Cardiac tamponade in a preterm neonate secondary to a chest tube

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.

Expectant management of pneumothorax in ventilated neonates

OBJECTIVE

The purpose of this study was to assess the incidence and outcome of managing a pneumothorax without tube thoracostomy and to determine the clinical and laboratory characteristics that distinguish infants with a pneumothorax who can be treated without chest-tube insertion.

METHODS

A retrospective study was performed of neonates who were admitted to the neonatal intensive care unit at the University at Alabama at Birmingham from 1992 to 2005 and had a pneumothorax while on mechanical ventilation. Infant characteristics, respiratory and radiologic diagnoses, and respiratory management data (ventilator settings and blood gases) were compared between infants who initially were treated with a chest tube versus those initially treated without a chest tube.

RESULTS

A total of 136 ventilated infants with pneumothorax while on a ventilator were included in the final analysis; 101 (74%) were treated initially with a chest tube and 35 (26%) without a chest tube. Of those who did not receive a chest tube initially, 14 were treated with needle aspiration and 21 with expectant treatment. Infants who were treated initially without a chest tube were on a lower ventilator settings (mean airway pressure and fraction of inspired oxygen) and had better blood gases (arterial oxygen saturation, Pco(2), and pH) compared with infants who were treated with a chest tube. Infants who were treated initially with needle aspiration were more likely to require subsequent chest-tube insertion than infants who had expectant treatment (43% vs 10%).

CONCLUSIONS

It is possible to treat expectantly without initial chest-tube placement a select group of ventilated neonates with pneumothorax.

A method for chest drainage after pediatric cardiac surgery: A prospective randomized trial

OBJECTIVES

The purposes of this study were to evaluate the clinical safety and efficacy of 10F, 15F, and 19F Blake drains (Ethicon, Sommerville, NJ) in a pediatric population after cardiac surgery and to compare their clinical effect with that of conventional chest drains.

METHODS

From January 2002 through December 2004, a prospective randomized trial was conducted on 189 patients who underwent surgical intervention for congenital heart disease at our institution. Statistical analyses were conducted to test the null hypothesis that there was no difference in the incidence of pericardial or pleural effusion requiring drainage. Secondary end points included total volume of drainage, drain size, and time to drain removal.

RESULTS

Ninety-eight patients (group A) received Blake drains, and 91 patients (group B) received conventional chest drains. There were no statistically significant difference in age, weight at the time of surgical intervention, open- and closed-heart procedures, and number of drains applied. Statistically significant differences were detected in the frequency of pericardial effusion (group A: 1.1% vs group B: 4.8%, P < .01), pleural effusion (group A: 1.1% vs group B: 5.3%, P < .01), size of the drain (group A: 12.37 French +/- 1.72 French vs group B: 16.81 French +/- 0.70 French, P < .001), and time to removal (group A: 43.75 +/- 20.76 hours vs group B: 55.62 +/- 26.48 hours, P < .001).

CONCLUSIONS

Blake drains are safer and more efficient than conventional chest tubes in pediatric populations after cardiac surgery. In comparison with conventional chest tubes, they showed fewer occurrences of effusions and the same amount of fluid drained but smaller size and earlier removal.

Silastic drains vs conventional chest tubes after coronary artery bypass

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.

An evidence-based approach to drainage of the pleural cavity: evaluation of best practice

Recent surveys have uncovered major variations in key aspects of intercostal drain management, suggesting that decisions are being made on individual preferences without resorting to sound evidence. We provide an up-to-date review of the best practice with evidence-based recommendations and expert consensus views. The following aspects of chest drain management have been addressed: indications for drainage, insertion technique, complications, management of an indwelling chest drain, indications and technique for removal. The emphasis in this review is that safe intercostal drain practice relies upon adherence to a few important principles. Furthermore, when in doubt, particularly with a complex thoracic problem, one should seek prompt specialist advice.

Cardiac tamponade secondary to chest tube placement

A 69-year-old woman was hospitalized because of a left-sided pneumothorax due to chronic obstructive pulmonary disease. During chest tube placement she developed hypotension and a decrease in peripheral oxygen saturation. A diagnosis of heart tamponade was made and the patient was treated successfully with pericardiocentesis and placement of a pericardial drain. Cardiac tamponade following chest tube placement is a rare and serious complication. When the clinical condition deteriorates following chest tube insertion, cardiac tamponade should be considered.

Selective use of chest tubes in thoracotomies for congenital cardiovascular procedures

BACKGROUND

Advantages and complications have been reported from the use of chest tubes (CT). To reduce the incidence of complications we have employed a selective use of CT in thoracotomy for congenital cardiovascular procedure; ie, in absence of air leaks and fluid to be drained, no CT was inserted.

METHODS

The lung was reexpanded and air evacuated during the chest closure. Early and 6 hours chest roentgenograms were performed on every patient. This study retrospectively reviews the results of this selective approach in 546 patients operated on between 1980 and 1998 mainly for patent ductus arteriosum ligation, pulmonary artery band, aortic coarctation, Blalock-Taussig shunt. Four hundred and eighteen patients did not receive a CT at the initial surgery (group I), and 128 patients received a CT either before or at surgery (group II).

RESULTS

40 patients in group I developed an air or fluid collection large enough to require a CT. Only one patient had complication, from an undetected hemothorax. Nine patients in group II required another CT, and one patient developed a pneumothorax upon pulling out the CT. No death in either group was related to the use or lack of use of the CT. A total of 378 CTs and collecting chambers were saved.

CONCLUSIONS

A selective approach to the use of CT in thoracotomies for cardiovascular procedures can be employed with minimal complications, more comfort for the patient, and cost savings.

Subclavian artery compression from a chest tube after thoracotomy in a premature infant

A premature baby underwent thoracotomy for repair of esophageal atresia and tracheoesophageal fistula, during which time a right chest tube was placed. In the immediate postoperative period, right subclavian artery occlusion was recognized and relieved by partial withdrawal of the chest tube, which had migrated high into the apex of the right hemithorax.