Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial

Nathaniel R McLauchlan; Noah M Igra; Lydia T Fisher; James P Byrne; Carl A Beyer; Zhi Geng; Daniela Schmulevich; Martha M Brinson; Ryan P Dumas; Daniel N Holena; Allyson M Hynes; Claire B Rosen; Amit N Shah; Michael A Vella; Jeremy W Cannon

doi:10.1136/tsaco-2022-001050

Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial

Trauma Surg Acute Care Open. 2023 Mar 20;8(1):e001050. doi: 10.1136/tsaco-2022-001050. eCollection 2023.

Authors

Affiliations

¹ Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
² Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
³ Johns Hopkins Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
⁴ Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁵ UT Southwestern Medical, Dallas, Texas, USA.
⁶ Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
⁷ University of New Mexico School of Medicine, Albuquerque, New Mexico, USA.
⁸ CLR Medical, Calverton, Maryland, USA.
⁹ Surgery, University of Rochester Medical Center, Rochester, New York, USA.

Abstract

Objective: To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial.

Summary background data: Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined.

Methods: A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage.

Results: A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001).

Conclusion: This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted.

Level of evidence: NA.

Keywords: Hemothorax; Thoracic Injuries.