTX). METHODS A retrospective chart review was performed of adult patients receiving a TT for HTX at a single, urban Level 1 Trauma Center from January 2019 to December 2020. Those who underwent irrigation during TT at the discretion of the trauma surgeon were compared to a control of standard TT without irrigation. Death within 30 d, as well as TTs, placed at outside hospitals, during traumatic arrest or thoracic procedures, and for isolated pneumothoraces were excluded. The primary outcome was the length of stay as hospital-free, ICU-free, and ventilator-free days (30-day benchmark). Subgroup analysis by irrigation volume was conducted using one-way ANOVA testing with P < 0.05 considered statistically significant. RESULTS Eighty-two (41.4%) of 198 patients underwent irrigation during TT placement. Secondary interventions, thoracic infections, and TT duration were not statistically different in the irrigated cohort. Hospital-free and ICU-free days were higher in the irrigated patients than in the controls. Groups irrigated with ≥1000 mL had significant more hospital-free days (P = 0.007) than those receiving less than 1000 mL. CONCLUSIONS Patients with traumatic HTX who underwent thoracic irrigation at the time of TT placement had decreased hospital and ICU days compared to standard TT placement alone. Specifically, our study demonstrated that patients irrigated with a volume of at least 1000 mL had greater hospital-free days compared to those irrigated with less than 1000 mL.
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Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg 2020; 89:679-685. [PMID: 32649619 DOI: 10.1097/ta.0000000000002881] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH. METHODS We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08-1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE Therapeutic/care management study, level III.
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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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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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Selective Operative Management of Penetrating Chest Injuries. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0233-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Feenstra TM, Dickhoff C, Deunk J. Systematic review and meta-analysis of tube thoracostomy following traumatic chest injury; suction versus water seal. Eur J Trauma Emerg Surg 2018; 44:819-827. [PMID: 29546613 PMCID: PMC6267148 DOI: 10.1007/s00068-018-0942-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 03/12/2018] [Indexed: 12/29/2022]
Abstract
Purpose Tube thoracostomy is frequently used in thoracic trauma patients. However, there is no consensus on whether low pressure suction or water seal is the optimal method of tube management. Against this background, we performed a systematic review of studies comparing suction and water seal management of chest tubes placed for traumatic chest injuries in adults. Evaluated outcomes are duration of chest tube treatment, length of stay in hospital, incidence of persistent air leak, clotted hemothorax, and the need for (re-)interventions. Methods A systematic literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was performed. Included studies were evaluated according to the Cochrane Collaboration’s tool for assessing the risk of bias, and according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for assessing the quality of evidence. Results After assessment of 120 identified studies, three RCT’s (randomized controlled trials) were included in this review and meta-analysis. A favorable effect of suction was found for duration of chest tube treatment [MD (mean difference) − 3.38 days, P = 0.005], length of stay in hospital (MD −3.90 days, P = 0.0003), and the incidence of persistent air leak [OR (odds ratio) 0.27, P = 0.001]. No significant difference was found for the incidence of clotted hemothorax and (re-)interventions. The quality of evidence according to GRADE was low, except for persistent air leak (moderate). Conclusions Suction seems to have a positive effect on duration of chest tube treatment, length of stay in hospital and persistent air leakage in chest trauma. However, available data was limited and the quality of evidence was (very) low to moderate according to GRADE.
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Affiliation(s)
- Tim Michael Feenstra
- Department of Trauma Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Chris Dickhoff
- Department of Thoracic Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jaap Deunk
- Department of Trauma Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis. J Trauma Acute Care Surg 2017; 83:1136-1141. [PMID: 28930941 DOI: 10.1097/ta.0000000000001700] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Thoracic trauma resulting in hemothorax (HTx) is typically managed with thoracostomy tube (TT) placement; however, up to 20% of patients develop retained HTx which may necessitate further intervention for definitive management. Although optimal management of retained HTx has been extensively researched, little is known about prevention of this complication. We hypothesized that thoracic irrigation at the time of TT placement would significantly decrease the rate of retained HTx necessitating secondary intervention. METHODS A prospective, comparative study of patients with traumatic HTx who underwent bedside TT placement was conducted. The control group consisted of patients who underwent standard TT placement, whereas the irrigation group underwent standard TT placement with immediate irrigation using 1 L of warmed sterile 0.9% saline. Patients who underwent emergency thoracotomy, those with TTs removed within 24 hours, or those who died within 30 days of discharge were excluded. The primary end point was secondary intervention defined by additional TT placement or operative management for retained HTx. A propensity-matched analysis was performed with scores estimated using a logistic regression model based on age, sex, mechanism of injury, Abbreviated Injury Scale chest score, and TT size. RESULTS In over a 30-month period, a total of 296 patients underwent TT placement for the management of traumatic HTx. Patients were predominantly male (79.6%) at a median age of 40 years and were evenly split between blunt (48.8%) and penetrating (51.2%) mechanisms. Sixty (20%) patients underwent thoracic irrigation at time of initial TT placement. The secondary intervention rate was significantly lower within the study group (5.6% vs. 21.8%; OR, 0.16; p < 0.001). No significant differences in TT duration, ventilator days, or length of stay were noted between the irrigation and control cohort. CONCLUSION Thoracic irrigation at the time of initial TT placement for traumatic HTx significantly reduced the need for secondary intervention for retained HTx. LEVEL OF EVIDENCE Therapeutic Study, Level III.
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11
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Management of Traumatic Hemothorax, Retained Hemothorax, and Other Thoracic Collections. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0101-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kugler NW, Carver TW, Paul JS. Thoracic irrigation prevents retained hemothorax: a pilot study. J Surg Res 2016; 202:443-8. [PMID: 27038661 DOI: 10.1016/j.jss.2016.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/19/2016] [Accepted: 02/26/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Upward of 20% of patients undergoing thoracostomy tube (TT) placement develop retained hemothorax (HTx) requiring secondary intervention. The aim of this study was to define the rate of secondary intervention in patients undergoing prophylactic thoracic irrigation. METHODS A prospective observational trial of 20 patients who underwent thoracic irrigation at the time of TT placement was conducted. Patients with HTx identified on chest x-ray were included. After standard placement of a 36-French TT, the HTx was evacuated using a sterile suction catheter advanced within the TT. Warmed sterile saline was instilled into the chest through the TT followed by suction catheter evacuation. The TT was connected to the sterile drainage atrium and suction applied. TTs were managed in accordance with our standard division protocol. RESULTS The population was predominantly (70%) male at median age 35 years, median ISS 13, with 55% suffering penetrating trauma. Thirteen (65%) patients underwent TT placement within 6 h of trauma with the remainder within 24 h. Nineteen patients received the full 1000-mL irrigation. The majority demonstrated significant improvement on postprocedure chest x-ray. The secondary intervention rate was 5%. A single patient required VATS on post-trauma day zero for retained HTx. Median TT duration was 5 d with median length of stay of 7 d. No adverse events related to the pleural lavage were noted. CONCLUSIONS Thoracic irrigation at the time of TT placement for traumatic HTx may decrease the rate of retained HTx.
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Affiliation(s)
- Nathan W Kugler
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Thomas W Carver
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jasmeet S Paul
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
Purpose of review In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs. Recent findings In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes. Summary Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively.
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Majercik S, Vijayakumar S, Olsen G, Wilson E, Gardner S, Granger SR, Van Boerum DH, White TW. Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg 2015; 210:1112-6; discussion 1116-7. [PMID: 26454653 DOI: 10.1016/j.amjsurg.2015.08.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 08/17/2015] [Accepted: 08/17/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Retained hemothorax (RH) is relatively common after chest trauma and can lead to empyema. We hypothesized that patients who have surgical fixation of rib fractures (SSRF) have less RH and empyema than those who have medical management of rib fractures (MMRF). METHODS Admitted rib fracture patients from January 2009 to June 2013 were identified. A 2:1 propensity score model identified MMRF patients who were similar to SSRF. RH, and empyema and readmissions, were recorded. Variables were compared using Fisher exact test and Wilcoxon rank-sum tests. RESULTS One hundred thirty-seven SSRF and 274 MMRF were analyzed; 31 (7.5%) had RH requiring 35 interventions; 3 (2.2%) SSRF patients had RH compared with 28 (10.2%) MMRF (P = .003). Four (14.3%) MMRF subjects with RH developed empyema versus zero in the SSRF group (P = .008); 6 (19.3%) RH patients required readmission versus 14 (3.7%) in the non-RH group (P = .002). CONCLUSIONS Patients with rib fractures who have SSRF have less RH compared with similar MMRF patients. Although not a singular reason to perform SSRF, this clinical benefit should not be overlooked.
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Affiliation(s)
- Sarah Majercik
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84107, USA.
| | - Sathya Vijayakumar
- Surgical Services Clinical Program, Intermountain Medical Center, Murray, UT, USA
| | - Griffin Olsen
- Surgical Services Clinical Program, Intermountain Medical Center, Murray, UT, USA
| | - Emily Wilson
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Scott Gardner
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84107, USA
| | - Steven R Granger
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84107, USA
| | - Don H Van Boerum
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84107, USA
| | - Thomas W White
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84107, USA
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