Small-bore Drain Research Articles

1086 Improving the Use of Chest Drains in Trauma - Small but Perfectly Formed

Abstract Aim The Western Trauma Association (WTA) advocates using small-bore chest drains (e.g., 14Fr) in haemodynamically normal trauma patients for management of small Haemothoraxes (HTX) or Pneumothoraxes (PTX). This quality improvement project aimed to assess implementation of this guidance. Method We compared the use and outcomes of small-bore chest drains for management of HTX or PTX before (Cohort 1) and after (Cohort 2) adoption of WTA recommendations in a District General Hospital in London. We included all patients admitted under the General Surgeons with rib fractures. Results All patients were admitted with blunt chest injuries. Cohort 1: 60 patients [36 males, mean age 72 years (range 31-96)] admitted from May–December 2021. Cohort 2: 78 patients [42 males, mean age 73 years (range 23-102)] admitted from May–December 2022. In cohort 1, 10 patients (16%) required chest drains, all were surgically inserted large bore drains (median size 28 Fr) there were no peri-procedural complications. In cohort 2, 11 patients (14%) required chest drains; 5 were surgically placed large bore drains (median size 28 Fr) and 6 were small-bore drains inserted by Seldinger technique (median size 18Fr). Two large-bore drains had periprocedural complications and both required re-insertion. The mean age was 60 years. In the small-bore group, there were no peri-procedural complications, no drains occluded and the mean age was 75 years. Conclusions After the implementation of this policy, small-bore drain use increased and appeared safe. This audit supports recent literature suggesting small-bore drains are as effective as larger bore and better tolerated.

FTP1.13 Improving the use of chest drains in trauma - Small but perfectly formed

Abstract Aims The Western Trauma Association (WTA) advocates using small-bore chest drains (e.g. 14Fr) in haemodynamically normal trauma patients for management of small Haemothoraxes (HTX) or Pneumothoraxes (PTX). This quality improvement project aimed to assess implementation of this guidance. Method We compared the use and outcomes of small-bore chest drains for management of HTX or PTX before (Cohort 1) and after (Cohort 2) adoption of WTA recommendations in a District General Hospital in London. We included all patients admitted under the General Surgeons with rib fractures. Results All patients were admitted with blunt chest injuries. Cohort 1: 60 patients [36 males, mean age 72 years (range 31-96)] admitted from May–December 2021. Cohort 2: 77 patients [42 males, mean age 73 years (range 23-102)] admitted from May–December 2022. In cohort 1, 10 patients (16%) required chest drains, all were surgically inserted large-bore drains (median size 28 Fr) there were no peri-procedural complications. In cohort 2, 11 patients (14%) required chest drains; 5 were surgically placed large bore drains (median size 28 Fr) and 6 were small-bore drains inserted by Seldinger technique (median size 18Fr). Two large-bore drains had periprocedural complications and both required re-insertion. The mean age was 60 years. In the small-bore group there were no peri-procedural complications, no drains occluded and the mean age was 75 years. Conclusion After the implementation of this policy, small-bore drain use increased and appeared safe. This audit supports recent literature suggesting small-bore drains are as effective as larger bore and better tolerated.

Efficacy of Small versus Large-Bore Chest Drain in Pleural Infection: A Systematic Review and Meta-Analysis

Background: Pleural infection represents a significant clinical challenge worldwide. Although prompt drainage of pleural fluid is thought to play a key role in pleural infection management, the optimal size of intrapleural catheter has yet to be defined. Objectives: The aim of this systematic review and meta-analysis was to summarize data on efficacy and complications of small-bore drain (SBD), defined as ≤14F, in comparison to large-bore drain (LBD) in patients with pleural infection. Method: We searched MEDLINE and Embase for all studies reporting outcomes of interest published up to October 2021. Two authors reviewed selected full text to identify studies according to predefined eligibility criteria. Summary estimates were derived using the random-effects model. Results: Twelve original studies were included for qualitative analysis and 7 of these for quantitative analysis. The surgical referral rate of SBD and LBD were, respectively, 0.16 (95% confidence interval [CI], 0.12–0.21) and 0.20 (95% CI, 0.10–0.32), the pooled mortality were 0.12 (95% CI, 0.05–0.21) and 0.20 (95% CI, 0.10–0.32), and the length of hospital stay was 24 days in both groups. Data on complications suggest similar proportions of tube dislodgement. Intensity of pain was evaluated in one study only, reporting higher scores for LBD. Conclusions: This systematic review and meta-analysis provide the first synthesis of data on performance of SBD and LBD in management of pleural infection, and, overall, clinical outcomes and complications did not substantially differ, although the limited number of studies and the absence of dedicated randomized trials does limit the reliability of results.

Efficacy of High Level Intrapleural Suction and Small Bore Drain in the Conservative Management of Multiloculated Pleural Effusions

Efficacy of High Level Intrapleural Suction and Small Bore Drain in the Conservative Management of Multiloculated Pleural Effusions

Outpatient management of primary spontaneous pneumothorax: a prospective study

We prospectively assessed the safety and cost saving of a small-bore drain based procedure for outpatient management of first episodes of primary spontaneous pneumothorax. Patients were managed by observation alone or insertion of an 8.5-F "pig-tail" drain connected to a one-way valve, according to size and clinical tolerance of the pneumothorax. All patients were reassessed after 4 h, on the first working day after discharge and on day 7. Patients still exhibiting air leak on day 4 underwent thoracoscopy. The primary end-point was complete lung re-expansion at day 7. 60 consecutive patients entered the study. 48 (80%) met the definition of large pneumothorax. The success rate was 83%. The 1-year recurrence rate was 17%. 36 (60%) patients were discharged after 4 h and 50% had full outpatient management. No severe complication was observed. The mean ± SD length of hospitalisation was 2.3 ± 3.1 days. This policy resulted in about a 40% reduction in hospital stay-related costs. The present study supports the use of a single system combined with a well-defined management algorithm including safe discharge criteria, as an alternative to manual aspiration or chest tube drainage. This approach participates in healthcare cost-savings.

Editorial: Acute subdural hematoma

In the accompanying case report, Flint and colleagues1 describe the use of an urgently placed closed subdural drain as a temporizing measure for the treatment of an acute subdural hematoma (SDH) in an acutely decompensating patient. This drain was used to stabilize the patient until a definitive craniotomy could be performed in an emergency fashion. Although the authors are to be commended for their innovative approach to saving the life of a patient in extremis, there are some definite risks, and caveats, to using this strategy as a matter of course for the treatment of acute SDH. First, it is important to note that this particular patient was receiving anticoagulation drugs at the time of presentation (aspirin and clopidogrel) and that the appearance of a “hyperacute” collection on CT scanning may have represented a lack of intrinsic clotting rather than true hyperacute bleeding. This fact also likely improved the chances that a small-bore, percutaneous drain will have remained patent for any period of time. One would not be able to count on that happening in other patients so treated. It is also fortunate that the rate of active bleeding in this patient was likely rather low, allowing a small-bore drain to keep pace with the ongoing accumulation of subdural blood. This would not necessarily be the case in many patients in whom larger veins or arteries are the source of bleeding. Furthermore, there is a theoretical risk that decompressing the existing SDH may unleash much more furious bleeding that the percutaneous drain would not be able to handle. My biggest concern with the authors’ strategy is that it may result in an unnecessary delay in definitive therapy. The procedure itself would likely take at least 30 minutes to complete, and might inadvertently result in delaying a patient’s preparation and transportation to a neurosurgical operating room, where the necessary craniotomy could be performed. This is to say nothing about the added risk of infection that is inherent in performing an emergency percutaneous procedure at the bedside. Despite these cautions, I think this report points out a strategy that can be used in unique circumstances in an effort to temporize an acutely deteriorating patient with poor clotting and an enlarging acute SDH. Flint and colleagues demonstrate that when there is an insurmountable delay in getting such patients to the operating room, neurosurgeons can do more than just watch their patients deteriorate. Disclosure

Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces

To compare treatment success of large- and small-bore chest drains in the treatment of spontaneous pneumothoraces the case-notes were reviewed of those admitted to our hospital with a total of 73 pneumothoraces and who were treated by trainee doctors of varying experience. Both a large- and a small-bore intercostal tube drain system were in use during the two-year period reviewed. Similar pneumothorax profile and numbers treated with both drains were recorded, resulting in a similar drain time and numbers of successful and failed re-expansion of pneumothoraces. Successful pneumothorax resolution was the same for both drain types and the negligible tube drain complications observed with the small-bore drain reflected previously reported experiences. However the large-bore drain was associated with a high complication rate (32%) with more infectious complications (24%). The small-bore drain was prone to displacement (21%). There was generally no evidence of an increased failure and morbidity, reflecting poorer expertise, in the non-specialist trainees managing the pneumothoraces. A practical finding however was that in those large pneumothoraces where re-expansion failed, the tip of the drain had not been sited at the apex of the pleural cavity irrespective of the drain type inserted.