Category Archives: Thorax

Retained Hemothorax Part 3: VATS

March 6, 2017 The Trauma Pro Leave a comment

I’ve written about the use of lytics to treat retained hemothorax over the past few days. Although it sounds like a good idea, we just don’t know that it works very well. And they certainly don’t work fast. Lengths of stay were on the order of two weeks in both studies reviewed.

The alternative is video assisted thoracoscopic surgery (VATS). So let’s take a look at what we know about it. This procedure is basically laparoscopy of the chest. A camera is inserted, and other ports are added to allow insertion of instruments to suck, peel, and scrape out the hemothorax.

A prospective, multi-center study was performed over a 2 year period starting in 2009. Twenty centers participated, contributing data on 328 patients with retained hemothorax. This was defined as CT confirmation of retained blood and clot after chest tube placement, with evidence of pleural thickening.

Here are the factoids:

41% of patients had antibiotics given for chest tube placement (this is interesting given the lack of consensus regarding their effectiveness!)
A third of patients were initially managed with observation, and most of them (82%) did not need any further procedures (83 of 101 patients)
Observation was more successful in patients who were older, had smaller hemothoraces (<300cc), smaller chest tubes (!!, <34 Fr), blunt trauma, and peri-procedure antibiotics (?)
An additional chest tube was inserted in 19% of patients, image guided drain placement in 5%, and lytics in 5%. Half to two-thirds of these patients required additional management.
VATS was used in 34% of patients. One third of them required additional management including another chest tube, another VATS, or even thoracotomy.
Thoracotomy was most likely required if there was a diaphragm injury or large hemothorax (<900cc)
Empyema and pneumonia were common (27% and 20%, respectively)

Bottom line: There’s a lot of data in this paper. Most notably, many patients resolve their hemothorax without any additional management. But if they don’t, additional tubes, guided drain placement, and lytics work only a third of the time and contribute to additional time in the hospital. Even VATS and thoracotomy require additional maneuvers 20-30% of the time. And infectious complications are common. This is a tough problem!

Tomorrow, I’ll try to roll it all together and suggest an algorithm to try to optimize both outcomes and cost.

Posts in this series:

Reference: Management of post-traumatic retained hemothorax: A prospective, observational, multicenter AAST study. 72(1):11-24, 2012.

Complications, Thorax

Retained Hemothorax Part 2: Lytics (again)

March 3, 2017 The Trauma Pro Leave a comment

Yesterday, I reviewed a small case report that was published a couple of years ago on lytics for treatment of retained hemothorax. But surely, there must be something better, right?

After digging around, I did find a paper from 2007 that prospectively looked at protocolized management of retained hemothorax, and its aftermath. It was carried out at a busy Level I trauma center over a 16 month period.

All patients with a hemothorax treated with chest tube received daily chest x-rays. Those with significant opacification on day 3 underwent CT scan of the chest. If more than 300 cc of retained blood was present, the patient received streptokinase or urokinase (surgeon preference and drug availability) daily, and rolled around in bed for 4 hours to attempt to distribute it. The chest tube was then unclamped and allowed to drain. This was repeated for 3 days, and if there was still opacification, a repeat CT was obtained. If the volume was still greater than 300 cc, the cycle was repeated for the next 3 days. If the opacification cleared at any point, or the repeat CT showed less than 300 cc, the protocol was stopped and the chest tube removed. If the chest was still opacified after 6 days, VATS was offered.

Here are the factoids:

A total of 203 patients with hemothorax were admitted during the study period and 25 (12%) developed a retained hemothorax
While a few had treatment start within 4 days, the majority did not receive lytics until day 9 (range 3 –30 days!)
The average length of time in hospital after start of lytics was 7 days, leading to a total length of stay of 18 days
92% of patients had “effective” evacuation of their retained hemothorax, although 1 had VATS anyway which found only 100 cc of fluid
16 patients had “complete” evacuation, and 5 had “partial” evacuation
There were no hemorrhagic complications, but one third of patients reported significant pain with drug administration

Bottom line: Sounds good, right? The drug seems reasonably effective, although lengths of stay are relatively long. However, streptokinase and urokinase are no longer available in the US, having been replaced with tissue plasminogen activator (tPA). This paper does a cost analysis of lytics vs VATS and found that the former treatment cost about $15000 (drug + hospital stay) vs $34000 for VATS. However, a big part of this was that the drug only cost about $75 per dose. tPA is much more expensive.

So once again, small series, longer lengths of stay, but at least nicely done. Unfortunately, the drug choice is no longer available so use of tPA tilts the balance away from lytics. Tomorrow, I’ll explore the results of using VATS for this condition.

Posts in this series:

Reference: Intrapleural Thrombolysis for the Management of Undrained Traumatic Hemothorax: A Prospective Observational Study. J Trauma 62(5):1175-1179, 2007.

Anatomy, Procedures, Thorax

EAST 2017 #10: A Simple Way To Predict Complications After Rib Fracture?

January 10, 2017 The Trauma Pro Leave a comment

Rib fractures are a common injury, and a very common cause of morbidity. Every time I admit an elderly patient with rib fractures, I debate whether they should go to the ICU or a ward bed. Could there be a more objective way of determining the likelihood of complications, aggressiveness of treatment, and admission unit?

A group at West Virginia University implemented a rib fracture pathway in 2009, and have been collecting data on patients ever since. It was based on the measurement of forced vital capacity (FVC) on admission. This is the total amount of air that can be exhaled during a forced breath.

The authors subdivided their patients into two groups based on the total volume exhaled (<1.5L, and >1.5L). They retrospectively reviewed 6 years of data, looking at specific injuries, complications, and unexpected transfer to ICU. They hypothesized that patients in the highest FVC group would have fewer complications.

Here are the factoids:

There was a nearly even split in groups, with 678 patients who had FVC > 1.5L, and 682 with FVC < 1.5
There were significantly fewer complications and pneumonia, as well as fewer readmissions in the FVC > 1.5 group
Higher FVC was not associated with fewer unexpected transfers to ICU
Length of stay was half as long (4d vs 8d) in the high FVC group, but no p value was provided
The authors conclude that patients with FVC much greater than 1.5 are at lower risk for complications regardless of the number of fractures (???!)
They even suggest that patients with FVC > 1.5 could be discharged from the ED rather than be admitted (!)

Bottom line: Well, it started out good! The abstract showed that the high FVC patients had fewer complications and readmissions. And the length of stay was shorter, although significance was not noted. But the jump to correlating complication risk with number of fractures was not addressed in the abstract. And I can’t quite grasp the leap to suggesting possible discharge from the ED.

FVC may be an inexpensive and simple test to administer in new rib fracture patients. But it’s ability to predict who goes to ICU and who goes home from the ED was not really identified in the study.

Questions and comments for the authors/presenters:

A minor point, but the upper limit was defined as > 1.5L in some parts of the abstract, and > 1.5L in others. Small point, but keep it clean. Make sure all the greater than, less than, and equals signs are consistent.
Was the shorter length of stay significantly different between the groups?
Did you do any stratification by age?
How did you make the conclusion that patients could be sent home from the ED?
And did you do any correlations with your FVC data and the number of fractures? It’s not in the abstract.

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related post:

Reference: Is an FVC of 1.5 adequate for predicting respiratory sufficiency in rib fractures? Paper #4, EAST 2017.

Procedures, Thorax

EAST 2017 #7: Pigtail vs Chest Tube – Does Size Matter?

January 5, 2017 The Trauma Pro Leave a comment

I’ve been somewhat old school when it comes to chest tubes. Unlike some, I don’t believe that you have any control of where a chest tube goes if you are placing it in a closed chest. Only in the OR with an open one. And I’ve got plenty of x-rays to prove it.

And I used to think that chest tube size mattered when dealing with hemothorax. In theory, you need a big tube to get clots out, right?

Well, maybe not! The trauma group at the University of Arizona Tucson has previously done work on using 14 French pigtail catheters in lieu of a full-size tube. They will be presenting their extended experience with this concept at EAST 2017.

They have maintained a prospectively collected database of information on trauma patients with chest tubes for many years. This study focused only on those who had blood in their chest, either hemothorax (HTX) or hemopneumothorax (HPTX). They also looked at trends in their selection of chest drain tubes.

Here are the factoids:

Nearly 500 patients were treated with a tube for HTX or HPTX during the 7 year study period, 2/3 with a chest tube and 1/3 with a pigtail
Pigtails had more fluid drain initially (430cc vs 300cc, significant), and 1 less treatment day (4 vs 5, also significant)
Failure rate and insertion-related complications were the same (about 22% and 6%, respectively)
The group found that their use of pigtails steadily and significantly increased over the years

Bottom line: I’m coming around. The literature does appear to be tilting toward smaller tubes, and this longer-term study helps confirm that. How can this be? Although this is speculation on my part, it probably has to do with the fact that any size tube will drain liquid blood. And probably no size of tube will successfully get all the clot out.

And certainly, smaller tubes are much better tolerated and do not require the degree of sedation that a mega-tube does. The authors suggest that a multi-center trial should be carried out to confirm this. For my part, I’m going to review the literature we have to date and consider modifying my own chest tube policy (see links below).

Questions and comments for the authors/presenters:

Where did you typically insert the pigtails? Anterior chest or classic chest tube position? Was it consistent?
Was/is the selection of tube type an attending surgeon specific choice, or did you implement a policy to direct them?
Did patient injury pattern or body habitus have any part in tube selection?
What about removal failures? That is, how many had to have a tube replaced, and how many went on to require VATS or other surgical procedure for drainage?
I enjoyed this provocative paper!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: A prospective study of 7-year experience of using percutaneous 14-French pigtail catheter for traumatic hemothorax at a Level I trauma – size still does not matter. Quick Shot #4, EAST 2017.

Thorax, Tips, Video

How To: Insert A Small Percutaneous Chest Tube

Video November 16, 2015 The Trauma Pro Leave a comment

This short (10 minute) video demonstrated the technique for inserting small chest tubes, also known as “pigtail catheters.” It features Jessie Nelson MD from the Regions Hospital Department of Emergency Medicine. It was first shown at the third annual Trauma Education: The Next Education conference in September 2015, for which she was a course director.

Please feel free to leave any comments or ask any questions that you may have.

(Source: https://www.youtube.com/)

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