Chest Tube Research Articles

Use of colloids and crystalloids for perioperative clinical infusion management in cardiac surgery patients and postoperative outcomes: a meta-analysis

BackgroundThe optimal fluid management strategy for patients undergoing cardiac surgery was controversial regarding fluid volume and intraoperative fluid types. This study aimed to assess the correlation between colloids and crystalloids used for perioperative fluid therapy in cardiac surgery patients and postoperative prognosis.MethodsThe Ovid MEDLINE(R) ALL, Embase, and Cochrane Central Register of Controlled Trials databases were searched for eligible studies on fluid management strategies using colloids and crystalloids for cardiac surgery patients published before August 25th, 2023.ResultsTen randomized controlled trials met the eligibility criteria. Compared to the use of crystalloids, the use of colloids, including hydroxyethyl starch (HES), albumin, and gelatine, did not show any differences in mortality, transfusion, acute kidney injury, and atrial fibrillation rates, postoperative blood loss, the length of hospital stay, or the length of intensive care unit (ICU) stay. The results of this meta-analysis showed that the crystalloid group had significantly reduced postoperative chest tube output compared to the colloid group. In the subgroup analysis, the amount of fresh frozen plasma (FFP) infused was significantly lower when using fluid management in the ICU and when using isotonic crystalloids compared to the colloids. In addition, when using fluid management in the ICU, patients in the colloid group had a significant increase in urine volume 24 h after surgery. However, other related factors, including the type of crystalloid solution, type of colloidal solution, and timing of liquid management, did not affect most outcomes.ConclusionBoth colloids and crystalloids could be used as alternatives for perioperative fluid management after cardiac surgery. The use of crystalloids significantly reduced the postoperative chest tube output, and the need for FFP infusion decreased significantly with the use of isotonic crystalloids or fluid management during the ICU stay. ICU patients in the colloid group had higher urine output 24 h after surgery. In addition, although the infusion method was not related to most outcomes, the rates of red blood cell and FFP transfusion and postoperative blood loss in the crystalloid group seemed to be lower, which needed to be further studied in high-quality and large-sample RCTs.Trial registrationPROSPERO, CRD42023415234.

Chest Tube Placement for Possible Hemothorax

In this case, Drs. Suah, Clarkson-During, and Cone place a chest tube in a female patient with a possible hemothorax.

Perioperative fluid management for adult cardiac surgery: network meta-analysis pooling on twenty randomised controlled trials

BackgroundThe aim of this study was to evaluate colloids and crystalloids used in perioperative fluid therapy for cardiac surgery patients to further investigate the optimal management strategies of different solutions.MethodRCTs about adult surgical patients allocated to receive perioperative fluid therapy for electronic databases, including Ovid MEDLINE, EMBase, and Cochrane Central Register of Controlled Trials, were searched up to February 15, 2023.ResultsNone of the results based on network comparisons, including mortality, transfuse PLA, postoperative chest tube output over the first 24 h following surgery, and length of hospital stay, were statistically significant. Due to the small number of included studies, the results, including acute kidney injury, serum creatinine, serum microglobulin, and blood urea nitrogen, are from the direct comparison. For transfusion of RBCs, significant differences were observed in the comparisons of 3% gelatine vs. 6% HES 200/0.5, 4% albumin vs. 5% albumin, 4% gelatine vs. 5% albumin, 5% albumin vs. 6% HES 200/0.5, and 6% HES 130/0.4 vs. 6% HES 200/0.5. In transfusion of FFP, significant differences were observed in comparisons of 3% gelatine vs. 4% gelatine, 3% gelatine vs. 6% HES 200/0.5, 5% albumin vs. 6% HES 200/0.5, 4% gelatine vs. 5% albumin, 4% gelatine vs. 6% HES 200/0.4, and 6% HES 130/0.4 vs. 6% HES 200/0.5. For urinary output at 24 h after surgery, the results are deposited in the main text.ConclusionThis study showed that 3% gelatin and 5% albumin can reduce the transfuse RBC and FFP. In addition, the use of hypertonic saline solution can increase urine output, and 5% albumin and 6% HES can shorten the length of ICU stay. However, none of the perioperative fluids showed an objective advantage in various outcomes, including mortality, transfuse PLA, postoperative chest tube output over the first 24 h following surgery, and length of hospital stay. The reliable and sufficient evidences on the injury of the kidney, including acute kidney injury, serum creatinine, serum microglobulin, and blood urea nitrogen, was still lacking. In general, perioperative fluids had advantages and disadvantages, and there were no evidences to support the recommendation of the optimal perioperative fluid for cardiac surgery.

Characterisation of pulmonary air leak measurements using a mechanical ventilator in a bench setup

Prolonged air leakage (AL) following pulmonary resections leads to prolonged hospital stay and post-operative complications. Intra- and postoperative quantification of AL might be useful for improving treatment decisions, but these measurements have not been characterised. AL calculations based on inspiratory and expiratory tidal volumes were investigated in an Intensive Care Unit mechanical ventilator circuit (Servo-I). AL was also measured by a digital chest drainage system. This study shows that AL measurements increase in accuracy when corrected for baseline deviations (R: 0.904 > 0.997, p < 0.001). Bland-Altman analysis revealed a funnel-shape, indicative of a detection threshhold. Corrected measurements were most accurate when averaged over five breaths and AL was >500 mL/min, with an estimated mean systemic bias of 7.4% (95%-limits of agreement [LoA]: 1.1%-13.7%) at 500 mL/min air leak. Breath-by-breath analysis showed most accurate results at AL >20 mL/breath (R: 0.989–0.991, p < 0.001) at tidal volumes between 350–600 mL. The digital drain had a mean systemic bias of −11.1% (95%-LoA: −18.9% to −3.3%) with homogenous scatter in Bland-Altman analysis and a strong correlation to the control measurement over a large range (0–2000mL/min, R: 0.999, p < 0.001). This study indicates that the Servo-I can be used for air leak quantification in clinically relevant ranges (>500 mL/min), but is unsuited for small leak detection due to a detection threshold. Researchers and clinicians should be aware of varying accuracy and interoperability characteristics between AL measurement devices.

Chest tube management following two row vertebral body tethering for adolescent idiopathic scoliosis

Background The current gold standard of scoliosis correction procedures is still posterior spinal fusion, an extensively studied procedure. anterior vertebral body tethering is a newer surgical technique for the correction of scoliotic curves. Consequently, best practices have yet to be determined. Methods A single-institution, retrospective, review of all patients diagnosed with adolescent idiopathic scoliosis who underwent two row anterior vertebral body tethering between June 2020 and April 2022 was performed. Results Over the study period, 95 patients met inclusion: 79 females (83.2%) and 16 males (16.8%), age 14.4 ± 2.5 years, with a body mass index of 20.0 ± 2.9, and an average of 8.4 ± 2.1 levels treated. 28 (29.5%) procedures were for double curves and 67 (70.5%) for single curves. After tethering, a chest tube was positioned in each corrected side. A total of 123 chest tubes were analyzed, including 67 single curves and 28 double curves. The average chest tube duration was 2.5 ± 1.1 days and the average length of stay was 5.0 ± 2.0 days. The average chest tube output eight hours prior to removal was 61.1 ± 45.6 mL. There was no significant difference in average length of stay for patients who underwent correction of a single curve versus a double curve nor was there a difference in average length of stay or chest tube duration for revisions compared to primary procedures. For the entire cohort, the 30-day emergency department visit rate was 7.4% (n = 7) and the readmission rate was 4.2% (n = 4). Conclusions This early review of a 2-year two row vertebral body tethering postoperative experience provides a report of a safe and effective approach to chest tube management at a single academic center.

Recurrent spontaneous pneumothorax secondary to lung cystic lesions in a case of convalescent COVID-19: a case report and literature review

BackgroundWhile spontaneous pneumothorax has been documented in COVID-19 patients, reports on recurrent spontaneous pneumothorax due to cystic lesions in convalescent COVID-19 patients are scarce. The progression of these lung cystic lesions remains inadequately explored.Case presentation and literature reviewAn 81-year-old male, a non-smoker with a history of rheumatoid arthritis, presented with fever, cough, and expectoration for 14 days. Initially diagnosed with moderate COVID-19, he deteriorated to severe COVID-19 despite adherence to local treatment guidelines. Successive identification of three cystic lesions termed “bulla” or “pneumatocele”, and one cystic lesion with air-fluid level, referred to as “pneumo-hamatocele” (PHC), occurred in his lungs. Gradual improvement followed anti-inflammatory therapy and optimal supportive care. However, on day 42, sudden worsening dyspnea prompted a computed tomography (CT) scan, confirming a right spontaneous pneumothorax and subcutaneous emphysema, likely due to PHC rupture. Discharge followed chest tube implementation for pneumothorax resolution. On day 116, he returned to the hospital with mild exertional dyspnea. Chest CT revealed recurrent right pneumothorax from a remaining cyst in the right lung. Apart from our patient, literature retrieval identified 22 COVID-19 patients with spontaneous pneumothorax due to cystic lesions, with a male predominance (95.6%; 22/23). Diagnosis of pneumothorax and lung cystic lesions occurred around day 29.5 (range: 18–35) and day 26.4 (± 9.8) since symptom onset, respectively. Except for one patient whose pneumothorax occurred on day seven of illness, all patients eventually recovered.ConclusionsRecurrent spontaneous pneumothorax secondary to lung cystic lesions may manifest in convalescent COVID-19 patients, particularly males with COVID-19 pneumonia. Chest CT around 2 to 3 weeks post-symptom onset may be prudent to detect cystic lesion development and anticipate spontaneous pneumothorax.

Safety of one 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage after uniportal video-assisted thoracoscopic surgery pneumonectomy

ObjectivesUniportal video-assisted thoracoscopic surgery pneumonectomy (U-VATS-P) is feasible and safe from a perioperative standpoint. How to choose the proper chest tube and drainage method is important in enhanced recovery after surgery (ERAS) protocols. In this study, we aimed to assess the safety of one 8.5-Fr (1Fr = 0.333 mm) pigtail catheter for postoperative continuous open gravity drainage after U-VATS-P.MethodsWe retrospectively reviewed a single surgeon’s experience with U-VATS-P for lung cancer from May 2016 to September 2022. Patients were managed with one 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage after U-VATS-P. The clinical characteristics and perioperative outcomes of the patients were retrospectively analyzed.ResultsIn total, 77 patients had one 8.5-Fr pigtail catheter placed for postoperative continuous open gravity drainage after U-VATS-P for lung cancer. The mean age was 60.9\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}7.39 (40–76) years; The mean FEV1 was 2.1\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}0.6 (l/s), and the mean FEV1% was 71.2\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}22.7. The median operative time was 191.38\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}59.32 min; the mean operative hemorrhage was 109.46\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}96.56 ml; the mean duration of postoperative chest tube drainage was 6.80\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}2.33 days; the mean drainage volumes in the first three days after operation were 186.31\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}50.97, 321.97\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}52.03, and 216.44\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}35.67 ml, respectively; and the mean postoperative hospital stay was 7.90\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document}2.58 days. No patient experienced complications resulting from chest tube malfunction. Ten patients experienced minor complications. One patient with nonlife-threatening empyema and bronchopleural fistula required short rehospitalization for anti-inflammatory therapy and reintubation. Three patients with chylothorax were treated with intravenous nutrition. Four patients had atrial fibrillation that was controlled by antiarrhythmic therapy. Two patients had more thoracic hemorrhagic exudation after the operation, which was found in time and was cured effectively, so they were discharged from the hospital uneventfully after early hemostatic therapy and nutritional support.ConclusionsAll patients in this study received early postoperative rehabilitation, and the rate of relevant complications was low. We therefore recommend a single 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage as an effective, safe and reliable drainage method for the management of U-VATS-P.

Outcomes after 4 years’ experience with low suction drains. Would it be safe to go drainless or low suction?

BackgroundThe principles of chest drainage have not changed significantly since 1875 when Bülau introduced the idea of underwater drainage tube which became a trademark of thoracic surgery. We performed a prospective, randomized trial comparing omitting pleural drain (drainless group) versus drainage with small low suction drain (drainage group) strategies of thoracic surgery when the visceral pleura remains intact. Aiming to investigate whether these approaches represent safe treatment options.MethodsA multi-center, prospective, parallel group, randomized, controlled trial enrolling patients after thoracic procedures in which visceral pleura remained intact at the end of surgery between August 2020 and September 2023. After completion of the procedure a suction-seal test was conducted on all patients. If suction-seal test was positive to confirm absence of air leak, patients were randomized to either receive low auto-suction drain as a solo pleural drain (drainage group) or not to receive drain (drainless group).ResultsDuring the study period, 111 patients were recruited. Eleven patients had negative Suction-seal test and were excluded by inserting a traditional underwater seal. The remaining 100 patients were randomly assigned to either drainage group with low suction drain (Fig. 1) (n = 50) or drainless group (n = 50).ConclusionThe results of this study suggest that either omitting drain or inserting a low auto suction drain safely substitutes the one-way valve when the visceral pleura remains intact. Omitting drain or inserting portable small caliber drain encourages early mobilization and is associated with shorter hospital stay.

Bed occupancy and nosocomial infections in the intensive care unit: A retrospective observational study in a tertiary hospital

Background. Healthcare-associated infections (HAI) are a major problem globally, contributing to prolonged hospital admissions and poor outcomes. Objective. To examine HAI incidence and risk factors in an intensive care unit (ICU) during high v. low occupancy periods. Methods. This retrospective, descriptive analysis investigated HAI incidence among adult patients admitted to the ICU at Chris Hani Baragwanath (CHBH) during a high (H2019) and low (L2020) occupancy. Data were extracted from the clinical records of 440 eligible patients. Results. We found an increased risk of HAI during H2019 compared with L2020 (relative risk (RR) 1.42, 95% confidence interval (CI) 1.03 - 1.94). The overall frequency density of HAI was 25/1 000 ICU days. There was no difference in the distribution of the site of infection (blood v. other) (p=0.27) or bacterial category (Gram stain) (p=0.62). Five organisms accounted for 89% of pathogens: Klebsiella (26%), Staphylococcus (21%), Acinetobacter (16%), Candida (16%) and Enterobacter (10%). The incidence of multidrug-resistant/extensively drug-resistant (MDR/XDR) organisms was 4.2-fold higher (95% CI 1.3 - 13.4) during H2019 compared with L2020. Logistic regression analysis revealed two independent predictors of nosocomial infection: ICU length of stay (odds ratio (OR) 1.12, 95% CI 1.02 - 1.22) and intercostal drain duration in days (OR 1.27, 95% CI 1.09 - 1.47). Conclusion. High occupancy in the ICU was associated with an increased risk of HAI and a greater incidence of MDR and XDR pathogens. Increasing ICU length of stay and invasive device duration were independent predictors of HAI.

When are pulmonologists consulted? Trends and outcomes of pulmonary consultations for unspecified hypoxia

Background Clinical judgment is essential in determining the need for specialist consultation. We evaluated patients for whom the pulmonary team was consulted for unspecified hypoxia or acute hypoxic respiratory failure to better understand the characteristics and outcomes of such encounters. Methods We retrospectively studied patients who received consults for unspecified hypoxia or acute hypoxic respiratory failure at a tertiary center. Outcomes evaluated were length of stay, duration of follow-up, and clinical trajectory. Results We identified 103 patients over a 2-year period. The level of care was escalated in 69.9% (n = 72) of patients, and the majority had procedural interventions such as bronchoscopies and chest tube placement. Common diagnoses were pneumonia and volume overload. The mortality rate was 17.5% (n = 18). The mean length of stay was 24 days (standard deviation [SD] 24.1), with an average of 6.6 hospital days (SD 9.9) to consultation. The mean duration of consecutive follow-up was 4.5 days (SD 7.5). Patients who underwent procedures had a shorter duration of follow-up. Conclusion Pulmonary consults were noted for common diagnoses with a high need for escalation in care and procedural interventions, highlighting the importance and appropriateness of specialist consultations. Further studies are needed to explore what triggers an unspecified consult.

Successful management of a delayed presentation of traumatic descending thoracic aorta pseudoaneurysm: a literature review based on a case report

BackgroundBlunt traumatic aortic injury (BTAI) is the second leading cause of death due to traumas in young patients. The primary presentation might be chest or interscapular pain, difficulty in breathing, and, in severe cases, hypotension. Considering the rapid deterioration of these patients’ clinical conditions, prompt diagnosis and treatment initiation are crucial. In these injuries, the most involved parts of the aorta are the isthmus (distal to the left subclavian artery) and the descending part in the thorax. Therefore, the main diagnostic strategies include transthoracic echocardiography, CT angiography, and endovascular diagnostic approaches.Case presentationThe patient was a 19-year-old male presenting with the symptoms of chest pain, dyspnea, and extremities excruciating pain after a car turnover. The initial evaluation showed no abnormal cardiovascular finding except bilateral hemothorax, addressed with chest tubes. Twelve hours later, when the patient was under observation for orthopedic surgeries, his chest pain and dyspnea started, and TTE and CTA showed a grade three descending aneurysm of the aorta. The patient was treated immediately with an endovascular procedure of stent implantation. A delayed debranching surgery was also performed, which resulted in desirable outcomes and uneventful follow-up.ConclusionAlthough open thoracic surgery is the main and almost the only option for treating aneurysms of the aorta in hemodynamically unstable patients, the endovascular procedure has shown superior outcomes in selected patients with appropriate anatomy. Debranching surgery, which can be done simultaneously or with delay after the initial procedure, has proven protective against thromboembolic cerebral events.Clinical key pointPatients with an aneurysm of the aorta should be transported to a medical center with a multidisciplinary team for an urgent evaluation and treatment. The initial resuscitation and diagnosis are challenging, considering the fatal nature of these injuries, and the selection of the treatment is based on the patient's clinical condition and evaluated anatomy in cardiovascular imaging.

The Simultaneous Bilateral Surgical Procedure for Bilateral Primary Lung Cancer.

Objective: At present, the incidence of synchronous multiple primary lung cancer (SMPLC) is increasing, and the treatment is still a challenge. This study aims to investigate the appropriate surgical procedure for treating bilateral primary lung cancer simultaneously. Methods: A retrospective analysis was conducted on clinical data from 32 patients who underwent simultaneous bilateral lung cancer surgery in our team. This data included patient characteristics, pulmonary function indicators, surgical procedures, operation duration, chest tube removal time, postoperative hospital stay, and postoperative complications. Results: Out of the 32 patients, 15 were male, and 17 were female, with an average age of 56.4 ± 8.8 years. The average maximum diameter of the main and minor tumors was 1.8 ± 1.0 cm and 1.0 ± .5 cm, respectively. All surgeries were performed thoracoscopically through intercostal approach. The procedure for the minor tumor was performed first, followed by the main tumor operation after turning over. One case was converted to thoracotomy during the main tumor operation because of bleeding. Postoperative complications occurred in one patient. No instances of respiratory insufficiency or failure were observed after the operation, and there were no perioperative deaths or readmissions within 90 days. Conclusion: Simultaneous bilateral thoracoscopic surgery is deemed a secure and feasible option for eligible patients with bilateral primary lung cancer, and it is advisable to commence the operation on the minor tumor first.

The Possible Role of Lymphaticovenous and Lymph Node to Vein Anastomosis for Improvement of Milroy Disease Related Congenital Chylothorax and Lower Extremity Lymphedema.

Primary lymphedema is characterized by lymphatic dysplasia in which one variant is Milroy's disease. The association with congenital chylothorax is even rarer with poor outcome. This is the first report to utilize peripheral lymphovenous anastomosis (LVA) and lymph node to vein anastomosis (LNVA) for the management of such condition. Retrospective chart review of patients with Milroy's disease with complication of chylothorax between 2019 till 2023 was performed. Clinical assessment and radiological investigations were reviewed. Six patients with mean age of 12±3.9 years and disease duration of 10.5±2.8 years were reviewed. Three had ISL stage 3 while others had stage 2 late disease. All had bilateral lower extremity lymphedema and chylothorax with history of chest tube drainage. After LVA and LNVA, significant reduction in extremity volume was noted (p=0.028) along with near complete resolution of chylothorax was noted during the long-term follow-up (32 ±17.9 months). Milroy's disease complicated with chylothorax remains to be challenging. This is the first report utilizing peripheral bypass (LVA and LNVA) which resulted in improvement of both lower extremity lymphedema and chylothorax. The utility of this approach represents a promising modality in the management of this devastating condition.

A Comprehensive Study on Ruptured Liver Abscess in a Tertiary Care Center.

Background Bacteria and parasites cause liver abscesses (LAs), with the unusual but fatal consequence of ruptured LA. Along with the clinical signs of icterus, right upper quadrant pain, and a history of loose stools, patients present with non-specific symptoms such as fever, nausea, and generalized weakness. Consistent findings include male sex prevalence and frequent alcohol consumption. Leukocytosis, abnormal liver function, and an increased international normalized ratio have been identified by biochemical analysis; however, these findings are not specific to a ruptured LA diagnosis, and imaging is necessary to reach a definitive diagnosis. Ultrasonography usually confirms the diagnosis, and computed tomography is required in certain situations. In confined ruptures, percutaneous drainage combined with antibiotic therapy is typically the initial treatment course. Generally reserved for non-responders or moribund patients with delayed presentation, an open surgical approach may involve simple draining of a ruptured abscess or ileocecal resection, or right hemicolectomy in cases of large bowel perforations, both of which increase patient morbidity. A definite guide to management is still missing in the literature. In this article, we have discussed and correlated with data the predictors of surgery and preoperative predictors of perforation. Materials and methods This retrospective study was performed at Safdarjung Hospital, New Delhi, between January 2022 and December 2023. The study included 115 patients diagnosed with ruptured LA by ultrasound. Medical records were analyzed, and various parameters of the illness, clinical features, hematological and biochemical profiles, ultrasound features, and therapeutic measures were noted and assessed. Results Of the 115 patients, 88% (n = 101) were male. The most common symptoms were abdominal pain (114 patients) and right upper abdominal tenderness (107 patients).Fifty-two patients were treated with percutaneous drainage, and 42 underwent laparotomy. Intercostal drainage (ICD) tubes were placed in 19 patients. Sixteen patients had large bowel perforations. Twenty-three patients died (20%), including 17 patients who underwent laparotomy and nine patients who had large bowel perforation (39.1% associated with overall mortality, 52.9% associated with mortality in laparotomy). One patient with percutaneous drainage and a right ICD tube died in the intensive care unit. Four patients died before intervention. Significant associations were noted between perforation and mortality in patients who underwent surgical drainage. Loose motions, alcohol and smoking consumption, and deranged creatinine and albumin levels were found to have a significant association with surgical drainage. Conclusion The study found that a ruptured liver abscess (LA)may require surgery to drain the collection or repair the pathological bowel, which increases the morbidity, but it is a lifesaving procedure over percutaneous catheter drainage. The study also identified factors associated with a higher risk of death, such as a history of loose stools and low blood albumin levels.

A dimensional analysis of experienced intensive care unit nurses' clinical decision-making for bleeding after cardiac surgery.

Bleeding following cardiac surgery is common and serious, yet a gap persists in understanding how experienced intensive care nurses identify and respond to such complications. To describe the clinical decision-making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery. This qualitative study adopted the Recognition-Primed Decision Model as its theoretical framework. Thirty-nine experienced nurses from four adult intensive care units participated in semi-structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory. Participants maintained consistent vigilance towards post-cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision-making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability. Nurses' decision-making was shaped by their personal attributes, the patient's condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision-making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation. This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability-focused educational programmes, and understanding decision-making intricacies are crucial for informing nursing education and decision-support systems.

Simultaneous bilateral video-assisted thoracic surgery is safe and feasible for multiple primary lung cancers

BackgroundThe treatment for bilateral synchronous multiple primary lung cancers (MPLC) remains challenging. Simultaneous bilateral video-assisted thoracic surgery (VATS) may be an optimal treatment with curative intent, but its safety and feasibility are controversial.MethodsOne hundred and fifty-eight patients who underwent simultaneous bilateral VATS (simultaneous group) and 79 who underwent two-staged bilateral VATS (two-staged group) were included in this study. Their medical records were retrospectively reviewed and analyzed.ResultsThe majority of patients were female and non-smokers. The most common surgical plan was lobectomy and contralateral wedge resection in both groups. There was no significant difference in the postoperative complication rate between the simultaneous groups and two-staged group (13.3% vs. 11.4%, p = 0.73). Patients who underwent simultaneous bilateral resection had shorter hospital stays, shorter anesthesia time and less chest drainage compared with those who underwent two-staged resection. Advanced TNM stage, complicated surgical plan and aggressive lymph node resection were risk factors for postoperative complications in simultaneous bilateral VATS. Patients in two groups had similar overall survival and disease free survival (p = 0.2).ConclusionsSimultaneous bilateral VATS for bilateral lung nodule resection is as safe and feasible as two-staged bilateral VATS. Patients who underwent simultaneous bilateral resection had similar or even better outcomes compared to that of the two-staged group. Simultaneous bilateral VATS is potentially an optimal treatment option for patients with erarly cTNM stage and good physical condition.

Patent conversion of a novel closed chest drainage device

Closed chest drainage is typically necessary following Lobar and Sublobar resections to evacuate gases and fluids from the thoracic cavity, eliminate residual pleural space for lung expansion, and maintain negative pressure. Currently, three conventional closed chest drainage systems are commonly employed: single-chamber, double-chamber, and triple-chamber systems; each system has its own advantages and disadvantages. Despite the emergence of digital drainage systems in recent years, their high cost hinders their widespread adoption. Based on this premise, our research team has achieved a patent for a micro air pump-integrated chest closed drainage bottle, which has been further developed into a novel device integrating a three-chamber system with negative pressure control and power supply capabilities. This device enables patients undergoing perioperative lung procedures to ambulate freely while simultaneously receiving chest suction therapy—a concept that theoretically promotes rapid postoperative recovery. Moreover, this device offers economic benefits and holds potential for clinical implementation (particularly in economically underdeveloped regions). In this article, we modified the thoracic closed drainage device based on our patent and presented this novel thoracic closed drainage device after 3D printing and assembly.

Safety and efficacy of tract embolization using gelatin sponge particles in reducing pneumothorax after CT-guided percutaneous lung biopsy in patients with emphysema

BackgroundThe incidence of pneumothorax is higher in patients with emphysema who undergo percutaneous lung biopsy. Needle embolization has been shown to reduce the incidence of pneumothorax in patients with emphysema. Existing studies have reported small sample sizes of patients with emphysema, or the degree of emphysema has not been graded. Therefore, the efficacy of biopsy embolization in the prevention of pneumothorax induced by percutaneous pulmonary biopsy in patients with emphysema remains to be determined.MethodsIn this retrospective, controlled study, patients with emphysema who underwent CT-guided PTLB were divided into two groups: group A (n = 523), without tract embolization, and Group B (n = 504), with tract embolization. Clinical and imaging features were collected from electronic medical records and Picture Archiving and Communication Systems. Univariate and multivariate analyses were performed to identify risk factors for pneumothorax and chest tube placement.ResultsThe two groups did not differ significantly in terms of demographic characteristics and complications other than pneumothorax. The incidence of pneumothorax and chest tube placement in group B was significantly lower than in group A (20.36% vs. 46.12%, p < 0.001; 3.95% vs. 9.18%, p < 0.001, respectively). In logistic regression analyses, variables affecting the incidence of pneumothorax and chest tube placement were the length of puncture of the lung parenchyma (odds ratio [OR] = 1.18, 95% confidence interval [CI]: 1.07–1.30, p = 0.001; OR = 1.55, 95% CI: 1.30–1.85, p < 0.001, respectively), tract embolization (OR = 0.31, 95% CI: 0.24–0.41, p < 0.001; OR = 0.39, 95% CI: 0.22–0.69, p = 0.001, respectively), and grade of emphysema.ConclusionsTract embolization with gelatin sponge particles after CT-guided PTLB significantly reduced the incidence of pneumothorax and chest tube placement in patients with emphysema. Tract embolization, length of puncture of the lung parenchyma, and grade of emphysema were independent risk factors for pneumothorax and chest tube placement.Trial registrationRetrospectively registered.

A Multidisciplinary Curriculum to Standardize Chest Procedures Training for Trainees in General Surgery, Emergency Medicine, and Critical Care.

Critical care, emergency medicine, and surgical trainees frequently perform surgical and Seldinger-technique tube thoracostomy, thoracentesis, and thoracic ultrasound. However, approaches to teaching these skills are highly heterogeneous. Over 10 years, we have developed a standardized, multidisciplinary curriculum to teach these procedures. Emergency medicine residents, surgical residents, and critical care fellows, all in the first year of their respective programs, underwent training in surgical and Seldinger chest tube placement and securement, thoracentesis, and thoracic ultrasound. The curriculum included preworkshop instructional videos and 45-minute in-person practice stations (3.5 hours total). Sessions were co-led by faculty from emergency medicine, thoracic surgery, and pulmonary/critical care who performed real-time formative assessment with standardized procedural steps. Postcourse surveys assessed learners' confidence before versus after the workshop in each procedure, learners' evaluations of faculty by station and specialty, and the workshop overall. One hundred twenty-three trainees completed course evaluations, demonstrating stable and positive responses from learners of different backgrounds taught by a multidisciplinary group of instructors, as well as statistically significant improvement in learner confidence in each procedure. Over time, we have made incremental changes to our curriculum based on feedback from instructors and learners. We have developed a unique curriculum designed, revised, and taught by a multidisciplinary faculty over many years to teach a unified approach to the performance of common chest procedures to surgical, emergency medicine, and critical care trainees. Our curriculum can be readily adapted to the needs of institutions that desire a standardized, multidisciplinary approach to thoracic procedural education.

Management of patient with Fusobacterim nucletum related pleural empyema: intrapleural antibiotic therapy can be considered for salvage therapy

Pleural empyema can lead to significant morbidity and mortality despite chest drainage and antibiotic treatment, necessitating novel and minimally invasive interventions. Fusobacterium nucleatum is an obligate anaerobe found in the human oral and gut microbiota. Advances in sequencing and puncture techniques have made it common to detect anaerobic bacteria in empyema cases. In this report, we describe the case of a 65-year-old man with hypertension who presented with a left-sided encapsulated pleural effusion. Initial fluid analysis using metagenomic next-generation sequencing (mNGS) revealed the presence of Fusobacterium nucleatum and Aspergillus chevalieri. Unfortunately, the patient experienced worsening pleural effusion despite drainage and antimicrobial therapy. Ultimately, successful treatment was achieved through intrapleural metronidazole therapy in conjunction with systemic antibiotics. The present case showed that intrapleural antibiotic therapy is a promising measure for pleural empyema.