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Although an uncommon complication, inadvertent suturing of the chest tube to the chest wall during closure of a thoracotomy, unfortunately can happen. This frustrating situation likely leads to a rethoracotomy and cutting of the suture in order to release the chest tube. In this report, we propose a fast and easy solution to this problem.
BACKGROUND: We undertook this study to compare the frequency and type of complications, as well as the length of hospital stay, in children who underwent closed cardiovascular surgery with chest tube drainage during the postsurgical period with children in whom the drainage was withdrawn with continuous suction, once thoracotomy was completed. METHODS: A retrospective, descriptive and analytic study was performed at the IMSS Hospital de Pediatria, located at the XXI Century National Medical Center in Mexico City. Eighty eight children who underwent closed cardiovascular surgery (Group I) without chest tubes and 42 with chest tubes (Group II) were studied. RESULTS: In Group I the frequency of complications was 27.3% and in group II 59.5%. Complications were as follows: subcutaneous emphysema was seen in 13.6% (n=12) of group I and in 45.2% (n=19) of group II (p=0.0001); pneumothorax in 13.6% (n=12) vs. 28.6% (n=12), p=0.04; and chylothorax in 2.3% (n=2) vs. 2.4% (n=1), p=1.0, respectively. The median time of hospital stay in group I was 3 days and in group II was 6 days (p=0.0001). CONCLUSIONS: In children, in some closed cardiovascular surgeries, withdrawal of chest tube drainage with negative suction when thoracotomy is completed may decrease the frequency of pneumothorax, subcutaneous emphysema and length of hospital stay, in comparison with patients in whom chest tube drainage is left during the postoperative period.
PURPOSE: To retrospectively evaluate the incidence of and risk factors for pneumothorax, pleural effusion, and chest tube placement for pneumothorax after radiofrequency (RF) ablation of lung tumors. MATERIALS AND METHODS: Institutional review board approval was obtained, with waiver of informed consent. This retrospective study comprised 224 ablation sessions for 392 tumors in 142 patients (92 men, 50 women; mean age, 64.0 years). Multiple variables were analyzed by using the Student t test or the Mann-Whitney U test for numerical values and by using the chi(2) test or the Fisher exact test for categorical values in order to assess risk factors for pneumothorax, pleural effusion, and chest tube placement for pneumothorax. RESULTS: The incidence of pneumothorax, pleural effusion, and chest tube placement for pneumothorax was 52% (117 of 224 sessions), 19% (42 of 224 sessions), and 21% (24 of 117 sessions), respectively. For pneumothorax, risk factors included male sex (P = .030), no history of pulmonary surgery (P < .001), a greater number of tumors ablated (P < .001), involvement of the middle or lower lobe (P = .008), and increased length of the aerated lung traversed by the electrode (P = .014). For pleural effusion, risk factors included the use of a cluster electrode (P = .008), decreased distance to the nearest pleura (P = .040), and decreased length of the aerated lung traversed by the electrode (P = .019). For chest tube placement for pneumothorax, risk factors included no history of pulmonary surgery (P = .002), the use of a cluster electrode (P < .001), and involvement of the upper lobe (P < .001). CONCLUSION: Pneumothorax and pleural effusion can occur after RF ablation in patients with lung tumors, and chest tube placement for pneumothorax is sometimes required.
Occasionally patients require long-term chest tube drainage. We describe a method whereby a short chest tube may be drained into a colostomy bag to alleviate the necessity of keeping the patient attached to a bulky drainage system. The colostomy bag allows greater mobility, and the patient can be discharged with the bag.
BACKGROUND: We assessed the impact of coverage of the mediastinum with a local hemostyptic agent as well as the impact of perioperative thromboembolic prophylaxis on cumulative chest drain volume and on the duration of chest tubes after surgical resection with complete mediastinal lymph node dissection for stage I or II non-small cell lung cancer. METHODS: In a prospective, randomized two-by-two factorial design, 80 patients with clinical stage I or II non-small cell lung cancer were allocated to one of two surgical therapy arms (TachoComb or conventional surgical hemostasis) and one of two anticoagulation arms (enoxaparin 4,000 IU or dalteparin 5,000 IU). Primary end point was cumulative chest drain volume; secondary end point was duration of chest tubes. Additionally clinical data were obtained. RESULTS: Comparison of the surgical arms revealed significantly lower cumulative chest drain volumes and thereby an earlier chest tube removal in the TachoComb group (p = 0.045). With regard to thromboembolic prophylaxis, a significantly earlier chest tube removal was found for patients treated with dalteparin (p = 0.039). Analysis of the interaction of surgical and anticoagulation treatment revealed the combined use of TachoComb and dalteparin was superior to other combinations (cumulative chest drain volumes 498 +/- 67 mL versus 1,000 +/- 88 mL, 924 +/- 87 mL, and 895 +/- 118 mL; p = 0.008; mean duration of chest tubes 1.78 +/- 0.15 days versus 2.96 +/- 0.21 days, 2.93 +/- 0.17 days, and 3.06 +/- 0.27 days; p = 0.019). CONCLUSIONS: The combined use of a local hemostyptic agent and dalteparin seems superior as compared with other regimens of hemostasis and thromboembolic prophylaxis in patients undergoing surgical resection and complete mediastinal lymph node dissection for stage I and II non-small cell lung cancer with regard to cumulative chest drain volume as well as duration of chest tubes.
OBJECTIVE: A prolonged air leak after an upper lobectomy is a major determinant of morbidity and hospital stay. Creation of a pleural tent after upper lobectomy was used to investigate whether obliterating the usual postoperative intrapleural apical space with the parietal pleura would help shorten chest tube time. METHODS: From August, 1994, through January, 1997, 48 consecutive patients undergoing an isolated upper lobectomy for a neoplasm were reviewed. Twenty-eight patients had creation of a pleural tent and 20 patients did not. Demographic and clinical profiles of both groups were not significantly different. Chest tubes were removed when there was no air leak for 48 hours and chest tube drainage was less than 75 ml per 8 hours. RESULTS: The tented patients had significantly shorter mean air leak (tented 1.6 +/- 0.3 days vs nontented 3.9 +/- 1.2 days, p = 0.04), mean chest tube total drainage (tented 1619.5 +/- 95.5 ml vs nontented 2476.3 +/- 346.4 ml, p = 0.009), mean chest tube duration (tented 4.0 +/- 0.2 days vs nontented 6.6 +/- 1.0 days, p = 0.004), mean total hospitalization time (tented 6.4 +/- 0.4 days vs nontented 8.6 +/- 1.0 days, p = 0.02). No operative deaths occurred. Morbidity was not significantly different between groups. CONCLUSIONS: (1) Creation of a pleural tent at the time of upper lobectomy appears to significantly reduce chest tube time and shorten hospitalization. (2) No morbidity or mortality was associated with this simple, quick procedure. (3) Surgeons should consider creation of a pleural tent at the time of upper lobectomy.
Insertion of chest drain is always a life saving procedure in emergent conditions. Especially in crowded traffic accidents more than one patient has brought to the emergency service. In this study we review our experience in chest drainage by using classic laparoscopic trocars. During the period between August 1997, and March 2000 chest tubes were inserted using laparoscopic trocars in 27 patients in emergency service, Yozgat State Hospital. We have no complications related to use of this technique. We concluded that use of laparoscopic trocars in chest tube insertion in emergency conditions is an safe and rapid procedure.
Twelve patients with a chest tube positioned in the major fissure of either lung were collected prospectively in a two-year period. In eight of these 12, there was evidence of chest tube malfunction, with poor drainage of pleural air or fluid collections; in six of these eight, placement of additional tubes or tube repositioning resulted in improved pleural drainage. In all 12, the tube had been placed through the lateral chest wall. Although tube placement in the major fissure can sometimes be suspected on the anteroposterior portable chest roentgenogram because of the tube's characteristic course, in such cases a lateral roentgenogram is not usually obtained for confirmation of location unless there is evidence of tube malfunction.
STUDY OBJECTIVES: To investigate differences in drainage amounts and early clinical outcomes associated with the use of Silastic drains, as compared with the conventional chest tube after coronary artery bypass grafting (CABG). DESIGN: Retrospective nonrandomized case control study. SETTING: A tertiary teaching hospital. PATIENTS AND PARTICIPANTS: Outcome data from 554 patients who underwent postoperative pericardial decompression using small Silastic drains were compared with those from 556 patients who had conventional chest tubes after first-time CABG at our institution between January 1 and August 1, 2000. MEASUREMENT AND RESULTS: Univariate analysis of preoperative characteristics was used to ensure similarity between the two patient groups. Operative mortality, mediastinitis, reoperation for bleeding, and early and late cardiac tamponade occurred in 9 patients (1.6%), 6 patients (1.1%), 6 patients (1.1%), 6 patients (1.1%), and 1 patient (0.2%), respectively, in the Silastic drain group, compared with 11 patients (2.0%), 9 patients (1.6%), 4 patients (0.7%), 2 patients (0.4%), and 6 patients (1.1%) in the conventional group. No statistically significant differences between the two drains were identified. Drainage amounts (mean +/- SD) were 552.2 +/- 281.8 mL and 548.8 mL +/- 328.7 mL for the Silastic and conventional groups, respectively (p = 0.51). Postoperative length of stay was longer for the conventional chest tube group (median, 5 d; range, 1 to 119 d) when compared to the Silastic drain group (median, 4 d; range, 1 to 66 d; p = 0.01). CONCLUSIONS: We demonstrated that small Silastic drains are equally as effective as the conventional, large-bore chest tubes after CABG with no significant risk of bleeding or pericardial tamponade. Additionally, use of Silastic drains allows more mobility than the conventional chest tubes. As a result of this study, there was a change in our clinical practice toward the exclusive use of Silastic drains after all cardiac surgical procedures.
Closed-chest thoracostomy with tube drainage is recognized as a necessary skill for primary care physicians. The usual teaching methods used to train medical students and resident physicians involve either instruction on patients or the use of costly animal models. An inexpensive model using commonly available materials to teach this skill is described.
BACKGROUND: Several reports have suggested that early chest tube drainage (CTD) may not be necessary in the treatment of severe pleural empyema (PE) in pediatric patients if appropriate antibiotic therapy and supportive care are provided. OBJECTIVES: A prospective open study to compare the short-term course of two treatment protocols of severe PE in pediatric patients. STUDY DESIGN: One group of 32 patients was treated with early insertion of a chest tube for CTD, and a second group of 35 patients was treated by a repeated ultrasound-guided needle thoracocentesis (RUSGT). The severity of the empyema was assessed by chest radiograph, the amount of fluid drained, the number of days the patient had experienced a fever, and the duration of antibiotic treatment. RESULTS: No significant differences were found between the two groups (RUSGT vs CTD) in all of the following measurements: mean (plus minus SD) duration of a temperature > or = 39 degreesC, 6.2 +/- 2.4 vs 6.5 +/- 1.8 days, respectively; mean duration of a temperature > or = 38 degreesC, 9 +/- 3.9 vs 8.2 +/- 4.5 days, respectively; fluid drained, 35.1 + 23.8 vs 30 +/- 28.2 mL/kg, respectively; duration of antibiotic treatment, 30 +/- 13.2 vs 30.2 +/- 7.3 days, respectively; and length of hospitalization and home IV treatment, 22 +/- 7.6 vs 24.2 +/- 7.5 days, respectively. A failure to respond to treatment occurred in three patients in the RUSGT-treated group and in five patients in the CTD-treated group. The failure to respond occurred in the RUSGT-treated group only in those patients with very large empyemas that caused mediastinal deviation. CONCLUSION: The treatment of PE by RUSGT is as efficacious as CTD, unless PE causes mediastinal deviation.
The authors describe an unusual complication of chest tube placement: subclavian vein lesion. After a literature review concerning complications of chest tube placement, the authors conclude that associated risks may be best minimized with a strict adherence to standardized technique and management protocol.
Here we report an unexpected and possibly overlooked cause of postoperative myocardial ischemia: a chest tube compressing a vein graft. After the position of the chest tube was adjusted, graft flow was reestablished, right ventricular contractility returned, and myocardial infarction was probably prevented. The literature on chest tube complications is briefly reviewed and experience from our institution is reported.
BACKGROUND: Recurrent pneumothorax is the most significant complication after discontinuation of thoracostomy tubes. The primary objective of the present study was to determine which method of tube removal, at the end of inspiration or at the end of expiration, is associated with a lesser risk of developing a recurrent pneumothorax. A secondary objective was to identify potential risk factors for developing recurrence. METHODS: A prospective study of 102 chest tubes in 69 trauma patients (1.5 tubes per patient) randomly assigned to removal at the end of inspiration (n = 52) or the end of expiration (n = 50). RESULTS: Recurrent pneumothorax or enlargement of a small but stable pneumothorax was observed after the removal of four chest tubes in the end-inspiration group (8%) and after discontinuation of three chest tubes (6%) in the end-expiration group (p = 1.0). Of those, only two tubes in the end-inspiration group and 1 tube in the end-expiration group required repeat closed thoracostomy. Multiple factors were analyzed that did not adversely affect outcome. These included patient age, Injury Severity Score, Revised Trauma Score, mechanism of injury, hemothorax, thoracotomy, thoracostomy, previous lung disease, chest tube duration, the presence of more than one thoracostomy tube in the same hemithorax, or a small (but stable) pneumothorax at the time of tube removal. CONCLUSIONS: Discontinuation of chest tubes at the end of inspiration or at the end of expiration has a similar rate of post-removal pneumothorax. Both methods are equally safe.
Knowledge of the indications, placement, and management of chest tubes in the intensive care unit is essential for the care of the critically ill patient. Awareness of the complications and mechanical difficulties that can occur with chest tubes and their drainage systems is essential for the safe and effective use of these devices.
Newborn infants with severe respiratory distress syndrome have an increased incidence of pulmonary interstitial emphysema, pneumomediastinum, and pneumothorax. A chest tube inserted for treatment of a pneumothorax may inadvertently perforate the lung. Recognition of chest tube perforation can be suggested by the occurrence of: (1) persistent or repeated pneumothoraces despite the presence of a chest tube and (2) atelectasis and/or infiltrate near the end of the chest tube.
STUDY OBJECTIVE: To evaluate the efficacy of small-bore (12 French vanSonnenberg) catheters compared with standard large-bore chest tubes in the drainage and sclerotherapy of malignant pleural effusions. DESIGN: Retrospective review. SETTING: An academic tertiary care hospital. PATIENTS: Adult patients with documented neoplasms and malignant pleural effusions, treated between 1986 and 1995. INTERVENTION: All patients included in the study underwent drainage of malignant pleural effusions either by large-bore chest tube or by ultrasound-guided small-bore catheter. After drainage, pleurodesis was performed. RESULTS: Outcome as defined by recurrence of effusion was determined by blinded examination of all postpleurodesis chest radiographs. We identified 58 cases of malignant pleural effusion in which small-bore catheters were used and 44 in which large-bore chest tubes were used. The majority of patients had breast (n = 56, 55%) or lung cancer (n = 29, 28%). The median age was 65 years. Fifty-nine patients were actively being treated with chemotherapy at the time of pleurodesis. The following sclerosing agents were used: talc, 27 (26%); tetracycline, 72 (70%); bleomycin, 2 (2%); and interferon, 1 (1%). Actuarial probabilities of recurrence at 6 weeks and 4 months were 45% and 53% for the small tubes vs 45% and 51% for the large tubes. Univariate and multivariate analyses failed to demonstrate that tube size had any influence on the rate of recurrence. CONCLUSIONS: We were unable to detect any major differences in outcomes with the use of either size of chest tube. Our study suggests that small-bore catheters may be effective in the treatment of malignant pleural effusions and deserve further evaluation in prospectively designed trials.
OBJECTIVES: The aim of this study was to evaluate the efficacy of topical valdecoxib as an analgesic during chest tube removal in postcardiac surgical patients. DESIGN: A prospective, randomized, double-blind, placebo-controlled study. SETTING: The study was performed in the cardiac intensive care unit. PARTICIPANTS: Fifty-three patients undergoing elective cardiac surgery were randomized to receive either topical valdecoxib or liquid paraffin on the chest tube exit sites. INTERVENTION: Topical valdecoxib was applied to 1 of the 2 chest tube sites (mediastinal or pericardial) in a randomized manner before drain removal. Liquid paraffin was used as the control on the other tube site. The patient and observer were blinded to the drug and control. MEASUREMENTS AND MAIN RESULTS: Pain was assessed by using the visual analog scale. The heart rate and systolic blood pressure were recorded at each stage by the blinded observer. Statistical analysis of the obtained data was undertaken using the nonparametric Mann-Whitney U test. The median pain scores before, during, and after tube removal in the control group were 2, 5, and 4, respectively. The valdecoxib group had corresponding scores of 1, 2, and 2. The pain scores were significantly lower in the valdecoxib group. No differences were seen in the heart rate and systolic blood pressure between the 2 groups. No adverse effects were noted. CONCLUSIONS: Topical valdecoxib is a safe and effective topical analgesic for chest tube removal in cardiac patients.