Post-Pull Hemothorax

 Right-sided hemothorax

Right-sided hemothorax

Thanks to Dr. Gordon for her fantastic "cross cover" style report presentation on a patient for whom she was called with acute hypotension, tachycardia, and dyspnea with mild hypoxemic respiratory failure after the removal of a chest tube. Some takeaways from Dr. Gordon's presentation:

Tube thoracostomy is associated with a 3-18% complication rate. (1)

  • Small-bore catheters may be associated with higher rates of "complications," but this study included failure to drain/resolve the pneumothorax due to clotting, kinking, and dislodgement as the main complications.
  • Most common complications:
    • Pain
    • Pneumothorax
    • Empyema
    • Site infection
    • Tube dislodgement
    • Tube blockage
  • Rare complications:
    • Puncture of viscera
    • Intercostal nerve injury
    • Hemorrhage
    • Visceral injury
    • Subcutaneous emphysema
    • Horner's Syndrome
    • AV Fistula
  • Intercostal artery injury with chest tube placement is a rare but potentially life-threatening complication, more common in elderly and due to variant anatomy
  • IR embolization is an effective and less invasive approach than thoracotomy for control of intrathoracic hemorrhage, potentially safer alternative for poor surgical candidates, yet may not in all cases prevent the need for further intervention for evacuation of hemothorax (2)

Additionally, a discussion arose regarding the relationships amongt pleural effusion, dyspnea, and hypoxemic respiratory failure. Summarized are some points from Drs. Slatore and Kansagara: (3,4,5)

Intercostal VAN.png

References:

  1. Kuhajda I, Zarogoulidis K, Kougioumtzi I, et al. Tube thoracostomy; chest tube implantation and follow up. J Thorac Dis. 2014;6(Suppl 4):S470-9.
  2. Chemelli AP, Thauerer M, Wiedermann F, Strasak A, Klocker J, Chemelli-steingruber IE. Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries. J Vasc Surg. 2009;49(6):1505-13.
  3. Feller-kopman D, Light R. Pleural Disease. N Engl J Med. 2018;378(8):740-751.
  4. Ost DE, Jimenez CA, Lei X, et al. Quality-adjusted survival following treatment of malignant pleural effusions with indwelling pleural catheters. Chest. 2014;145(6):1347-1356.
  5. Cartaxo AM, Vargas FS, Salge JM, et al. Improvements in the 6-min walk test and spirometry following thoracentesis for symptomatic pleural effusions. Chest. 2011;139(6):1424-1429.