Tag Archives: pigtail

What The Heck? Pigtail Catheter Chest Tube – The Answer

I previously described a trauma patient who had a pigtail type chest tube inserted with some odd CT findings after insertion:

So what is wrong in this picture? Well, the catheter has been inserted into the spleen! This can occur if it is inserted too low, or if there are adhesions between lung and chest wall or diaphragm.

How can it be avoided? Make sure that the insertion point is no lower than the 5th intercostal space. This is the level of the nipple in a male. And depending on what type of kit you use, be careful! Some are based on Seldinger technique, which would seem to be a bit safer. Others use a small trochar, which can be inserted a little too deeply at times. Note that this complication can occur with any kit, and can also occur when using a standard tube and open insertion technique.

Does a pigtail tube even work for hemothorax? There’s some debate about this. Traumatic hemothorax is not defibrinated like a medical one. Thus, there are frequently clots present which may not fully evacuate through a standard chest tube, let alone a tiny one. Thus, I don’t recommend a pigtail for acute traumatic hemothorax.

How should I manage this issue? Obviously, this tube needs to come out. And assuming that the initial indication for the tube is still present, a better one needs to be inserted. Dont’ pull it out yet! First, look at the vital signs. If there is significant bleeding and/or vitals are not normal, an immediate trip to the operating room is in order. In this case, the patient will likely lose their spleen.

If vital signs are stable, book both an interventional radiology suite and an OR. Or better yet, use a hybrid room. Have the radiologist obtain a baseline angiogram, and position a catheter in the main splenic artery. Incrementally remove the pigtail, hand injecting a small amount of contrast each time. If extravasation is noted at any time, the radiologist can then attempt to embolize. If selective embolization isn’t successful, then the main splenic artery should be embolized. If embolization doesn’t work, or vital signs deteriorate at any time, the surgeon should immediately proceed to laparotomy. Attempts at splenic salvage will probably not be successful.

Finally, insert a new, conventional chest tube using finger guidance. Don’t make the same mistake twice! And by the way, this works for pigtails in the liver, too. They are less likely to bleed significantly when withdrawn, and obviously the radiologist can only used selective embolization if they do.

What The Heck? Pigtail Catheter Chest Tube

Here’s a case to make you think!

A patient arrives after being t-boned in his driver side door. He complains of left sided chest and abdominal pain. Chest x-ray shows a modest left hemopneumothorax. The decision is made to insert a pigtail type chest tube, and this is carried out in your trauma bay. It is uneventful, and a small amount of blood but no air is returned. The pelvis x-ray is unremarkable

The patient is then taken to CT, where an abdomen/pelvis scan with contrast is performed. This interesting slice is noted. What the heck?!

Here are my questions:

  • What is wrong in this picture?
  • How could it have been avoided?
  • Does a pigtail chest tube work for hemothorax?
  • How should this issue be managed, and where?

I’ll address these questions in my next post, and more!

Image source: internet

How To: Insert A Small Percutaneous Chest Tube

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.

Related posts:
Pigtail catheters vs regular chest tubes
Tips for regular chest tubes 

Conventional Chest Tube vs Pigtail Catheter

Traditionally, hemothorax and pneumothorax in trauma has been treated with chest tubes. I’ve previously written about some of the debate regarding using smaller tubes or catheters. A paper that will be presented at the EAST meeting in January looked at pain and failure rates using 14Fr pigtail catheters vs 28Fr chest tubes.

This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.

The following interesting findings were noted:

  • Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
  • Tube site pain was significantly less with the pigtail
  • The failure rate was the same (5-10%)
  • Complication rate was also the same (10%)
  • Time that the tube was in, and hospital stay was the same

Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.

Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, 2013.

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

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.