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PubMed2004

Impact of clopidogrel in coronary artery bypass grafting.

OBJECTIVE: Clopidogrel has become the standard of care to prevent thrombotic complications following cardiological interventions, in particular intracoronary stenting. In addition, patients with aspirin intolerance and those with carotid and peripheral vascular disease are also increasingly treated with clopidogrel. Platelet inhibition may become a concern for hemostasis in patients treated with clopidogrel who need emergency and undelayed surgery. METHODS: We prospectively analyzed the intra- and postoperative outcome of 505 consecutive patients who underwent isolated CABG and compared two groups: those with clopidogrel exposure until 72 h prior to surgery (n = 136) with those without exposition to clopidogrel (n = 369). Patients undergoing emergency surgery because of failed PTCA and cardiogenic shock, associated valvular surgery, redo-CABG, and those with additional platelet IIb/IIIa receptor inhibitor exposure were excluded. Patients who received aspirin and/or heparin treatment prior to surgery were not excluded. RESULTS: Patients who received clopidogrel had a higher prevalence of angina class III or IV (67 vs 39%, P < 0.01), received more often revascularization within 48 h (41 vs 14%, P = 0.02), and had received more frequently stenting (57 vs 13%). Chest tube drainage was significantly increased during the first 24 h following CABG in the group of patients who had clopidogrel treatment (1485 vs 780 ml, P = 0.003) These patients also required more transfusion of platelets and fresh frozen plasma. Overall re-exploration rate because of bleeding was significantly higher in the clopidogrel group (5.9 vs 1.2%, P < 0.01). Platelets transfused before chest closure had a beneficial effect on preservation of the hemostasis. CONCLUSIONS: Clopidogrel exposure 3 days or less prior to CABG surgery significantly increases the risk of postoperative bleeding, the need for perioperative transfusion and the incidence of re-exploration. Surgery should be performed using standard heparinization and anti-fibrinolytic strategies but aggressive correction of platelets dysfunction is required before chest closure.

Aged↗

PubMed2004

Routine X-ray control of upper central venous lines: Is it necessary?

BACKGROUND: Insertion of central venous catheters (CVCs) is a procedure associated with a varying risk of complications, depending on the setting and the skill of the clinician who undertakes the procedure. The aim of this study was to monitor the complication rate of CVC insertion and evaluate the value of routine chest X-ray control. METHODS: Anesthesiologists at eight hospitals filled in a questionnaire immediately after insertion of a CVC. The post-procedural clinical evaluation, including expected complications, was compared to actual radiological findings. Chest X-ray was ordered by the anesthesiologist, and described by staff radiologists. RESULTS: The clinicians had from 2 months to 30 years of experience as anesthesiologists, and trainees inserted 34% and specialists 66% of the catheters, using landmark techniques. Over a period of 2 months, 473 CVC-insertion procedures were included in the investigation. Two patients (0.4%) had a pneumothorax: one was among the 11 cases in which the clinician suspected complications after the procedure, and another was found in a high-risk patient 13 h after CVC insertion. Both patients were treated successfully with chest tubes. The favorite approach was right vena jugularis interna with 324 (69%) catheters; of these patients one had a pneumothorax, catheter-tip placement was correctly predicted in 317 (97%), and no catheters were repositioned. CONCLUSION: In the hands of trained clinicians, insertion of CVCs is a safe procedure. We found no value of routine X-ray control and omission of routine chest X-ray must be considered.

Aged↗

PubMed1991

Utility of pleural fluid analysis in predicting tube thoracostomy/decortication in parapneumonic effusions.

Recommended criteria for surgical drainage of parapneumonic effusions include evidence of frank purulence, a glucose level less than 40 mg/dl, a pH of less than 7.00, or an LDH greater than 1,000 IU/L. To test the utility of these criteria, we reviewed the three-year experience of three Rochester, NY, hospitals. We identified 133 patients undergoing thoracentesis for putative parapneumonic effusions. Of 91 patients with neutrophilic exudates, 43 met one or more criteria for tube thoracostomy: 48 did not. Twenty-one of the 43, including 9 with frank empyema, underwent immediate drainage. Of the 22 who did not, 11 eventually required tube thoracostomy and/or decortication. Of the 48 not meeting any of the criteria, 7 also came to surgery. Using whether the patients eventually underwent surgery as a measure of outcome, we calculated for those patients not undergoing immediate drainage the sensitivity, specificity, positive predictive values, and negative predictive values for each of the criteria. The four criteria have relatively high specificity ranging from 82 to 96 percent, but have low sensitivity varying from only 18 percent for a positive Gram stain to 53 percent for a fluid LDH greater than 1,000 IU/L. We conclude that these criteria have limited usefulness in predicting the need for eventual chest tube drainage/decortication. Patients not meeting the criteria require close follow-up as well.

Chest Tubes↗

PubMed1992

Adult empyema in Zaria, Nigeria.

The clinical records of 41 adult patients who were treated for empyema thoracis at the ABU Hospital, Zaria from 1974 to 1986 have been reviewed. Twenty six (63%) of the patients were younger than 34 years. Bacterial pneumonia, pulmonary tuberculosis and chronic bronchitis were the underlying illnesses in 32 (78%) while advanced malignancies were present in two others. Gram-negative bacilli were as important as the gram-positive cocci as causative agents in the 16 patients whose pleural aspirates were culture-positive. Closed chest tube drainage was most often effective when combined with antibiotics. Overall, 5 patients died, 2 absconded, 34 were discharged home but the default rate from the follow up clinic was high.

Adolescent↗

PubMed1991

[Pleural empyema--rational diagnosis and therapy].

A pyothorax is a relatively rare occurrence in a general hospital and is posing a number of problems. Among these the long mean duration of hospitalisation is of note lasting 47 days for 24 patients at our clinic. The course and the mortality rate are influenced by early detection and judicious use of interdisciplinary treatment. Small effusions accompanying pneumonia are frequent and likely to disappear after treatment of the underlying disease. In these instances a precipitate punction may lead to secondary infection. In case of a sterile punctate the pH value and consideration of glucose and LDH values determine further measures. Computed tomography is of great value since it yields decisive information not available from conventional radiography. If the empyema is not segregated in compartments a closed drainage with a large caliber chest-tube ist the method of choice. Limited thoracotomy is advised when several empyema chambers develop after short duration of the illness. Persistent disease or widespread scarring necessitate decortication in most cases.

Adolescent↗

PubMed1995

Primary gas-containing mediastinal abscess in a diabetic patient.

A case of primary gas-containing mediastinal abscess is reported. Mediastinal widening was seen on the chest radiograph of a diabetic patient who presented with nonspecific symptoms of shortness of breath and abdominal pain of 3 days' duration. The diagnosis of primary gas-containing mediastinal abscess was established by the characteristic findings of computed tomography and exclusion of all the etiological possibilities. The patient was treated by closed chest tube drainage and antibiotic therapy with an uneventful outcome. Primary gas-containing mediastinal abscess should be included in the differential diagnosis when treating a diabetic patient with mediastinal widening.

Abscess↗

PubMed1991

[Pneumothorax in cystic fibrosis].

Longer life expectancy for patients with cystic fibrosis (CF) has resulted in an increased incidence of pneumothorax (PT), which occurs in advanced stages of CF. This study is based on 276 patients with CF followed up between 1974 and 1989 at the Department of Pediatrics, University of Berne, Switzerland. 23 children or adolescents (10 boys and 13 girls) experienced 51 events of PT, 18 of which were tension pneumothoraces. The average age at first episode was 15.6 years. The long-term success rates of the four different therapeutic modalities used were 24% for observation, 9% for pleural suction drainage only, 75% for quinacrine sclerosis and 90% for open thoracotomy. Sclerosis was associated with fewer complications and shorter hospital stays than thoracotomy. We therefore conclude that, following initial evacuation of the PT using a chest tube, quinacrine sclerosis should be considered as primary prophylaxis for recurrent PT. Only in 3 of the 23 patients did the course of the basic disease deteriorate substantially following PT, and there was no death related to the PT episodes.

Adolescent↗

PubMed1993

Video-assisted thoracoscopic resection of pulmonary metastases.

Pulmonary lesions in patients with malignancy often require resection to provide prognostic information and to dictate further therapy. Metastasectomy may also favorably influence survival in select patients with favorable tumor histologies. Seventy-two patients with a history of malignancy and new lung lesions identified by high resolution computed tomography underwent thoracoscopic resection. The operative approach was with standard techniques using two or three trocar sites. Preoperative needle localization was used in 13 patients with small lesions that were not immediately subpleural. All target lesions were identified at thoracoscopy. Exploratory thoracoscopy was followed by parenchymal sparing wedge resection with the endoscopic stapler, the neodymium:yttrium-aluminum garnet laser, or both. Histologic analysis revealed metastatic disease in 63 patients and benign disease in 9 patients. The mean diameter of the lesions was 1.6 cm. The mean duration of chest tube drainage and postoperative hospital stay were 2.1 and 4.1 days, respectively. Thoracoscopic resection appears to be a valid approach for diagnostic resection of presumed metastases. The role of thoracoscopy in therapeutic metastasectomy remains to be defined.

Chest Tubes↗

PubMed1999

Techniques of pneumonectomy. Drainage after pneumonectomy.

After most pneumonectomies, the pleural space can be safely closed without drainage. If a chest tube must be used, a balanced drainage system is recommended. This article specifically addresses some of the controversial issues in the early management of the postpneumonectomy space. It also describes the indications, advantages, and disadvantages of drainage and the methods commonly used for this purpose.

Chest Tubes↗

PubMed1995

The intraoperative use of Amicar to reduce bleeding associated with open heart surgery.

In an effort to reduce morbidity associated with transfusion of blood products, Amicar is used as a prophylactic inhibitor of hyperfibrinolysis associated with diffuse perioperative bleeding in patients undergoing open heart surgery. Previous studies indicate a significant reduction of intraoperative and postoperative bleeding in patients receiving Amicar during open heart surgery. Fifteen historical controls who did not receive Amicar were compared to 15 nonrandomized, prospective patients who received Amicar and who underwent open heart surgery by the same surgeon. The study found a significant reduction in postoperative chest tube output for the group receiving Amicar, as well as a reduction in perioperative blood product transfusion in patients who received Amicar. One patient in the Amicar group experienced a thrombotic event.

Aged↗

PubMedDate not supplied

Pleural drainage after repair of tetralogy of Fallot.

Prolonged pleural effusion after congenital heart surgery results in extended hospitalization. Pleural drainage was evaluated in 39 consecutive patients undergoing repair of tetralogy of Fallot, to identify risk factors for persistent pleural effusion. Duration and amount of drainage was examined by the Kaplan-Meier method and risk factors were evaluated by univariable and multivariable analyses. Median time of pleural drainage was 6.1 days, range 3 to 42 days. Duration of pleural drainage correlated with length of hospital stay (p < 0.0001). Postrepair right atrial pressure (p = 0.018) and preoperative hemoglobin (p = 0.035) were risk factors for persistent drainage. The presence of a previous right thoracotomy reduced drainage duration (p = 0.034). Prolonged mechanical ventilation increased the average daily volume of effusion (p < 0.0001). In conclusion, prolonged pleural effusion is an important morbidity factor after repair of tetralogy of Fallot. Bilateral chest tube insertion is indicated in patients with high preoperative hemoglobin and elevated postrepair right atrial pressure. Right thoracotomy is the preferred surgical approach when a preliminary palliative shunt is required.

Adolescent↗

PubMed1991

Pneumoscrotum after spontaneous pneumothorax with air leak.

A case of pneumoscrotum associated with a chest wall air leak following placement of a chest tube for spontaneous pneumothorax is reported. The patient recovered uneventfully once the air leak surrounding the tube was successfully closed at the entry wound. Two previous cases have described pneumoscrotum occurring after colonoscopy and after diagnostic peritoneoscopy. All 3 (previous and current) cases report the associated development of subcutaneous and retroperitoneal emphysema, which provides a possible etiological mechanism for this entity.

Chest Tubes↗

PubMed1994

Resolution of hepatic hydrothorax after transjugular intrahepatic portosystemic shunt (TIPS) placement.

A 59-year-old woman underwent chest tube placement, repeated pleurodesis, and pleuroperitoneal shunt implantation for unsuccessful treatment of a large refractory hepatic hydrothorax. Two days after placement of a transjugular intrahepatic portosystemic shunt for treatment of variceal hemorrhage, her pleural effusion resolved. At 10 months' follow-up, only minimal fluid remains.

Chest Tubes↗

PubMed1993

Physician experience with viewing digital radiographs in an intensive care unit environment.

After several years of continuous operation, the utility of digital viewing stations as assessed by bedside clinicians has been investigated through the distribution of questionnaires to past and present users. The results of the questionnaire have indicated that the bedside physicians prefer using the workstations over handling film. For evaluation of line placements, chest tubes, and pleural effusions, the physicians prefer softcopy display over hardcopy. However, for analysis of air space disease and diagnosis of pneumothorax, images displayed on the workstation were not believed to be as useful as standard hardcopy.

Attitude of Health Personnel↗

PubMed1994

[Pneumothorax in laparoscopic cholecystectomy (II)].

This case report deals with pneumothorax during elective laparoscopic cholecystectomy in a young woman with no history of severe pulmonary disease. After inflating the capnoperitoneum, pulse oximetry and capnography raised suspicion of pneumothorax whereas the physical examination showed no irregularities. Surgical drapes provided a lack of information from percussion and auscultation. Changing respiratory parameters including the use of pressure-controlled ventilation in absence of tension pneumothorax enabled sufficient ventilation until the insertion of a chest tube. There were no further postoperative complications. Pulse oximetry, capnography and relaxometry proved helpful in monitoring. There may be a benefit from the use of pressure-controlled-ventilation in certain situations, if all changes in volume-controlled-ventilation fail.

Carbon Dioxide↗

PubMed1993

Thoracoscopy in the management of empyema in children.

Many pediatric surgeons advocate early open drainage or decortication for children with acute empyema. Unfortunately, such procedures can be associated with significant morbidity. Since 1981, we have used early thoracoscopic adhesiolysis and pleural debridement as an alternative to open thoracotomy in 9 children with acute empyema. The average age was 7.8 +/- 1.8 years (range, 2 to 16). All patients had failed initial treatment, which included antibiotics and chest tube drainage. All procedures were performed under general anesthesia. Following thoracoscopy, 8 of the 9 patients were managed with a single drainage tube and the average duration of tube drainage was 8.4 +/- 1.4 days. One patient died of underlying leukemia. Of the 8 patients who recovered, the average postoperative hospital stay was 13.4 +/- 2.9 days. No complications resulted from the thoracoscopies and there was no need for further surgical intervention in any of these patients. We conclude that thoracoscopy allows for minimally invasive, yet effective treatment of acute empyema with loculated collections. Thoracoscopic visualization of the pleural cavity permits efficient debridement, thorough adhesiolysis, and optimal placement of drainage tubes. Since we have begun using early thoracoscopy in the treatment of pediatric empyema, open drainage or decortication has not been required in any of these patients. Thoracoscopy is a useful adjunct in the treatment of empyema in children and its early application may eliminate the need for decortication.

Chest Tubes↗

PubMed1993

Effects of tube thoracostomy on pleural fluid characteristics in sheep.

We studied the pleural inflammatory response to tube thoracostomy by inserting an Argyle 32-Fr tube in the pleural space of 10 anesthetized sheep. An experimental pleural effusion was created by infusion of sterile normal saline (10 ml/kg) into the pleural space, and the animals were allowed to recover. Systemic blood and experimental pleural effusion (EPE) samples were obtained at time 0, 30 min, hourly for 6 h, and at 6-h intervals for a total of 48 h. EPE white cell count rose from 125 +/- 125 to 6,323 +/- 2,268/microliters (SE) at 6 h (P < 0.05) but showed marked variability at 42 and 48 h (P < 0.05), with values ranging from 8,000 to 22,000/microliters. The systemic white cell count rose from 5,195 +/- 914 to 9,640 +/- 1,110/microliters (P < 0.01) within the first 12 h and then remained stable. EPE protein increased from 0 +/- 0 to 3.73 +/- 0.2 g/dl at 48 h (P < 0.05). EPE lactate dehydrogenase rose from 44 +/- 12 IU/l to a peak of 638 +/- 55 IU/l at 24 h (P < 0.05). EPE glucose was significantly lower than serum glucose at 36, 42, and 48 h (P < 0.05). These data indicate that chest tube placement rapidly induces significant pleural inflammation and results in formation of a sterile exudate.

Animals↗

PubMed1998

Video-assisted thoracic surgery in the treatment of posttraumatic empyema.

BACKGROUND: Video-assisted thoracic surgery (VATS) appears to be replacing open thoracotomy for the treatment of posttraumatic thoracic complications. OBJECTIVE: To compare operative times, complication rates, and outcomes in patients who underwent VATS vs open thoracotomy. DESIGN: Retrospective review. SETTING: University hospital, level I trauma center. PATIENTS: Trauma patients who between December 1993 and May 1997 underwent open thoracotomy or VATS to drain a persistent thoracic collection. METHODS: Medical records were reviewed for demographic data, operative times, and clinical outcomes. RESULTS: Of the 524 trauma patients requiring tube thoracostomy, 22 underwent 23 procedures to drain empyema (17 VATS, 6 thoracotomies [based on surgeon preferencel). There were no differences in age, Injury Severity Score, or mechanism of injury between the 2 groups. Three patients who underwent VATS (18%) required conversion to open thoracotomy for adequate drainage. All remaining patients who underwent VATS had successful treatment of their empyema. Complication rates (VATS=29%, open thoracotomy=33%; P=.99), operative times (VATS=3.4+/-1.3 hours [mean+/-SD], open thoracotomy=3.0+/-1.5 hours; P=.46), postoperative epidural catheter use (VATS=31%, open thoracotomy=50%; P=.63), duration of chest tube drainage (VATS=5.1+/-1.7 days [mean+/-SD], open thoracotomy=4.5+/-1.5 days; P=.48), and hospital stay after the procedure (VATS=16+/-14 days [mean+/-SD], open thoracotomy=11+/-5 days; P=.39) were similar for both groups. CONCLUSIONS: Video-assisted thoracic surgery was a safe and effective operative strategy for the treatment of posttraumatic empyema. Therefore, because VATS has been shown in nontrauma patients to reduce morbidity and because it provides better cosmesis, we believe that it should be the initial operative approach to trauma patients with suspected posttraumatic empyema.

Adult↗