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PubMed1999

Family presence during invasive procedures in the pediatric intensive care unit: a prospective study.

OBJECTIVES: To determine if allowing 1 or both parents to be present during invasive procedures reduces the anxiety that parents experience while their child is in the pediatric intensive care unit; to evaluate if the parent's presence was helpful to the child and parent; and to determine whether this presence was harmful to the nurses or physicians. DESIGN: A prospective study using surveys (5-point Likert scale) of parents of children requiring intubation, placement of central lines, or chest tubes. Additional surveys were completed by bedside nurses to evaluate the effects of parental presence. SETTING: A 12-bed pediatric intensive care unit in upstate New York. PARTICIPANTS: The study population consisted of the parents of 16 children undergoing 1 or more procedures; 7 had undergone intubation, 11 had central lines placed, and 2 had chest tubes placed. The control population consisted of the parents of 7 children undergoing 1 or more procedures; 7 had undergone intubation, 5 had central lines placed, and 3 had chest tubes placed. RESULTS: Parental presence significantly reduced the parental anxiety related to the procedure (P = .005; Mann-Whitney test), but did not change condition-related anxiety (P = 0.9; Mann-Whitney test). Thirteen of 16 parents found their presence helpful to themselves (10 very, 3 somewhat) and the medical staff (11 very); 14 of 16 found their presence helpful to their child (11 very). Fifteen (94%) of 16 parents would repeat their choice to watch. Fifteen (94%) of 16 nurses found parents' presence helpful to the child (9 very) and to the parents (10 very). One nurse found a parent's presence somewhat harmful to nurses and very harmful to the parent. Thirteen (72%) of 18 nurses indicated that allowing parents to observe procedures was an appropriate policy. There were no significant differences noted in response of nurses based on years of experience. CONCLUSIONS: Allowing parental presence during procedures decreases procedure-related anxiety. The implications of such a policy change on physicians and other aspects of pediatric intensive care, including medical education, need further evaluation.

Adolescent↗
PubMed2005

Video-assisted thoracoscopic decompression of tubercular spondylitis: clinical evaluation.

STUDY DESIGN: A prospective, observational study using a novel procedure of video-assisted thoracoscopy and conventional, long spinal instruments for decompression of dorsal tubercular spondylitis. OBJECTIVES: To assess the efficacy of video-assisted thoracoscopic decompression of dorsal tubercular spondylitis and compare it with the published data of classic thoracotomy procedures. SUMMARY OF BACKGROUND DATA: Surgical decompression of dorsal tubercular spine with the transpleural transthoracic method is a standard procedure. It is a major surgery with significant morbidity in terms of blood loss, intensive care unit (ICU) and hospital stay, postoperative incision pain, and chest tube insertion. A procedure that has the potential to achieve comparable recovery in patients with dorsal tubercular spondylitis but with a surgery of lesser magnitude and morbidity has immense potential. METHODS: There were 16 patients with mid-dorsal tubercular spondylitis with paraplegia/paraparesis requiring surgery who were included in the study. Every patient had a recent paradiscal disease at a single level. A soft tissue shadow was visible on plain radiographs of the spine, and conservative treatment for at least 3 weeks had shown no recovery. Patients with obvious respiratory insufficiency and likely to have significant pleural adhesions were excluded from the study. Single lung anesthesia and ipsilateral lung collapse using a double-lumen tube were administered. A 3-portal thoracoscopy approach was used, and conventional but long spinal instruments were used through an open port to decompress the spine. Patients were assessed for blood loss, duration of surgery, postoperative incision pain, duration of chest tube insertion, ICU and hospital stay, and neurologic recovery. Patients were observed for a minimum of 6 months. RESULTS: Of 16 patients, 14 (88%) had good neurologic recovery. In 1 patient, thoracoscopy was abandoned, and open thoracotomy was performed because of persistent bleeding. Another patient did not recover, and anterolateral decompression was performed 10 weeks after thoracoscopy. She recovered subsequently. Other complications included fracture of the sixth rib in 1 patient and breakage of suction tip in another. Adequate tissue biopsy for histopathologic examination could be obtained in all patients. Duration of surgery was 223 minutes (+/-56), blood loss was 497 ml (+/-302), and blood transfusion was required in 3 patients (3 U in 1 and 1 U in 2). Postoperative analgesic (tramadol) was 243 mg (+/-70) for 2-4 days (median 3), median hospital stay was 5.5 days (range 4-9), chest tube requirement was 3 days (range 2-7), and 2 patients were required to stay in the ICU for 1 day each. CONCLUSION: Video-assisted thoracoscopic decompression of tubercular dorsal spondylitis is a viable option to achieve significant neurologic recovery with less morbidity, blood requirement, and hospital stay compared to the open thoracotomy procedures.

Adolescent↗
PubMed1989

[Treatment of spontaneous pneumothorax].

Experience with 300 episodes of spontaneous pneumothorax in 209 patients is reported. The treatment results of two time periods 1980-1983 (A) and 1985-1987 (B) are compared. During the second period the diagnostic work-up was much more extensive and included pleurography, CT-scan and thoracoscopy. This resulted in a more differentiated therapy and a reduction in the recurrence rate from 41% to 22%. Among the different modes of treatment chest-tube drainage alone had the worst results with a 44% rate of early and late recurrence. Better results were obtained with pleurodesis using fibrin adhesive either through a pleural catheter (24%) or thoracoscopically (13%). Operative treatment had the lowest recurrence rate (4%). In the primary treatment of spontaneous pneumothorax chest-tube drainage had a recurrence rate of 33% and catheter-pleurodesis with fibrin adhesive of 18% while no relapse could be observed in the group treated by thoracoscopy or operation. In the treatment of recurrent pneumothorax chest-tube drainage alone is unsuitable because of a failure rate of 64%. Catheter pleurodesis also had a high rate of recurrence (30%). The best results were again obtained by thoracoscopic (19%) and operative treatment (4%). On the basis of the described experience an individualized approach to the treatment of spontaneous pneumothorax is recommended.

Adolescent↗
PubMed1984

Incidence and significance of early pericardial effusions after cardiac surgery.

Echocardiography (echo) is frequently performed postoperatively to evaluate patients suspected of having cardiac tamponade or pericarditis. The overall incidence and significance of echocardiographic pericardial effusions (PE) early after cardiac surgery are unknown. Therefore, M-mode and 2-dimensional (2-D) echo were used to study 39 stable patients 4 to 10 days after cardiac surgery. Twenty-two patients (56%) had unequivocal moderate-to-large PEs. PEs were identified on serial chest x-rays in only 6 patients. PEs were significantly more common after heavy postoperative bleeding, and occurred in 16 of 19 patients with more than 500 ml of total chest tube output; only 6 of 20 patients with chest tube output less than 500 ml had PE. There was no correlation of PE by echo with pericardial friction rubs, chest pain or atrial arrhythmias. Elevated erythrocyte sedimentation rate did not correlate with PE by echo or clinical pericarditis. In 1 of 22 patients with PE, tamponade developed, and the patient required reoperation on day 5; the other 21 were discharged without related therapy. Thus, early postoperative PEs are common and related to postoperative bleeding. Because they do not correlate with symptoms of pericarditis and rarely lead to tamponade, their identification is usually of limited clinical significance.

Adult↗
PubMedDate not supplied

Intraoperative identification and effective "blood patch" prevention of persistent air leak in lung resections.

Persistent air leak (PAL) is the most common complication after lung resection, requiring additional treatments and hospital stay. Intraoperative prevention of PAL is usually left to the surgeon's subjective judgement, with inconsistent results. The aim of the study was to establish systematic, reproducible quantification of air leaks at thoracotomy in order to identify those which are potentially persistent, to be preventively treated by intraoperative "blood patch" pneumo-stasis. In a consecutive series of 570 lung resections, parenchymal suture air tightness was tested intraoperatively at end-inspiratory pressure intervals from 15 to 35 cm H2O. Air leaks at 15 cm H2O (n=40) were considered too critical, while air escape beyond 30 cm H2O (n=437) was deemed quickly self-sealing postoperatively; these conditions were managed by further surgery and standard chest tubes only, respectively. Air leaks between 16 and 30 cm H20 (n=93) were assumed to be the main source of postoperative PAL and were preventively treated with 50 cc of blood left in the cavity for 3 hours after closing the thoracotomy. Chest tubes were set up so as to avoid tension pneumothorax or occult bleeding. No early or late major complications were related to the intraoperative "blood patch" procedure. The cumulative incidence of PAL was 1.4%, most of which (6/8) belonging to the group leaking air in the 16-30 cm H2O pressure interval. In contrast, the PAL rate in the 437 patients reputed to be at low risk was 0.2%. The overall mean hospital stay was 7.2 days, the mean duration of chest tube duration 3.5 days, and the complication rate 15%. According to our retrospective data, air leaks occurring between 16 and 30 cm H2O of pressure in the intubated lung were identified as carrying the highest risk of becoming persistent postoperatively; intraoperative "blood patch" pneumo-stasis is a convenient and successful preventive method to minimize PAL occurrence in this group of patients.

Adolescent↗
PubMed1996

Fluid resuscitation with Haemaccel vs. human albumin following coronary artery bypass grafting.

Several colloid preparations are available for fluid resuscitation following heart surgery. We conducted a randomized prospective trial to compare a polygeline infusion versus human albumin with respect to hemodynamic and pulmonary function. 20 patients were randomly assigned to receive either Haemaccel or human albumin using a standardized protocol for the first 8 hours following heart surgery. The double-indicator dilution method was used to measure total blood volume index (TBVI), intrathoracic blood volume index (ITBVI) and extravascular lung water index (EVLWI) three times during the study period. Pulmonary shunt fraction, time on ventilator, and chest tube drainage were measured as well. Hemodynamic stability was achieved in both groups throughout the study period, as judged from mean arterial pressure, pulmonary capillary wedge pressure, and cardiac index. ITBV and TBVI were higher in the albumin group, although only significant at 4 hours for TBVI. There was no significant difference in EVLWI, pulmonary shunt fraction, and time on mechanical ventilation. Likewise, chest tube drainage was not significantly different in both groups. Haemaccel is effective in maintaining hemodynamic stability following heart surgery without ill effects of lung function or chest tube drainage. Treatment costs are substantially lower compared to human albumin.

Aged↗
PubMedDate not supplied

Bleeding post coronary artery bypass surgery. Clopidogrel--cure or culprit?

BACKGROUND: Clopidogrel, in addition to aspirin, has become a common treatment of acute coronary syndrome and for stent thrombosis prevention, when given before percutaneous transluminal coronary angioplasty. However, some patients turn out to have surgical coronary artery disease and are sent for coronary artery bypass grafting (CABG) where the irreversible effect of aspirin and clopidogrel on platelet function becomes a concern. This study was conducted to evaluate the role of preoperative use of clopidogrel in bleeding complications after CABG. MATERIAL AND METHODS: A total of 462 patients who underwent CABG between 2001 and 2003 were studied as a retrospective cohort. Comparison was made between patients who had taken clopidogrel within 7 days of surgery (n=162), and those who were not exposed to clopidogrel (n=300). Chest tube output and bleeding index (a modified TIMI criteria), were the primary outcomes measured. RESULTS: Our data showed that patients taking clopidogrel within 7 days of surgery have a higher bleeding index than those who were not exposed to the drug (p = 0.024). Similarly, chest tube output was significantly higher in those who were exposed to clopidogrel within 7 days compared to those not taking clopidogrel (p = 0.01). To further dissect this relationship, we divided our population into three categories. We found that patients taking clopidogrel within 3 days prior to CABG (immediate exposure) have a higher bleeding index and TIMI major bleeding than either patients taking the drug between 3 and 7 days (recent exposure) or patients not exposed to clopidogrel at all (p = 0.009 and 0.03 respectively for inter-groups comparison). The same was true for chest tube output (p = 0.05 and 0.01 respectively). CONCLUSION: Clopidogrel increased the risk of post-CABG bleeding if taken within three days prior to surgery but not if taken before that.

Clopidogrel↗
PubMed1987

Pleural fluid pH: diagnostic, therapeutic, and prognostic value.

Measurement of pleural fluid pH has diagnostic, therapeutic, and prognostic implications in exudative pleural effusions (Table II). A parapneumonic effusion with a pleural fluid pH below 7.2 indicates an empyema is forming which necessitates chest tube drainage in all patients, whereas a pleural fluid pH over 7.3 does not require drainage. If the pH of a parapneumonic effusion is 7.2 to 7.3, serial pleural fluid pH measurements with clinical observation will help to determine the need for chest tube drainage. A pleural fluid glucose level of below 60 mg/dl and a lactic dehydrogenase level over 1,000 IU/dl in conjunction with a pleural fluid pH of 7.2 to 7.3 indicate an impending empyema. These findings are consistent with our clinical experience in patients with parapneumonic effusion. Tuberculous pleural effusions had a pleural fluid pH below 7.4 in all reported patients. This pH may be of value in distinguishing tuberculous pleural effusions from recent malignant effusions, which tend to have a higher pleural fluid pH, particularly if used in conjunction with other pleural fluid values, cell counts, and other clinical parameters. In patients with malignant pleural effusions, a pH of less than 7.3 is usually seen in those effusions present for several months and is associated with a lower glucose level and a higher white cell count and lactic dehydrogenase level. Results of cytologic study of the pleural fluid and pleural biopsy are often positive, there is poor response to sclerosing agents, and the prognosis is poor. A rheumatoid pleural effusion most often has a pleural fluid pH below 7.3. A pleural fluid pH below 6 is seen almost exclusively in esophageal rupture but rarely with empyemas, whereas a pleural fluid pH below 7 occurs in esophageal rupture, empyema, and rheumatoid pleural effusions. In pleural effusions secondary to congestive heart failure, the pH is almost always greater than 7.4 unless systemic acidemia coexists, in which case the pleural fluid pH is within 0.04 units of the simultaneous arterial pH. The major value of pleural fluid pH is to determine the need for chest tube drainage in parapneumonic effusions and to determine the response to sclerosing agents in patients with malignant pleural effusions. As with all diagnostic tests, the results should be interpreted in the context of other diagnostic tests of the pleural fluid and clinical aspects before diagnostic or therapeutic decisions are made.

Arthritis, Rheumatoid↗
PubMed1994

Advanced trauma life support program increases emergency room application of trauma resuscitative procedures in a developing country.

Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990--post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The frequency of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access (i.v.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies (%) were 83.5 vs. 65.3 for ET, 97.3 vs. 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. In the emergency room these frequencies (%) were 26.1 vs. 36.4 for ET, 98.8 vs. 98.7 for i.v., 11.0 vs. 97.1 for Foley, 3.2 vs. 95.9 for NG, and 3.9 vs. 95.2 for CT. The differences in the application of these life saving procedures between the pre-ATLS and post-ATLS periods were statistically significant (p < 0.05) except i.v. access, which showed no difference between the pre-ATLS and post-ATLS groups. Of the patients with severe chest injuries (AIS > or = 3) 87.7% had chest tubes post ATLS (94.4% in ER) compared with 48.1% pre ATLS (3.2% in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Catheterization, Peripheral↗
PubMed2001

Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study.

HYPOTHESIS: It is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality. DESIGN: A retrospective case series. SETTING: Five urban trauma centers. STUDY SELECTION: Patients undergoing urgent thoracotomy (within 48 hours of injury) for hemorrhage (excluding emergency department thoracotomy). DATA EXTRACTION: Respective registries identified patients who underwent urgent thoracotomy. Injury characteristics, initial and subsequent chest tube outputs, time before thoracotomy, and outcomes were evaluated. MAIN OUTCOME MEASURE: Death. RESULTS: One hundred fifty-seven patients (36 with blunt and 121 with penetrating injuries) underwent urgent thoracotomy for hemorrhage between January 1, 1995, and December 31, 1998. Mortality correlated with mean (+/- SD) Injury Severity Score (38 +/- 19 vs 22 +/- 12.6 for survivors; P<.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; P<.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetrating-injured patients (4.4 +/- 9.0 h vs 1.6 +/- 3.0 h; P =.02) and also had a greater total chest tube output before thoracotomy (2220 +/- 1235 mL vs 1438 +/- 747 mL; P =.001). CONCLUSIONS: The risk for death increases linearly with total chest hemorrhage after thoracic injury. Thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours, regardless of injury mechanism.

Adult↗
PubMed2000

Outpatient pleurodesis of malignant pleural effusions using a small-bore pigtail catheter.

STUDY OBJECTIVE: Patients with symptomatic malignant pleural effusion are usually treated with large-bore chest tube placement and pleurodesis requiring > or = 3 days of hospitalization. We sought to demonstrate the feasibility of ambulatory drainage and sclerosis using a small-bore pigtail catheter in patients with malignant pleural effusions. We reasoned that this approach would improve symptoms and quality of life at a reduced cost. METHODS: A 14F pigtail catheter was percutaneously inserted into the pleural space and connected to a closed gravity-drainage bag system. The patients were instructed in the use of the drainage system and discharged to return for sclerosis with 4 g of talc after the drainage was < 100 mL/24 h. Patients were graded for dyspnea and performances status using the Eastern Cooperative Oncology Group score (ECOG) and baseline and transitional dyspnea index score (BDI-TDI) before tube placement and again at 30 days. Radiographic response was graded as total response, partial response, or failure. Telephone follow-up was initiated when the patient could not return for evaluation. RESULTS: Ten ambulatory women, ages 41 to 79 years, were enrolled. The chest tube was left in place from 1 to 10 days, draining a mean of 2,956 mL (1,685 to 6,050 mL). Only two patients were unable to undergo sclerosis owing to catheter dislodgment and minimal drainage. Six reported symptomatic improvement at 30 days confirmed by TDI and ECOG scores in four of six. One with a prior history of a lobectomy was found to have a chylous pleural effusion and experienced a hydropneumothorax, for which sclerosis was unsuccessful. One died in hospital on day 26 after sclerosis despite radiographic resolution. Of the four patients who had improved dyspnea and functional status by TDI and EGOG scores, radiographic response was complete in three and partial in one. Two of the six were not able to return for follow-up because of weakness but reported improvement by telephone inquiry. CONCLUSION: Ambulatory sclerosis of malignant effusion using a small-bore catheter is a feasible alternative to inpatient sclerosis with a large-bore chest tube, especially in patients with strong preferences for outpatient care.

Adult↗
PubMed2001

Blood loss in elective coronary artery surgery: a comparison of centrifugal versus roller pump heads during cardiopulmonary bypass.

OBJECTIVES: To compare the effects of centrifugal pumps versus roller pumps for cardiopulmonary bypass (CPB) in routine cardiac surgery on hematologic parameters in the context of modern practice. DESIGN: Prospective, randomized, partially blinded. SETTING: University teaching hospital. PARTICIPANTS: Elective coronary artery surgery patients (n = 113) INTERVENTION: Patients were randomized to be perfused with either a roller head (group R, n = 56) or a centrifugal head (group C, n = 57) pump. Patients received epsilon-aminocaproic acid before and during CPB. Core body temperatures were allowed to drift down to approximately 32 degrees C. MEASUREMENTS AND MAIN RESULTS: Postoperative chest tube blood loss, blood product requirements, hemoglobin, and platelet counts were assessed. There were no significant differences in preoperative or intraoperative parameters, including CPB time, complexity of procedure, and minimum core temperature. There were the expected reductions in hemoglobin and platelet levels post-CPB in both groups to a similar extent. Chest tubes remained in situ for similar durations, and the final volume of drainage was not significantly different (group C, 1300 +/- 92 mL; group R 1117 +/- 83 mL; p = 0.14). Allogeneic blood was given to 23% of patients in group C and 18% in group R (p = 0.63). Aspirin was associated with an increase in early chest tube drainage. CONCLUSIONS: In this surgical and perfusion environment, the authors were unable to show an advantage, from the hematologic point of view, in the routine use of a centrifugal pump head in elective coronary artery surgical patients. The use of antifibrinolytic agents and mild hypothermia may have effects on hemostasis that overshadow the influence of pump head design in this type of surgery.

Aged↗
PubMedDate not supplied

Pharmacologic C5-complement suppression reduces blood loss during on-pump cardiac surgery.

BACKGROUND: Inflammation contributes to morbidity following on-pump cardiac surgery. Complement activation during cardiopulmonary bypass has been associated with the postoperative bleeding and tissue injury. This study examines the pharmacology and impact on blood loss of complement C5 suppression with pexelizumab in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: Pexelizumab, a humanized monoclonal antibody single-chain fragment that binds to the human C5 complement component, was studied in a Phase II multicentered clinical trial. CABG (n = 800) and CABG with concomitant valve surgery (n = 114) patients were evaluated. Patients were randomized to either: pexelizumab bolus (2.0 mg/kg) + placebo infusion; pexelizumab bolus (2.0 mg/kg) + pexelizumab infusion (0.05 mg/kg/hour for 24 hours); or placebo bolus + placebo infusion. Pharmacology, chest tube drainage, and transfusion requirements were assessed. RESULTS: Mean maximum pexelizumab serum concentration was similar for bolus and bolus + infusion-treated patients. Complement-dependent serum hemolytic activity was completely suppressed within 1 hour following pexelizumab bolus, however, suppression was maintained for a longer duration in the bolus + infusion compared to the bolus-only treated patients. A reduction in chest tube drainage was observed for all pexelizumab-treated patients, although transfusion of blood products was similar across all study groups. CONCLUSION: Pexelizumab administration inhibits complement-dependent hemolytic activity and is associated with a reduction in postoperative chest tube drainage in patients undergoing cardiac surgery requiring cardiopulmonary bypass. Further, clinical studies are needed to assess the value of complement attenuation in this setting.

Aged↗
PubMed1999

Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome.

OBJECTIVE: Despite modern diagnostic methods and appropriate treatment, pleural empyema remains a serious problem. Our purpose was to assess the feasibility and efficacy of the video-assisted thoracoscopic surgery in the management of nontuberculous fibrinopurulent pleural empyema after chest tube drainage treatment had failed to achieve the proper results. METHODS: We present a prospective selected single institution series including 45 patients with pleural empyema who underwent an operation between March 1993 and December 1996. Mean preoperative length of conservative management was 37 days (range, 8-82 days). All patients were assessed by chest computed tomography and ultrasonography and underwent video-assisted thoracoscopic debridement of the empyema and postoperative irrigation of the pleural cavity. RESULTS: In 37 patients (82%), video-assisted thoracoscopic debridement was successful. In 8 cases, decortication by standard thoracotomy was necessary. There were no complications during video-assisted thoracic operations. The mean duration of chest tube drainage was 7. 1 days (range, 4-140 days). At follow-up (n = 35) with pulmonary function tests, 86% of the patients treated by video-assisted thoracic operation showed normal values; 14% had a moderate obstruction and restriction without impairment of exercise capacity, and no relapse of empyema was observed. CONCLUSIONS: Video-assisted thoracoscopic debridement represents a suitable treatment for fibrinopurulent empyema when chest tube drainage and fibrinolytics have failed to achieve the proper results. In an early organizing phase, indication for video-assisted thoracic operation should be considered in due time to ensure a definitive therapy with a minimally invasive intervention. For pleural empyema in a later organizing phase, full thoracotomy with decortication remains the treatment of choice.

Adolescent↗
PubMed1981

Systematic approach to traumatic hemothorax.

We reviewed 395 patients with isolated hemo- or hemopneumothorax from penetrating injuries. All patients were treated with immediate insertion of a chest tube and drainage of various amounts of blood up to 1,500 ml. Forty-five patients (11 percent) were in hemorrhagic shock on admission to the hospital emergency room, and all were resuscitated with volume replacement. Twenty-one patients (5.3 percent) whose blood pressure decreased again were found on exploration to have lacerated internal mammary or intercostal arteries or major lung lacerations extending into the hilus. All other patients were treated aggressively with chest tubes, aspiration of residual blood and fibrinolytic enzymes until the lung was fully expanded. We conclude that the clinical course of patients with hemothorax after insertion of a chest tube should determine whether exploration is necessary or whether nonoperative treatment should continue.

Drainage↗
PubMed2003

Thoracotomy for blunt trauma: traditional indications may not apply.

The indications for performing as urgent thoractomy after trauma are based on the criteria used for penetrating injuries. However, few data are available on the use of these indications for patients with blunt injuries. In a retrospective study (June 1996 to July 2001), we compared the indications of urgent thoracotomy after blunt injury and penetrating injury in patients who underwent thoracotomy within 24 hours of hospital admission at our institution. Patients with blunt aortic injuries or emergency department thoracotomies were excluded from evaluation. Fifty-nine patients were identified (37 penetrating injuries, 22 blunt injuries). Blunt trauma victims had a higher mortality rate than penetrating trauma victims (73% vs. 22%). Chest tube output was the indication for nontherapuetic thoracotomy in 5 patients with blunt injuries whereas this occurred in only 1 penetrating injury victim (P = 0.04). All 5 blunt injury patients underwent a prior procedure and were coagulopathic when thoracotomy was performed. In conclusion, thoracotomy following blunt trauma is associated with a high rate of mortality. The rate of nontherapeutic exploration is increased when chest tube output is the indication for thoracotomy after blunt trauma. Since the majority of such patients have multicavitary injuries that require prior operation and are commonly coagulopathic, caution should be exercised when deciding whether to proceed with thoracotomy based solely on chest tube output.

Accidents, Traffic↗
PubMed1997

Management of a giant fluid-filled bulla by closed-chest thoracostomy tube drainage.

A 53-year-old man was admitted to the hospital for management of pneumonia and a giant fluid-filled bulla. He appeared acutely ill and had persistent fever despite prolonged therapy with parenteral antibiotics and aggressive bronchial drainage. Percutaneous placement of an 8.5F catheter into the bulla enabled drainage of both fluid and air within the bulla and led to resolution of his symptoms within 24 h. This report demonstrates that drainage of giant fluid-filled bullae may lead to rapid resolution of symptoms and describes a novel management technique for this condition.

Acute Disease↗
PubMed2002

Prevention of postoperative pneumothorax in patients undergoing cardiac surgery.

BACKGROUND: Postoperative pneumothorax is a potentially fatal complication occurring in approximately 1.4% of patients after cardiac surgical procedures. Prevention of this complication could save lives, morbidity, and money in this large patient population. This study was undertaken to evaluate the effectiveness of a very simple technique to prevent this complication. METHODS: One thousand three hundred and ninety-seven consecutive adult patients undergoing cardiac surgical procedures performed by the author were evaluated. In each patient a 3-cm opening in the mediastinal pleura of any unopened hemithorax was performed to allow communication of the pleural space with the mediastinum. When a hemithorax had been opened for internal mammary harvesting, the usual pleural drain was inserted. A standard, straight mediastinal tube was then placed in routine fashion without any additional tube placement or unusual positioning. The essence of the approach was the establishment of communication of both pleural spaces with the mediastinum in such a way that any air exiting the lung would be able to evacuate through the mediastinal tube. RESULTS: One patient with obstructive lung disease developed a loculated basilar pneumothorax that was treated with chest tube placement. Two patients required maintenance of mediastinal tube drainage for persistent air leak for 7 and 9 days, respectively. No other patients required chest tube placement for pneumothorax. No patient experienced any complication that could be attributed to the small opening in the pleural space. CONCLUSIONS: The technique herein described is a safe and effective method for prevention of postoperative pneumothorax. It adds nothing to the cost of the surgical procedure. The author would recommend that this technique be adopted as a surgical routine.

Adult↗