Implementation of a Thoracic Irrigation Protocol for a retained hemothorax: an early analysis

Author(s):

Victoria Wagner; Vanessa Arientyl; Alejandro De Leon; Ryan B. Fransman; Elliot Bishop; Millard A. Davis; Erin Caddell; Randi N. Smith; Jonathan Nguyen; S Rob Todd; Jason Sciarretta

Background:

Retained Hemothorax (RH) is a major source of morbidity following thorax injury. Early employment of video-assisted thoracoscopic (VATS) surgery is traditionally recommended for RH.

Hypothesis:

Early implementation of thoracic irrigation (TI) for a RH reduces the need for unplanned thoracic surgery.

Methods:

A single-center prospective observational study was performed of adult (age ≥18) trauma patients diagnosed with a RH. Implementation of thoracic irrigation guideline for RH during 6-month period was reviewed. A RH was defined as >300cc identified on computed tomography (CT) of the chest, with or without a thoracic tube (TT). Timing of TI for RH diagnosis was defined as early (<6 hours) vs late (>6 hours) from TT placement. Demographics, thoracic injury patterns, ISS, timing of RH+TI, and TI failure rate requiring OR were reviewed.

Results:

Of the 4,084 admissions, 29 patients met inclusion. The majority of the cohort had a penetrating (62%) injury. Median (IQR) age was 28 years (22–51.5), with 79% males and an ISS of 18.5 (14–26). Most common thoracic injuries on CT included: rib fractures (72%), pulmonary contusion or laceration (52%), and diaphragmatic injury (21%). No patients required emergent thoracic surgery for their injuries. Most TT (72%) were placed on day of injury with a 28F TT (93%) and a median volume of hemothorax drainage of 500cc (250–850) either in the trauma center (41%), OR (34%) or ICU (24%). Early TI was observed in 83% with a median time from TT to TI of 83 min (10-170.5). The volume of normal saline TI in the early group was 2,000cc (1000-2000) with a total RH drainage of 350cc (275-550). No patients required operative intervention with early TI for bleeding or thoracic related complications. Late TI included 4 patients whose median time from TT to TI was 726.5 min (394.5–1184.5) and had a total RH drainage of 325cc (100–450). Two patients failed TI requiring a VATS, one presenting 10 days post injury and another following a subclavian injury (7 days post injury and post TI).  

Conclusions:

These data provide early evidence to suggest that TI minimizes the need for operative intervention for a RH and can be successfully performed following thoracic injury without sequelae.