Retained Hemothorax and Empyema After Trauma: Predictive Factors and Cost

Authors:
Benjamin Stocker, Briana Britton, Daniel VanDerPloeg, Dante Yeh, Eric Campion, Ernest Moore, Fredric M Pieracci, Kassandra Samuel, Mandi Roberts, Renaldo Williams

Body of Abstract:
Background: Thoracostomy tubes (TT) placed for traumatic hemothorax can be complicated by retained hemothorax (rHTX) with a recorded incidence ~20%, and rHTX may lead to complications including empyema. Secondary interventions to treat rHTX include additional TT, instillation of lytic agents (tPA), and operative intervention (thoracoscopy or thoracotomy). The purpose of this quality improvement project was to review our institution’s incidence and consequences of rHTX and identify opportunities for improvement.
Methods: This retrospective, single-center study from Jan 2021 to Dec 2023 included adult trauma patients receiving TT for hemothorax. Patients were excluded if: non-survivable injuries on arrival, died or transitioned to comfort care within 48 hours, bilateral TT, TT placed at an outside institution or in the operating room during thoracic procedure, TT for pneumothorax only, video-assisted thoracoscopic surgery (VATS) for rib fixation, and VATS or thoracotomy within 6 hours of arrival. rHTX was defined as residual pleural blood on subsequent imaging after TT or dictated as an intraoperative finding. Data collected included demographics, TT-specific details, hospital charges, and clinical outcomes. Subjects were divided into two groups based on the presence/absence of rHTX and group characteristics and outcomes were compared. We additionally divided patients into thoracic irrigation vs. no thoracic irrigation and compared rHTX incidence.
Results: A total 113 patients were included, of whom 30 (27%) developed rHTX (Table. The majority of TT were placed for hemopneumothorax (68%) and placed in the Emergency Department (67%). Univariate analysis did not identify any predictive factors for rHTX. All rHTX patients required additional intervention, most commonly VATS, which was performed in two-thirds of rHTX patients. Three patients received tPA and two required additional TT. Thoracotomy (3%) and empyema (2%) were overall rare. However, patients with a rHTX had a trend towards more commonly developing an empyema (7% vs. 0%, p=.069). rHTX patients had significantly longer hospital length of stay (13 [6-24] vs. 8 [4-15] days, p=.044), and total hospital charges were higher for the rHTX group ($231K vs. $167K USD, p=.056), though not statistically significant due to sample size. Thoracic irrigation was uncommon (n=19; 17% overall) and the difference between rHTX and no rHTX groups was not statistically significant (10% vs. 19%, p=.393). When comparing patients receiving thoracic irrigation (n=19) vs. no thoracic irrigation (n=94), the rate of rHTX was 16% vs. 29%, respectively (p=.393).
Conclusions: At our institution, the rate of retained hemothorax is higher (27%) than published rates in the literature (~20%), and the incremental cost of retained hemothorax is approximately $64,500 USD. Thoracic irrigation utilization is low and routine implementation may be considered to decrease the rate of retained hemothorax in a cost-effective manner.