Mediastinal perforation and contralateral hemothorax by a chest tube

Report of Massive Bleed after Chest-drain Insertion in a Case of Job's (hyper-IgE) Syndrome

Chest-drain insertion is considered to be a benign procedure. A 6-year-old girl who is a known case of hyper-IgE/Job's syndrome presented to us following three episodes of fresh bleed following chest-drain insertion for the left lung abscess. The site of bleed was localized to be the ruptured pseudoaneurysm of the anterior segmental branch of the left pulmonary artery. For successful management, various pitfalls and gray areas have been highlighted: (a) the procedure of chest-drain insertion has a potential for many complications some of which may be life-threatening, (b) the importance of proper history taking and a complete evaluation of all patients before surgical intervention, (c) role of ultrasound-guided chest-drain insertion, and (d) the importance of lateral and pragmatic approach with multidisciplinary involvement in such unusual and challenging cases cannot be overemphasized.

Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications

INTRODUCTION

Although seemingly straightforward, tube thoracostomy (TT) has been associated with complication rates as high as 30 %. A lack of a standardized nomenclature for reporting TT complications makes comparison and evaluation of reports impossible. We aim to develop a classification method in order to standardize the reporting of complications of TT and identify all reported complications of TT and time course in which they occurred to validate the reporting method.

METHODS

A systematic search of MEDLINE, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews from each databases inception through November 5, 2013 was conducted. Original articles written in the English language reporting TT complications were searched. This review adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards. Duplicate reviewers abstracted case reports for inclusion. Cases were then sorted into one of the five complication categories by two reviewers, and in case of disagreements, settled by a third reviewer.

RESULTS

Of 751 papers reporting TT complications, 124 case reports were included for analysis. From these reports, five main categories of TT complications were identified: insertional (n = 65); positional (n = 36); removal (n = 11); infective and immunologic (n = 7); and instructional, educational, or equipment related (n = 5). Placement of TT has occurred in nearly every soft tissue and vascular structure in the thoracic cavity and intra-abdominal organs.

CONCLUSION

Our classification method provides further clarity and systematic standardization for reporting TT complications.

Iatrogenic perforation of a pulmonary angiomatoid lesion: histopathological study and review of the literature

Percutaneous tube thoracostomy (PTT) remains the most widely performed procedure to manage blunt or penetrating chest traumas. This life-saving manoeuvre can be frequently associated with complications. We present the case of a 76-year-old man, admitted to a peripheral hospital after a car accident and treated by PTT, who died shortly after the withdrawal of the chest tube. At autopsy, the victim was found to be affected by an extensive haemothorax resulting from the perforation of a subpleural angiomatoid lesion. The histopathological characteristics and the pathogenesis of the iatrogenic injury involving the vascular abnormality, along with its causal role in determining the fatal haemothorax, are critically discussed under both clinical and forensic points of view.

Hemothorax in a medical intensive care unit: incidence, comorbidity and prognostic factors

BACKGROUND/PURPOSE

There is a lack of data regarding the occurrence of hemothorax in medical intensive care units (ICUs). The purpose of this study was to investigate the incidence, comorbidity and prognostic factors of hemothorax in medical ICU patients.

METHODS

From January 1997 to December 2004, patients with hemothorax that developed during an ICU stay were studied. Hemothorax was considered procedure-related if it developed within 24 hours after an invasive procedure. Medical records were reviewed and analyzed with respect to patients' demographic data, underlying diseases, reasons for admission, Acute Physiology and Chronic Health Evaluation II score, procedures related to hemothorax, management, duration of ICU stay, and outcomes.

RESULTS

Fifty-three patients (0.79%) suffered hemothorax during their ICU stay. Chronic kidney disease (77.4%) was the most common comorbidity. A total of 40 cases (75.5%) were procedure-related. Thoracentesis and chest tube thoracostomy were the most common procedures. The 28-day mortality rate was 35.8%. Multivariate logistic regression analysis revealed that a prothrombin time/international normalized ratio > or = 1.6 (odds ratio = 10.99, 95% confidence interval = 1.08-112.05) and a hemoglobin decrease > or = 3 g/dL (odds ratio = 5.55, 95% confidence interval = 1.26-24.45) were significantly associated with 28-day mortality.

CONCLUSION

Chronic kidney disease was the most common comorbidity associated with hemothorax. Patients with chronic kidney disease might require close observation for hemothorax after invasive procedures, such as thoracentesis and chest tube thoracostomy. Prolonged prothrombin time and decreased hemoglobin level might be of prognostic value for critically ill patients with hemothorax.

Malfunction of a Heimlich flutter valve causing tension pneumothorax: case report of a rare complication

BACKGROUND

Thoracic injuries play an important role in major trauma patients due to their high incidence and critical relevance. A serious consequence of thoracic trauma is pneumothorax, a condition that quickly can become life-threatening and requires immediate treatment.Decompression is the state of the art for treating tension pneumothorax. There are many different methods of decompression using different techniques, devices, valves and drainage systems. Referring to our case report we would like to discuss the utilization of these devices.

CASE PRESENTATION

We report of a patient suffering from tension pneumothorax despite insertion of a chest drain at the accident scene. The decompression was by tube thoracostomy which was connected to a Heimlich flutter valve. During air transportation the patient suffered from cardiorespiratory arrest with asystole and was admitted to the trauma room undergoing manual chest compressions. The initial chest film showed a persisting tension pneumothorax, despite the chest tube that had been correctly placed and connected properly to the Heimlich valve. We assume that the Heimlich valve leaves did not open up and thus tension pneumothorax was not released.

CONCLUSION

We would like to raise awareness to the fact that if a Heimlich flutter valve is applied in the pre-hospital setting it should be used with caution. Failure in this type of valve may lead to recurrent tension pneumothorax.

Emergency chest tube placement in trauma care - which approach is preferable?

BACKGROUND

Pneumothorax is present in about 20% of blunt major trauma cases. Insertion of an intercostal tube drainage is one effective treatment, however it is unclear whether the thoracostomy has more advantages if placed in the ventral (2.-3. intercostal space) or lateral (4.-6. intercostal space) approach. The aim of this study was to determine, whether there are any differences between the two approaches in respect of malposition and complications.

MATERIAL AND METHODS

The data from 851 consecutive patients, admitted to our trauma centre from January 2000 to June 2004, was collected and analysed prospectively. The inclusion criteria were: ISS > or = 16, insertion of an intercostal tube and subsequent thoracic computed tomography. Epidemiological and physiological data were analysed together with the location of the tube (ventral or lateral). The attending physician was free to choose the location of insertion. Chest tubes placed both on-scene and in-hospital chest tubes were investigated. Malpositions, defined as extrathoracic, abdominal, parenchymal or interlobal positions, were analysed by reviewing the computed tomography of the thorax (CT). Complications, like injuries to vessels or organs, infection or empyaema were analysed using our standardised prospective trauma protocol. Furthermore, the rate of clinically relevant malfunctions due to malposition was investigated as well as the number of chest tubes that had to be replaced.

RESULTS

One hundred and one chest tubes were inserted in 68 patients with multiple trauma (mean age 40.7, ISS=38.1, AIS thorax=3.9). In 21 cases a ventral approach was chosen (20.8%) and in 80 a lateral approach (79.2%). CT revealed malposition in two of the ventrally placed tubes (9.5%) and in 20 of the laterally placed tubes (25%) (p=0.15, Fisher's exact test). One tube was identified in a subcutaneous location 17 chest tubes, after ventral approach all of them as a result of lateral approaches, were placed in the interlobe. No interlobal positions were observed in the ventral group. The interlobal position was found to be significantly higher in the lateral approach (p=0.013, Fisher's exact test). Clinically relevant malfunction was diagnosed in 6 of the 22 malpositioned chest tubes (5.9%). These tubes had to be repositioned, one was placed ventrally, the other five were placed laterally.

CONCLUSIONS

In our setting physicians preferred the lateral approach on-scene as well as in-hospital. In every fifth patient malpositioning of the tube was observed, mostly interlobal after lateral chest tube, however only few were associated with relevant clinical malfunctions. The probability of interlobal malpositioning is significantly higher when using the lateral approach as opposed to the ventral approach. Correction of malpositioned and ineffective chest tubes was necessary in every 17th case. No statistically significant difference between the two approaches for functional malposition was observed. Hence both approaches for emergency chest tube insertion seem to be equally justified.

Do junior doctors know where to insert chest drains safely?

BACKGROUND

The safe insertion of a chest drain is a skill doctors across specialties require. Incorrect placement can lead to significant morbidity and even mortality.

METHODS

This audit surveyed junior doctors working in a teaching hospital about their specialty and level of experience with intercostal drains. They were then asked to mark on a photograph where they would insert a chest drain for a pneumothorax in a non-emergency situation.

RESULTS

Of the 55 junior doctors surveyed, 45% were outside the safe area of chest drain insertion as defined by the British Thoracic Society. The most common error was a choice of insertion site too low (24%).

CONCLUSIONS

In this audit 45% of juniors surveyed would have placed a chest drain outside the safe triangle recommended by the British Thoracic Society. The common mistake of a choice of insertion site too low should be discussed in postgraduate teaching programmes.

Pleural Disease in the Intensive Care Unit

Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.