PIGTAIL CATHETERS - UnityPoint Health...TENSION PNEUMOTHORAX Failure Rate Of Prehospital Chest Decompression After Severe Thoracic Trauma Alexander Kaserer, Philipp Stein, Hans-Peter

PIGTAIL CATHETERSBellal Joseph M.D, F.A.C.S

Professor of SurgeryVice Chairman of Research The University of Arizona

Nothing to Disclose

Introduction Thoracic trauma Tension Pneumothorax Pneumothorax Hemothorax Management Pigtail catheters vs Chest tube

SUMMARY

THORACIC TRAUMA

THORACIC TRAUMA

THORACIC TRAUMA

■ Incidence: Blunt 8% of all trauma admissions Penetrating 7% of all trauma admissions

■ Mortality: Blunt 28% Penetrating 7%

THORACIC TRAUMA

■ Fatal Intrathoracic Injuries Tension pneumothorax Uncontrolled hemorrhage Airway obstruction Cardiac tamponade

TENSION PNEUMOTHORAX


■ 33% of preventable combat deaths■ Injured chest or lung acts as one-way valve■ Air becomes trapped between the lung and chest wall

causing the lung to collapse■ The heart is pushed to the other side causing blood vessels

to kink■ Death will result if not quickly recognized and treated with

needle decompression■ May occur in open and closed chest wounds


Presenter

Presentation Notes

Tension physiology causes compression of trachea and venous channels leading to decreased cardiac output.


Air collapses lung and pushes heart to other side

Blood return to heart restricted by kinked vessels, heart unable to pump

Air between lung and chest wall


■ Management:– GOLD STANDARD: 14G Angiocatheter


HIGH FAILURE

RATE

■ Causes of Failure– Length– Bore Diameter– Blind Sharp Needle

Insertion– Lack of Tactile or Visual

Feedback– Plastic Catheter

Kinking/Obstructing

Presenter

Presentation Notes

The failure of the angiocatheter is five-fold. First, is the length of the angiocatheter, which is 5cm. In a 2004 study published out of the Brooke Army and Wilford Hall Medical Centers in San Antonio, TX the average chest wall thickness in the patients studied averaged 4.24cm, and a quarter of these patients had chest walls greater than 5cm. Thus, in at least 25% of patients the length of the angiocatheter is inadequate.


Failure Rate Of Prehospital Chest Decompression After Severe Thoracic Trauma

Alexander Kaserer, Philipp Stein, Hans-Peter Simmen, Donat R. Spahn, and Valentin Neuhaus

Retrospective

24 patients with tension pneumothorax

17 Needle vs 8 tube thoracostomy

Outcomes Successful release of t-PTX

2017

Failure rate of Needle Thoracostomy was 82%

Presenter

Presentation Notes

hest decompression can be performed by different techniques, like 14G needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT). The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effectiveness of these techniques. Material and methods In this retrospective case series study, all medical records of adult trauma patients undergoing prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied. Results In a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen patients had NT, six patients TT, one patient NT as well as TT, and no patients had LT. Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT related complications were reported during hospitalization. Conclusion Prehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission.


Modified Veress Needle Decompression Of Tension Pneumothorax: A Randomized

Crossover Animal StudyLubin, Dafney MD; Tang, Andrew L. MD; Friese, Randall S. MD; Martin, Matthew MD;

Green, DJ MD; Jones, Trevor BS; Means, Russell R. BS; Ginwalla, Rashna MD; O’Keeffe, Terence S. MBChB; Joseph, Bellal A. MD; Wynne, Julie L. MD; Kulvatunyou,

Narong MD; Vercruysse, Gary MD; Gries, Lynn MD; Rhee, Peter MD

Swine randomized trial

43 tension pneumothorax events

14G AC vs modified Veress needle (mVN)

Outcomes: Successful decompression

2013

Presenter

Presentation Notes

BACKGROUND: The current prehospital standard of care using a large bore intravenous catheter for tension pneumothorax (tPTX) decompression is associated with a high failure rate. We developed a modified Veress needle (mVN) for this condition. The purpose of this study was to evaluate the effectiveness and safety of the mVN as compared with a 14-gauge needle thoracostomy (NT) in a swine tPTX model. METHODS: tPTX was created in 16 adult swine via thoracic CO2 insufflation to 15 mm Hg. After tension physiology was achieved, defined as a 50% reduction of cardiac output, the swine were randomized to undergo either mVN or NT decompression. Failure to restore 80% baseline systolic blood pressure within 5 minutes resulted in crossover to the alternate device. The success rate of each device, death, and need for crossover were analyzed using [chi]2. RESULTS: Forty-three tension events were created in 16 swine (24 mVN, 19 NT) at 15 mm Hg of intrathoracic pressure with a mean CO2 volume of 3.8 L. tPTX resulted in a 48% decline of systolic blood pressure from baseline and 73% decline of cardiac output, and 42% had equalization of central venous pressure with pulmonary capillary wedge pressure. All tension events randomized to mVN were successfully rescued within a mean (SD) of 70 (86) seconds. NT resulted in four successful decompressions (21%) within a mean (SD) of 157 (96) seconds. Four swine (21%) died within 5 minutes of NT decompression. The persistent tension events where the swine survived past 5 minutes (11 of 19 NTs) underwent crossover mVN decompression, yielding 100% rescue. Neither the mVN nor the NT was associated with inadvertent injuries to the viscera. CONCLUSION: Thoracic insufflation produced a reliable and highly reproducible model of tPTX. The mVN is vastly superior to NT for effective and safe tPTX decompression and physiologic recovery. Further research should be invested in the mVN for device refinement and replacement of NT in the field.


Tension-PTX 50% reduction in C/O Thoracic

CO2 insufflation to 15 mm Hg


Tension-PTX Modified Veress

needle (mVN)

Presenter

Presentation Notes

mvN diameter of 3.5mm vs 14G AC which is 1.6mm in diameter


Presenter

Presentation Notes

SBP response to decompression between mVN and NT. B, CO response to decompression between mVN and NT


Presenter

Presentation Notes

Device performance between mVN and NT.


Bigger Is Better: Comparison Of Alternative Devices For Tension Hemopneumothorax And

Pulseless Electrical Activity In A Yorkshire Swine Model

Matthew L Leatherman, DO Laura M Fluke, DO Christian S McEvoy, MD Douglas M Pokorny, DO Robert L Ricca, MD Matthew J Martin, MD

Christopher S Gamble, DVM Travis Polk, MD

Swine randomized trial

195 tension Hemopneumothorax events

14G AC, 10G AC, modified Veress needle (mVN), and 3mm laparoscopic trocar (LT)

Outcomes: Return of spontaneous circulation

2017

Presenter

Presentation Notes

BACKGROUND: Tension pneumothorax is a cause of potentially preventable death in pre hospital and battlefield settings and 14g angiocatheter (14G AC) decompression remains the current treatment standard, despite its high incidence of failure. Traumatic pneumothorax is often associated with hemothorax, but 14G AC has no proven efficacy for associated hemothorax. We sought to compare the 14G AC to three alternative devices for treatment of tension hemopneumothorax (t-H/PTX) in a positive pressure ventilation swine model. METHODS: Our tension model was modified to incorporate a persistent air leak and pleural blood. Tension physiology was achieved with escalating CO2 insufflation via transdiaphragmatic trocar and 10% estimated blood volume was instilled into each chest. Intervention was randomized between 14G AC, 10gauge angiocatheter (10G AC), modified Veress needle (mVN), and 3mm laparoscopic trocar (LT). After recovery, serial tension-induced pulseless electrical activity (PEA) events were induced and decompressed. Success of rescue, time to rescue, and physiologic data were recorded. RESULTS: 195 t-H/PTX and 88 PEA events were conducted in 25 swine. LT and 10G AC were more successful and had faster median time to rescue for t-H/PTX, compared to 14G AC, while mVN performed comparably. Following PEA, 14G AC and mVN only succeeded at rescue 50% and 57% of the time, while 10G AC and LT had 100% success at return of spontaneous circulation. Time to successful return of circulation following PEA did not differ between devices; however, there was a noticeable difference in the rate of meaningful hemodynamic recovery following PEA favoring LT and 10G AC. There were no significant injuries noted. CONCLUSION: While mVN performed comparably to 14G AC, both have unacceptable failure rates. 10G AC and LT performed superiorly in both t-H/PTX and PEA. We believe there is now ample evidence supporting replacement of the 14G AC with 10G AC in current treatment recommendations.


Presenter

Presentation Notes

Successful rescue from t-H/PTX and Time to Rescue following t-H/PTX

THORACIC TRAUMA

THORACIC TRAUMA

PTX HTX H-PTX

WHAT TO DO ?

Remove Fluid and air as promptly as possible

Prevent Drained air & fluid from returning to the pleural space

Restore Negative pressure in the pleural space to re-expand the

lung

QUESTIONS

Should all Pneumothoraces or Hemothoraces be drained?

Does size matter? Pigtail catheter vs. Chest tube

HEMOTHORAX

Practice Management Guidelines for Management of Hemothorax and Occult

PneumothoraxMowery, Nathan T. MD; Gunter, Oliver L. MD; Collier, Bryan R. DO; Diaz, Jose' J. Jr. MD; Haut, Elliott MD; Hildreth, Amy MD; Holevar, Michelle MD;

Mayberry, John MD; Streib, Erik MD

All hemothoraces, regardless of size, should be considered for drainage

Surgical exploration: >1500ml/24hrs via chest tube

Persistent Htx after tube thoracostomy: Treat with VATS

2011

Presenter

Presentation Notes

Management of Massive Hemothorax 1. Patient physiology should be the primary indications for surgical intervention rather than absolute numbers of initial or persistent output (Level 2). 2. 1500 mL via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration (Level II). Management of Hemothorax 1. All hemothoraces, regardless of size, should be considered for drainage (Level 3). 2. Attempt of initial drainage of hemothorax should be with a tube thoracostomy (Level 3). 3. Persistent retained hemothorax, seen on plain films, after placement of a thoracostomy tube should be treated with early VATS, not a second chest tube (Level 1). 4. VATS should be done in the first 3 days to 7 days of hospitalization to decrease the risk of infection and conversion to thoracotomy (Level 2). 5. Intrapleural thrombolytic may be used to improve drainage of subacute (6-day to 13-day duration) loculated or exudative collections, particularly patients where risks of thoracotomy are significant (Level 3). � �

HEMOTHORAX

To Drain Or Not To Drain? Predictors Of Tube Thoracostomy Insertion And Outcomes Associated With Drainage Of Traumatic

HemothoracesBryan J. Wells, Derek J. Roberts, Sean Grondin, Pradeep H. Navsaria,

Andrew W. Kirkpatrick, Michael B. Dunham, and Chad G. Ball

Retrospective study

635 patients

Expected management vs tube thoracostomy

Outcomes: Mortality Hospital length of stay M

2015

Presenter

Presentation Notes

Introduction Historical data suggests that many traumatic hemothoraces (HTX) can be managed expectantly without tube thoracostomy (TT) drainage. The purpose of this study was to identify predictors of TT, including whether the quantity of pleural blood predicted tube placement, and to evaluate outcomes associated with TT versus expected management (EM) of traumatic HTXs. Patients and methods A retrospective cohort study of all trauma patients with HTXs and an Injury Severity Score (ISS) ≥12 managed at a level I trauma centre between April 1, 2005 and December 31, 2012 was completed. Mixed-effects models with a subject-specific random intercept were used to identify independent risk factors for TT. Logistic and log-linear regression were used to compute odds ratios (ORs) for mortality and empyema and percent increases in length of hospital and intensive care unit stay between patients managed with TT versus EM, respectively. Results A total of 635 patients with 749 HTXs were included in the study. Overall, 491 (66%) HTXs were drained while 258 (34%) were managed expectantly. Independent predictors of TT placement included concomitant ipsilateral flail chest [OR 3.03; 95% confidence interval (CI) 1.04–8.80; p = 0.04] or pneumothorax (OR 6.19; 95% CI 1.79–21.5; p < 0.01) and the size of the HTX (OR per 10 cc increase 1.12; 95% CI 1.04–1.21; p < 0.01). Although the adjusted odds of mortality were not significantly different between groups (OR 3.99; 95% CI 0.87–18.30; p = 0.08), TT was associated with a 47.14% (95% CI, 25.57–69.71%; p < 0.01) adjusted increase in hospital length of stay. Empyemas (n = 29) only occurred among TT patients. Conclusions Expectant management of traumatic HTX was associated with a shorter length of hospital stay, no empyemas, and no increase in mortality. Although EM of smaller HTXs may be safe, these findings must be confirmed by a large multi-centre cohort study and randomized controlled trials before they are used to guide practice.

HEMOTHORAX



Andrew W. Kirkpatrick, Michael B. Dunham, and Chad G. Ball 2015

Predictors of tube thoracostomyOutcomes OR [95% CI] pFlail chest 3.3 [1.4-8.8] 0.04Pneumothorax 6.9 [7.8-22.5] <0.01Hemothorax size(per 10cc increase)

1.1 [1.04-1.21] <0.01

HEMOTHORAX



Andrew W. Kirkpatrick, Michael B. Dunham, and Chad G. Ball 2015

HTX <300cc corresponds to 1.5-2.0 cm posterior lamellar strip on a CT scan and

can be safely managed expectantly

TUBE THORACOSTOMY

Pigtail Catheter

Chest Tube

TUBE THORACOSTOMY

Pigtail Catheter Chest Tube

PIGTAIL CATHETER

CHEST TUBE

TUBE THORACOSTOMY

Chest Tube Pigtail

PIGTAIL VS CHEST TUBE

TUBE THORACOSTOMY

Does Size Matter? A Prospective Analysis Of 2832 Versus 3640 French Chest Tube Size In

TraumaInaba, Kenji MD; Lustenberger, Thomas MD; Recinos, Gustavo MD;

Georgiou, Crysanthos MD; Velmahos, George C. MD; Brown, Carlos VR; Salim, Ali MD; Demetriades, Demetrios MD; Rhee, Peter MD 2012

Prospective observational

Small (28-32Fr) vs large (36-40Fr) chest tube

Outcomes: Efficacy of drainage Complications Residual hemo and pneumothoraces Need for additional tube insertion

Presenter

Presentation Notes

Background: The optimal chest tube size for the drainage of traumatic hemothoraces and pneumothoraces is unknown. The purpose of this study was to compare the efficacy of small versus large chest tubes for use in thoracic trauma. Our hypothesis was that (1) there would be no difference in clinically relevant outcomes including retained hemothoraces, the need for additional tube insertion, and invasive procedures and (2) there would be an increase in pain with the insertion of large versus small tubes. Methods: This is a prospective, institutional review board-approved observational study. All patients requiring open chest tube drainage within 12 hours of admission (January 2007–January 2010) were identified at a Level I trauma center. Clinical demographic data and outcomes including efficacy of drainage, complications, retained hemothoraces, residual pneumothoraces, need for additional tube insertion, video-assisted thoracoscopy, and thoracotomy were collected and analyzed by tube size. Small chest tubes (28–32 Fr) were compared with large (36–40 Fr). Results: During the study period, a total of 353 chest tubes (small: 186; large: 167) were placed in 293 patients. Of the 275 chest tubes inserted for a hemothorax, 144 were small (52.3%) and 131 were large (47.7%). Both groups were similar in age, gender, and mechanism; however, large tubes were placed more frequently in patients with a Glasgow Coma Scale ≤8, severe head injury, a systolic blood pressure <90 mm Hg, and Injury Severity Score ≤25. The volume of blood drained initially and the total duration of tube placement were similar for both groups (small: 6.3 ± 3.9 days vs. large: 6.2 ± 3.6 days; adjusted (adj.) p = 0.427). After adjustment, no statistically significant difference in tube-related complications, including pneumonia (4.9% vs. 4.6%; adj. p = 0.282), empyema (4.2% vs. 4.6%; adj. p = 0.766), or retained hemothorax (11.8% vs. 10.7%; adj. p = 0.981), was found when comparing small versus large chest tubes. The need for tube reinsertion, image-guided drainage, video-assisted thoracoscopy, and thoracotomy was likewise the same (10.4% vs. 10.7%; adj. p = 0.719). For patients with a pneumothorax requiring chest tube drainage (n = 238), there was no difference in the number of patients with an unresolved pneumothorax (14.0% vs. 13.0%; adj. p = 0.620) or those needing reinsertion of a second chest tube. The mean visual analog pain score was similar for small and large tubes (6.0 ± 3.3 and 6.7 ± 3.0; p = 0.237). Conclusions: For injured patients with chest trauma, chest tube size did not impact the clinically relevant outcomes tested. There was no difference in the efficacy of drainage, rate of complications including retained hemothorax, need for additional tube drainage, or invasive procedures. Furthermore, tube size did not affect the pain felt by patients at the site of insertion.

TUBE THORACOSTOMY

Presenter

Presentation Notes


TUBE THORACOSTOMY

No significant difference in: Efficacy of drainage Retained hemothorax Need for additional tube drainage Invasive procedures

Presenter

Presentation Notes


PIGTAIL CATHETERS

• Pigtail Catheter (PC) (14-French)

• Less invasive• Less pain• Is it effective?

PIGTAIL CATHETERS IN PTX

Two-Year Experience of Using Pigtail Catheters to Treat Traumatic Pneumothorax: A Changing

TrendKulvatunyou, Narong MD; Vijayasekaran, Aparna MD; Hansen, Adam MD;

Wynne, Julie L. MD; O'Keeffe, Terrance MD; Friese, Randall S. MD; Joseph, Bellal MD; Tang, Andy MD; Rhee, Peter MD 2011

Retrospective observational

480 patients with pneumothorax

Pigtail vs chest tube

Outcomes: Complications Need for mechanical ventilation

Presenter

Presentation Notes

Background: The traditional treatment of patients with traumatic hemopneumothorax has been an insertion of a chest tube (CT). But CT, because of its large caliber and significant trauma during an insertion, can cause pain, prevent full lung expansion, and worsen pulmonary outcome. Pigtail catheters (PCs) are smaller and less invasive; they have worked well in patients with nontraumatic pneumothorax (PTX). The purpose of this study was to review our early experience of PC use in trauma patients. Methods: We retrospectively reviewed the charts of trauma patients who required CT or PC placement over a 2-year period (January 2008 through December 2009) at a Level I trauma center. The PCs were 14-French (14-F) Cook catheters placed by the trauma team, using a Seldinger technique. We compared outcome for the subgroups that had CT or PC placed for a PTX. For our statistical analysis, we used the unpaired Student t-test, χ2 test, and Wilcoxon rank-sum test; we considered a p value < 0.05 as significant. Results: Of 9,624 trauma patients evaluated, 94 were treated with PC and 386 with CT. Of the PC patients, 89% was inserted for PTX. When comparing patients with PC and CT inserted for PTX, demographics, tube days, need for mechanical ventilation, and insertion-related complications were similar. The tube failure rate, defined by a requirement for an additional tube or by recurrence that needed intervention, was higher in PC (11%) than in CT (4%) (p = 0.06), but the difference was not statistically significant. We observed a trend of increased PC use over time. Conclusion: PC is safe and can be performed at the bedside. It has a comparable efficacy to CT in patients with PTX. A prospective study is needed to determine the precise role of PC placement, including its indication, the associated tube-site pain, and any significant clinical advantages.


Presenter

Presentation Notes

Increased PC use over time



Pigtail catheters (n=3) Intervention

1- left subclavian vein insertion Transfusion, withdrawal catheter1 - intercostal artery injury chest tube placement1 - subcutaneous placement tube replacement

Chest tubes (n=4)

3 - subcutaneous placement tube replacement1 - tube dislodgement tube replacement

Complications


Complications

We concluded that pigtails by surgeons:

“Pigtail catheter was safe and equally effective when compared to chest tubein traumatic pneumothorax”

TUBE THORACOSTOMY

Small Catheter Tube Thoracostomy: Effective in Managing Chest Trauma in Stable PatientsRivera, Louis MD; O’Reilly, Eamon B. MD; Sise, Michael J. MD; Norton,

Valerie C. MD; Sise, C Beth RN, JD; Sack, Daniel I. BA; Swanson, Sophia M. BA; Iman, Rahwa B. BS; Paci, Gabrielle M. BA; Antevil, Jared L. MD

Retrospective

202 Tube thoracostomy

Small catheter (10-14Fr) vs large catheter (32-40Fr) tube thoracostomy

Outcomes: Length of stay Complications

2009

Presenter

Presentation Notes

Background: Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. Methods: Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. Results: There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. Conclusion: SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.

TUBE THORACOSTOMY

Presenter

Presentation Notes

Patients in Whom a Single Nonemergent TT Was Performed

TUBE THORACOSTOMY


Randomized Clinical Trial Of Pigtail Catheter Versus Chest Tube In Injured Patients With Uncomplicated Traumatic Pneumothorax

Yu-Chao Lin, MD, Chih-Yen Tu, MD, Shinn-Jye Liang, MD, Hung-Jen Chen, MD, Wei Chen, MD, , Te-Chun Hsia, MD, Chuen-Ming Shih, MD, PhD, Wu-

Huei Hsu, MD

Randomized clinical trial

70 PTX

Successful Vs. failed pigtail treatments

a

2014

Presenter

Presentation Notes

There has been a paucity of data regarding the efficacy and safety of small-bore chest tubes (pigtail catheter) for the management of pneumothorax in mechanically ventilated patients. Methods We conducted a retrospective review of mechanically ventilated patients who underwent pigtail catheter drainage as their initial therapy for pneumothorax in the emergency department and intensive care unit from January 2004 through January 2007 in a university hospital. Results Among the 62 enrolled patients, there were 41 men (66%) and 21 women (34%), with a mean age of 63.8 ± 20.3 years. A total of 70 episodes of pneumothoraces occurred in the intensive care unit, and 48 episodes of pneumothoraces (68.6%) were successfully treated with pigtail catheters. The average duration of pigtail drainage was 5.9 days (1–27 days). No major complications occurred through use of this procedure, except for pleural infections (n = 3, 4.2%) and clogged tube (n = 1, 1.4%). Comparing the variables between the success and failure of pigtail treatment, the failure group had a significantly higher proportion of Fio2 >60% requirement (45.5% vs. 14.6%, P = .005) and higher positive end-expiratory pressure levels (8.7 ± 3.0 vs. 6.2± 2.3 mm Hg, P = .001) at the time of pneumothorax onset than the success group. Further comparing the efficacy of pigtail drainage between barotraumas and iatrogenic pneumothorax, pigtail catheters for management of iatrogenic pneumothorax had a significantly higher success rate than barotraumas (87.5% vs. 43.3%, P < .0001). Conclusion Pigtail catheter drainage is relatively effective in treating iatrogenic but less promising for barotraumatic pneumothoraces.

PIGTAIL CATHETERS

Presenter

Presentation Notes

Comparing the variables between the success and failure of pigtail treatment, the failure group had a significantly higher proportion of Fio2 N60% requirement (45.5% vs. 14.6%, P = .005) and higher positive end-expiratory pressure levels (8.7 ± 3.0 vs. 6.2± 2.3 mm Hg, P = .001) at the time of pneumothorax onset than the success group. ��


Presenter

Presentation Notes

Pigtail catheter drainage is relatively effective in treating iatrogenic but less promising for barotraumatic pneumothoraces.


Pigtail Catheter For The Management Of Pneumothorax In Mechanically Ventilated

PatientsN. Kulvatunyou, L. Erickson, A. Vijayasekaran, L. Gries, B. Joseph, R. F.

Friese, T. O'Keeffe, A. L. Tang, J. L. Wynne, and P. Rhee 2014

Prospective randomized trial 14-Fr Pigtail vs 28-Fr chest tube 40 patients Outcomes: Tube site pain and use of pain meds Pneumothorax resolution Complications

a


Day 0

Day 1

Day 2

Day 0

Day 1 Day 2

02

46

8Nu

mer

ical P

ain

Ratin

g Sc

ore

28F Chest tube 14F Pigtail

Day 0 Day 1 Day 2

Tube-site pain score

Presenter

Presentation Notes

Mean numerical rating scale (NRS) tube-site pain score, by day after insertion, in patients with traumatic pneumothorax treated with a 14-Fr pigtail catheter or 28-Fr chest tube. P < 0·001 on days 0 and 1, P = 0·040 on day 2

Data Concludes:

■ NO DIFFERENCE IN FAILURE■ SAME SUCCESS RATE■ SAME Complication Rate■ Reduced PAIN

PIGTAIL CATHETERS IN HTX


A Pilot Study Of Chest Tube Versus Pigtail Catheter Drainage Of Acute Hemothorax In

SwineRusso, Rachel M. MD; Zakaluzny, Scott A. MD; Neff, Lucas P. MD; Grayson,

J. Kevin DVM, PhD; Hight, Rachel A. MD; Galante, Joseph M. MD; Shatz, David V. MD 2015

Swine model

6 Yorkshire swine

32Fr chest tube vs 14 Fr Pigtail

Outcome: Drain output

Presenter

Presentation Notes

BACKGROUND: Evacuation of traumatic hemothorax (HTx) is typically accomplished with large-bore (28–40 Fr) chest tubes, often resulting in patient discomfort. Management of HTx with smaller (14 Fr) pigtail catheters has not been widely adopted because of concerns about tube occlusion and blood evacuation rates. We compared pigtail catheters with chest tubes for the drainage of acute HTx in a swine model. METHODS: Six Yorkshire cross-bred swine (44–54 kg) were anesthetized, instrumented, and mechanically ventilated. A 32 Fr chest tube was placed in one randomly assigned hemithorax; a 14 Fr pigtail catheter was placed in the other. Each was connected to a chest drainage system at −20 cm H2O suction and clamped. Over 15 minutes, 1,500 mL of arterial blood was withdrawn via femoral artery catheters. Seven hundred fifty milliliters of the withdrawn blood was instilled into each pleural space, and fluid resuscitation with colloid was initiated. The chest drains were then unclamped. Output from each drain was measured every minute for 5 minutes and then every 5 minutes for 40 minutes. The swine were euthanized, and thoracotomies were performed to quantify the volume of blood remaining in each pleural space and to examine the position of each tube. RESULTS: Blood drainage was more rapid from the chest tube during the first 3 minutes compared with the pigtail catheter (348 ± 109 mL/min vs. 176 ± 53 mL/min), but this difference was not statistically significant (p = 0.19). Thereafter, the rates of drainage between the two tubes were not substantially different. The chest tube drained a higher total percentage of the blood from the chest (87.3% vs. 70.3%), but this difference did not reach statistical significance (p = 0.21). CONCLUSION: We found no statistically significant difference in the volume of blood drained by a 14 Fr pigtail catheter compared with a 32 Fr chest tube


Presenter

Presentation Notes

Blood drainage was more rapid from the chest tube during the first 3 minutes compared with the pigtail catheter (348 T�109 mL/min vs. 176 T 53 mL/min), but this difference was not statistically significant ( p = 0.19). Thereafter, the rates of drainage�between the two tubes were not substantially different. The chest tube drained a higher total percentage of the blood from the chest�(87.3% vs. 70.3%), but this difference did not reach statistical significance ( p = 0.21).�


14 French Pigtail Catheters Placed By Surgeons To Drain Blood On Trauma Patients:

Is 14-fr Too Small?Kulvatunyou, Narong MD; Joseph, Bellal MD; Friese, Randall S. MD; Green,

Donald MD; Gries, Lynn MD; O’Keeffe, Terence MD; Tang, Andy L. MD; Wynne, Julie L. MD; Rhee, Peter MD 2012

Prospective study

36 pigtail vs 191 chest tubes

Outcomes: Initial drainage output Tube duration Failure rate

Presenter

Presentation Notes

Small 14F pigtail catheters (PCs) have been shown to drain air quite well in patients with traumatic pneumothorax (PTX). But their effectiveness in draining blood in patients with traumatic hemothorax (HTX) or hemopneumothorax (HPTX) is unknown. We hypothesized that 14F PCs can drain blood as well as large-bore 32F to 40F chest tubes. We herein report our early case series experience with PCs in the management of traumatic HTX and HPTX. METHODS: We prospectively collected data on all bedside-inserted PCs in patients with traumatic HTX or HPTX during a 30-month period (July 2009 through December 2011) at our Level I trauma center. We then compared our PC prospective data with our trauma registry–derived retrospective chest tube data (January 2008 through December 2010) at our center. Our primary outcome of interest was the initial drainage output. Our secondary outcomes were tube duration, insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student’s t-test, χ2 test, and Wilcoxon rank-sum test; we defined significance by a value of p < 0.05. RESULTS: A total of 36 patients received PCs, and 191 received chest tubes. Our PC group had a higher rate of blunt mechanism injuries than our chest tube group did (83 vs. 62%; p = 0.01). The mean initial output was similar between our PC group (560 ± 81 mL) and our chest tube group (426 ± 37 mL) (p = 0.13). In the PC group, the tube was inserted later (median, Day 1; interquartile range, Days 0–3) than the tube inserted in our chest tube group (median, Day 0; interquartile range, Days 0–0) (p < 0.001). Tube duration, rate of insertion-related complications, and failure rate were all similar. CONCLUSION: In our early experience, 14F PCs seemed to drain blood as well as large-bore chest tubes based on initial drainage output and other outcomes studied. In this early phase, we were being selective in inserting PCs in only stable blunt trauma patients, and PCs were inserted at a later day from the time of the initial evaluation. In the future, we will need a larger sample size and possibly a well-designed prospective study.


Presenter

Presentation Notes

IO= Initial output

TUBE THORACOSTOMY

CHEST TUBEPIGTAIL

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Presentation Notes

Blood drainage was more rapid from the chest tube during the first 3 minutes compared with the pigtail catheter (348 T�109 mL/min vs. 176 T 53 mL/min), but this difference was not statistically significant ( p = 0.19). Thereafter, the rates of drainage�between the two tubes were not substantially different. The chest tube drained a higher total percentage of the blood from the chest�(87.3% vs. 70.3%), but this difference did not reach statistical significance ( p = 0.21).�

CLOTTED HEMOTHORAX

Wise man once said“Clot doesn’t come

out of any size hole…”

SUMMARY

Size does not matter• Unclotted blood will drain……14F PCs

• Clotted blood will not……… 32-40F CTs

Pigtail catheters are now considered standard of care for Trauma Pneumothorax

THANK YOU

Documents

PIGTAIL CATHETERS - UnityPoint Health...TENSION PNEUMOTHORAX Failure Rate Of Prehospital Chest Decompression After Severe Thoracic Trauma Alexander Kaserer, Philipp Stein, Hans-Peter