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Johnson EH, Lee JS, Clement LP, Brockman V, Schmoekel N, Schroeppel TJ. The size paradox: An analysis of tube thoracostomy in trauma. Am J Surg 2024; 238:115829. [PMID: 39024726 DOI: 10.1016/j.amjsurg.2024.115829] [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: 04/17/2024] [Revised: 06/26/2024] [Accepted: 07/03/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Debate continues over chest tube (CT) size for traumatic hemothorax (HTX) and pneumothorax (PTX). We compared CT failure and opioid use between large-bore chest tubes (LB-CT) and small-bore chest tubes (SB-CT). METHODS A retrospective study comparing trauma patients with SB-CT (≤14Fr) or LB-CT (≥24Fr) was performed. CT failure includes HTX, PTX, or empyema requiring intervention. Secondary outcomes included opioid use (MME), mortality, and favorable discharge. RESULTS Of 252 patients, 65.1 % had SB-CT. SB-CT were older with lower ISS. Failure rate was lower for SB-CT (9.2 vs 22.7 %, p = 0.003), as was opioid use (332 vs 767, p < 0.001). In adjusted analysis there was no difference in CT failure between SB-CT and LB-CT. Subgroup analysis found SB-CT had lower total MME (234 vs 342, p = 0.018). CONCLUSIONS This study found no major differences in CT failure or opioid use by CT size, suggesting SB-CT are a safe, and effective alternative to LB-CT in trauma.
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Affiliation(s)
- Emily H Johnson
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Janet S Lee
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - L Paige Clement
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA; Department of Pharmacy, UCHealth Memorial Hospital, Colorado Springs, CO, USA.
| | - Valerie Brockman
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA.
| | - Nathan Schmoekel
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA.
| | - Thomas J Schroeppel
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA.
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Lewis MR, Georgoff P. Minimally invasive management of thoracic trauma: current evidence and guidelines. Trauma Surg Acute Care Open 2024; 9:e001372. [PMID: 38646032 PMCID: PMC11029362 DOI: 10.1136/tsaco-2024-001372] [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: 01/08/2024] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
Minimally invasive procedures are being increasingly proposed for trauma. Injuries to the chest wall and/or lung have historically been managed by drainage with a large bore thoracostomy tube, while cardiac injuries have mandated sternotomy. These treatments are associated with significant patient discomfort. Percutaneous placement of small 'pigtail' catheters was initially designed for drainage of simple pericardial fluid. Their use subsequently expanded to drainage of the pleural cavity. The role of pigtail catheters for primary treatment of traumatic pneumothorax and hemopneumothorax has increased, while their use for pericardial fluid after trauma remains controversial. Pericardial windows have alternatively been purposed as a minimally invasive treatment option for possible hemopericardium. The aim of this article is to review the current evidence and guidelines for minimally invasive management of chest trauma.
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Affiliation(s)
- Meghan R Lewis
- Surgery, University of Southern California, Los Angeles, California, USA
- LAC+USC Medical Center, Los Angeles, California, USA
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Beeton G, Ngatuvai M, Breeding T, Andrade R, Zagales R, Khan A, Santos R, Elkbuli A. Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis. Am Surg 2023:31348231157809. [PMID: 36802811 DOI: 10.1177/00031348231157809] [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: 02/22/2023]
Abstract
INTRODUCTION A debate currently exists regarding the efficacy of pigtail catheters vs chest tubes in the management of thoracic trauma. This meta-analysis aims to compare the outcomes of pigtail catheters vs chest tubes in adult trauma patients with thoracic injuries. METHODS This systematic review and meta-analysis were conducted using PRISMA guidelines and registered with PROSPERO. PubMed, Google Scholar, Embase, Ebsco, and ProQuest electronic databases were queried for studies comparing the use of pigtail catheters vs chest tubes in adult trauma patients from database inception to August 15th, 2022. The primary outcome was the failure rate of drainage tubes, defined as requiring a second tube placement or VATS, unresolved pneumothorax, hemothorax, or hemopneumothorax requiring additional intervention. Secondary outcomes were initial drainage output, ICU-LOS, and ventilator days. RESULTS A total of 7 studies satisfied eligibility criteria and were assessed in the meta-analysis. The pigtail group had higher initial output volumes vs the chest tube group, with a mean difference of 114.7 mL [95% CI (70.6 mL, 158.8 mL)]. Patients in the chest tube group also had a higher risk of requiring VATS vs the pigtail group, with a relative risk of 2.77 [95% CI (1.50, 5.11)]. CONCLUSIONS In trauma patients, pigtail catheters rather than chest tubes are associated with higher initial output volume, reduced risk of VATS, and shorter tube duration. Considering the similar rates of failure, ventilator days, and ICU length-of-stay, pigtail catheters should be considered in the management of traumatic thoracic injuries. STUDY TYPE Systematic Review and meta-analysis.
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Affiliation(s)
- George Beeton
- 12376University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Micah Ngatuvai
- Dr Kiran C. Patel College of Allopathic Medicine, 2814NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Tessa Breeding
- Dr Kiran C. Patel College of Allopathic Medicine, 2814NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Ryan Andrade
- 390414A.T. Still University School of Osteopathic Medicine, Mesa, AZ, USA
| | - Ruth Zagales
- 5450Florida International University, Miami, FL, USA
| | - Areeba Khan
- Department of Mathematics, 2814NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Radleigh Santos
- Department of Mathematics, 2814NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA.,Department of Surgical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
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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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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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