The impact of a chest tube management protocol on the outcome of trauma patients with tube thoracostomy / Impacto de um protocolo de cuidados a pacientes com trauma torácico drenado

ABSTRACTObjective:to investigate the effect of standardized interventions in the management of tube thoracostomy patients and to assess the independent effect of each intervention.Methods:A chest tube management protocol was assessed in a retrospective cohort study. The tube thoracostomy protocol (TTP) was implemented in August 2012, and consisted of: antimicrobial prophylaxis, chest tube insertion in the operating room (OR), admission post chest tube thoracostomy (CTT) in a hospital floor separate from the emergency department (ED), and daily respiratory therapy (RT) sessions post-CTT. The inclusion criteria were, hemodynamic stability, patients between the ages of 15 and 59 years, and injury severity score (ISS) < 17. All patients had isolated injuries to the chest wall, lung, and pleura. During the study period 92 patients were managed according to the standardized protocol. The outcomes of those patients were compared to 99 patients treated before the TTP. Multivariate logistic regression analysis was performed to assess the independent effect of each variable of the protocol on selected outcomes.Results:Demographics, injury severity, and trauma mechanisms were similar among the groups. As expected, protocol compliance increased after the implementation of the TTP. There was a significant reduction (p<0.05) in the incidence of retained hemothoraces, empyemas, pneumonias, surgical site infections, post-procedural complications, hospital length of stay, and number of chest tube days. Respiratory therapy was independently linked to significant reduction (p<0.05) in the incidence of seven out of eight undesired outcomes after CTT. Antimicrobial prophylaxis was linked to a significant decrease (p<0.05) in retained hemothoraces, despite no significant (p<0.10) reductions in empyema and surgical site infections. Conversely, OR chest tube insertion was associated with significant (p<0.05) reduction of both complications, and also significantly decreased the incidence of pneumonias.Conclusion:Implementation of a TTP effectively reduced complications after CTT in trauma patients.

RESUMOObjetivo:avaliar a implantação do Cuidado Padronizado com o Dreno de Tórax (CPDT) em um hospital público, referência para o trauma, e o impacto independente de cada um dos itens do protocolo no período do estudo sobre desfechos selecionados.Métodos: coorte retrospectiva avaliando implementação do Cuidado Padronizado para o Dreno de Tórax (CPDT). Foram incluídos pacientes entre 15 e 59 anos de idade, hemodinamicamente estáveis, com Injury Severity Score inferior a 17, com lesão isolada na parede do tórax, pulmão e pleura. Foram comparados 99 pacientes antes do CPDT com 92 depois do CPDT. Foi realizada comparação de desfechos selecionados por meio de diferença de proporções. A regressão logística multivariada foi feita para análise do efeito independente de cada variável do protocolo.Resultados:não houve diferença entre os grupos quanto às variáveis sociodemográficas, índice de gravidade e mecanismo de trauma. A implementação do CPDT resultou no aumento no percentual de todos os itens do protocolo. Houve redução significativa (p<0,05) de hemotórax retido, empiema, pneumonia, infecções de ferida operatória e nova operação, queda do percentual de pacientes retornados com complicações, tempo de internação e de permanência do dreno. A fisioterapia revelou-se independentemente associada à redução de sete dos oito desfechos (p<0,05). O antibiótico presuntivo revelou tendência de associação com a redução de empiema e de infecções de ferida operatória (p<0,10) e esteve associado à redução do hemotórax retido (p<0,05). A drenagem no centro cirúrgico esteve associada à redução de empiema, pneumonia e infecção de ferida operatória (p<0,05).Conclusão:a implementação do CPDT foi efetiva na redução de complicações de pacientes com dreno de tórax.

Comparison of techniques for transdiaphragmatic thoracic drainage after diaphragmatic defect closure in dogs: a cadaveric study

Four thoracic evacuation techniques for pneumothorax elimination after diaphragmatic defect closure were compared in 40 canine cadavers. After creating a defect in the left side of the diaphragm, thoracic drainage was performed by thoracostomy tube insertion through the defect and a small (DD-SP) or large (DD-LP) puncture created in the caudal mediastinum, or through both the diaphragmatic defect and intact contralateral diaphragm with a small (DI-SP) or large (DI-LP) puncture in made in the caudal mediastinum. Differences in intrapleural pressure (IPP) between the right and left hemithoraxes after air evacuation along with differences in IPP before making a defect and after air evacuation in each hemithorax were calculated. A difference (p or = 0.0835) were observed for the DI-LP, DD-LP, or DI-SP groups. Creation of a large mediastinal puncture or thoracic evacuation through both a diaphragmatic defect and intact contralateral diaphragm can facilitate proper pneumothorax elimination bilaterally after diaphragmatic defect closure in dogs with a small puncture in the caudal mediastinum.

Prosthesis for open pleurostomy (POP): management for chronic empyemas

OBJECTIVES: We developed a prosthesis for open pleurostomy cases where pulmonary decortication is not indicated, or where post-pneumonectomy space infection occurs. The open pleural window procedure not only creates a large hole in the chest wall that is shocking to patients, also results in a permanent deformation of the thorax. prosthesis for open pleurostomy is a self-retained silicone tube that requires the removal of 3 cm of one rib for insertion, and acts as a mature conventional open pleural window. Herein, we report our 13-year experience with this device in the management of different kinds of pleural empyema. METHODS: Forty-four consecutive patients with chronic empyema were treated. The etiology of empyema was diverse: pneumonia, 20; lung resections, 12 (pneumonectomies, 7; lobectomies, 4; non-anatomical, 1); mixed-tuberculous, 6; and mixed-malignant pleural effusion, 6. After debridment of both pleural surfaces, the prosthesis for open pleurostomy was inserted and attached to a small recipient plastic bag. RESULTS: Infection control was achieved in 20/20 (100 percent) of the parapneumonic empyemas, in 3/4 (75 percent) of post-lobectomies, in 6/7 (85 percent) of post-pneumectomies, in 6/6 (100 percent) of mixed-tuberculous cases, and in 4/6 (83 percent) of mixed-malignant cases. Lung re-expansion was also successful in 93 percent, 75 percent, 33 percent, and 40 percent of the groups, respectively CONCLUSIONS: Prosthesis for open pleurostomy insertion is a minimally invasive procedure that can be as effective as conventional open pleural window for management of chronic empyemas. Thus, we propose that the use of prosthesis for open pleurostomy should replace the conventional method.

Drenaje pleural asistido por radioscopía en el tratamiento del neumotórax / Radioscopally guided pleural drainage as tratment of pneumothorax

Objetivos: Determinar si el avenamiento pleural guiado por radioscopía en pacientes con neumotórax, se asocia con menos complicaciones y recolocaciones, disminuyendo la estadía hospitalaria.Lugar: Hospital PúblicoMaterial y Métodos: 31 pacientes con neumotórax entre enero y noviembre de 2004. Se los dividió en dos grupos, seleccionados al azar; en uno, el avenamiento pleural se realizó guiado por radioscopia y en el otro no. Sexo masculino 90%. Promedio de edad: 32 años. Neumotórax espontáneo 11, neumotórax traumático 20. Avenamiento pleural guiado por radioscopia: 16 y grupo control (sin radioscopia) 15.Resultados: En el grupo de pacientes tratados utilizando el IDI no hubo necesidad de recolocar el tubo, la estadía hospitalaria fue de 7.18 días; en el grupo control, se requirieron 3 recolocaciones por mal función del tubo de avenamiento y la estadía hospitalaria fue de 8.8 días.Conclusión: La colocación del tubo de avenamiento pleural guiado por radioscopia es un procedimiento seguro que facilita la colocación del tubo en el espacio pleural, corroborando la posición del mismo, disminuyendo la necesidad de recolocaciones, logrando resultados terapéuticos aceptables y reproducibles.

Atualidades em drenagem torácica / News on thoracic drainage

Procedimentos terapêuticos de drenagem pleuro-mediastinal fechada têm recebido substanciais modificações e novas proposições no decorrer da última década, no intuito de se minimizar intercorrências com um máximo de eficiência. Descrevem-se as atuais indicações, complicações, técnica e manuseio da drenagem torácica frente às principais toracopatias

Respiratory mechanics after tube thoracostomy in rats

The purpose of the present study was to determine the mechanical respiratory profile after the insertion of a catheter into the pleural cavity of anesthetized, paralyzed, mechanically ventilated rats, thus simulating the common use of chest tubes in clinical situations. Using the method of end-inflation occlusion during constant inspiratory flow in 7 adult Wistar rats, respiratory system, lung, and chest wall total resistance (0.353 +/- 0.058, 0.260 +/- 0.651, 0.092 +/- 0.012 (mean +/- SD) cmH2O.ml-1.s, respectively), viscous resistance (0.140 +/- 0.007, 0.100 +/- 0.007, 0.040 +/- 0.003 cmH2O.ml-1.s, respectively), and viscoelastic resistance (0.213 +/- 0.017, 0.160 +/- 0.022, 0.053 +/- 0.011 cmH2O.ml-1.s respectively) as well as respiratory system, lung and chest wall static elastance (4.51 +/- 0.27, 3.85...

Guía para la práctica de toracentesis y de toracostomía cerrada (inserción de tubo de tórax) / Guidelines in thoracocentesis and closed thoracostomy (chest drainege tube insertion)

Se actualizan las técnicas de torancentesis y torascostomía cerrada, complementadas o no de toracospia, indicadas para evacuar aire, líquido o sangre de la cavidad pleural y estabrecer su etiopatogenia. Deben seguirse estrictamente para realizarlas con éxito y evitar complicaciones.

Técnica quirúrgica: drenajes torácicos / Surgical technic: thoracic drenage

El empleo adecuado de la toracocostomía con sonda produce como resultado el drenaje de aire y/o líquidos acumulados en la cavidad pleural y contribuye a la ocupación completa de esta cavidad por el pulmón, con lo cual disminuye el número de complicaiones pleuropulmonares subsecuentes. Además, constituye un método de vigilancia continua de este espacio, mediante la cuantificación de aire y/o líquidos que se extraen. En este artículo explicamos en forma simple la utilización de los tubos de drenaje (drenes) que con mayor frecuencia se usan en patología pleuropulmonar. Sus indicaciones, instalación, manejo, tipo de tubos y frascos, complicaciones y momento de retiro serán los tópicos a tratar