Search

Objective: To point out our experience and assess the efficacy and safety of real-time ultrasound-guided central internal jugular vein (IJV) catheterization in the treatment of hemodialysis patients. Methods: This retrospective study comprised 150 patients with end-stage renal disease (ESRD) who had real-time ultrasonography (US)-guided IJV HD catheters placed in our hospital between March 2019 and March 2021. Patients were examined for their demographic data, etiology, site of catheter insertion, type (acute or chronic) of renal failure, technical success, operative time, number of needle punctures, and procedure-related complications. Patients who have had multiple catheter insertions, prior catheterization challenges, poor compliance, obesity, bony deformity, and coagulation disorders were considered at high-operative risk. Results: All patients experienced technical success. In terms of patient clinical features, an insignificant difference was observed between the normal and high-risk groups (p-value > 0.05). Of the 150 catheters, 62 (41.3%) were placed in high-risk patients. The first-attempt success rate was 89.8% for the normal group and 72.5% for the high-risk group (p = 0.006). IJV cannulation took less time in the normal-risk group compared to the high-risk group (21.2 ± 0.09) minutes vs (35.4 ± 0.11) minutes, (p < 0.001). There were no serious complications. During the placing of the catheter in the internal jugular vein, four patients (6.4%) experienced arterial puncture in the high-risk group. Two participants in each group got a small neck hematoma. One patient developed a pneumothorax in the high-risk group, which was managed with an intercostal chest tube insertion. Conclusions: Even in the high-risk group, the real-time US-guided placement of a central catheter into the IJV is associated with a low complication rate and a high success rate. Even under US guidance, experience lowers complication rates. Real-time US-guided is recommended to be used routinely during central venous catheter insertion. [ABSTRACT FROM AUTHOR]

Introduction: Critical Care Air Transport Team (CCATT) is a three-person United States Air Force (USAF) medical asset, typically providing intercontinental medical evacuation on large military aircraft. The CCATT equipment Allowance Standard (AS) weighs approximately 272 kg (600 lbs). In austere locations, CCATT teams may augment contract medical evacuation (CME) personnel or Pararescue (PJ) in small aircraft with limited space for medical equipment. It was unknown what deployed PJ and CME carry within their packouts. We sought to design a packout or "Go Bag," weighing less than 22.7 kg (50 lbs) and sourced from the CCATT AS, that a CCATT member could use to complement CME or PJ equipment to provide a higher level of care while limiting redundancy. Materials and Methods: Equipment lists were obtained from a CME and PJs from two separate USAF squadrons. The equipment lists were combined to provide a reference for development of a CCATT Go Bag. Three members of a deployed CCATT team independently generated a list of necessary equipment from the CCATT AS. The list was peer reviewed by a separate, deployed CCATT team. Results: A Go Bag was developed with the supplies and equipment necessary for video laryngoscopy, ventilation, invasive pressure monitoring, basic laboratory capability, chest tube placement, ultrasound, and advanced pharmacologic interventions. The Go Bag weighed 18.3 kg (40.4 lbs). A separate respiratory bag weighing 1.1 kg (2.4 lbs) was attached directly to a ventilator. Intravenous pumps and cardiac monitoring equipment were notable ICU equipment excluded from the Go Bag. Conclusion: Major components of the CCATT AS can be reduced into a Go Bag and accompanying Ventilator Accessory Bag. This may benefit CCATT teams required to augment PJs or CME in small aircraft during prolonged field care scenarios. [ABSTRACT FROM AUTHOR]

Background: Total thoracoscopic segmentectomy (TTS) is a technically challenging procedure in children but results in more parenchyma preservation, better pain control, better cosmetic results, and a shorter hospital stay. However, definitive data describing the learning curve of TTS has yet to be obtained. Here, we review the safety and efficiency of our initial experiences with pediatric TTS and evaluate our learning curve. Methods: This was a retrospective study of all pediatric patients undergoing TTS between December 2016 and January 2020. Pediatric patients who underwent TTS were included, while those undergoing lobectomy or wedge resection were excluded. Results: One hundred and twelve patients were retrospectively analyzed to evaluate the learning curve and were divided chronologically into three phases, the ascending phase (A), plateau phase (B) and descending phase (C), through cumulative summation (CUSUM) of the operative time (OT). Phases A, B, and C comprised 28, 51, and 33 cases, respectively. OT decreased significantly from phases A to B (p < 0.001) and from phase B to C (p = 0.076). No significant differences were observed in the demographic factors among the three phases. The conversion rate was zero, and the complication rate was 0.9%. Differences in technical parameters, such as length of stay and chest tube duration, were statistically insignificant between phases A and B or B and C. There were no mortalities. Conclusion: CUSUMOT indicates that the learning curve of at least 79 cases is required for TTS in our institute. We emphasize that the learning curve should be cautiously interpreted because many factors in different institutions may influence the exact parabola and actual learning curve. [ABSTRACT FROM AUTHOR]

Background. Conditions that appear four weeks after infection with SARS-CoV-2 are accepted as "post COVID". Spontaneous pneumothorax (SP) is one of these late COVID consequences. Our aim is to present a series of cases with this post COVID complication. Case series. We present four patients with post COVID expression of spontaneous pneumothorax. These patients were non-smokers; never ventilated and had no underlying pre-existing lung diseases and they were treated and recovered from COVID-19 pneumonia in an outpatient setting. Tube thoracostomy, under video-assisted control in three of the patients, was performed as a management of pneumothorax. Conclusion. With these case series, we highlight SP as an expression of long-term COVID-19 morbidity. The effectiveness of thoracoscopy in the diagnosis and management of such type of secondary late COVID-19 spontaneous pneumothorax was demonstrated. [ABSTRACT FROM AUTHOR]

The Research to Practice column critiques a current research article and translates the findings, in the context of a case, to a practice change within emergency settings. This article reviews the findings of a randomized controlled trial conducted by A. Theille et al. (2017) comparing the use of needle decompression versus chest tube insertion formanagement of spontaneous pneumothorax. The study found that use of needle aspiration was safe and effective and was associated with fewer procedure-related complications and significantly shorter hospital stays. The investigators concluded that needle aspiration be used as a first-line, definitive treatment in management of a spontaneous pneumothorax. As emergency providers examine improved and equally effective approaches to care that are associated with less costs and potential complications, needle aspiration offers a beneficial approach and should be shared with patients when discussing treatment options to ensure shared decision making. [ABSTRACT FROM AUTHOR]

Background: Traumas are the leading cause of death in the first four decade of life. Thoracic trauma might lead to severe life threatening complications. Tube thoracostomy is lifesaving procedure for these complications. Objectives: The study was performed to evaluate outcome related to chest tube malposition, to assess the requirement of replacement of chest tube and to study the role of HRCT in post intercostal drain (ICD) patients. Methods: It was a retrospective observational study. The study was conducted on post ICD patients with persistent collapsed lungs for >3 days. Injury severity and patient outcomes were analyzed with respect to insertion environment, and the positions of chest tubes and necessity for replacement is assed after HRCT thorax. Results: Fifty patients who underwent chest tube replacement met the inclusion criteria. Majority of the patients were male (68%), age in between 40-49 years (40%) with blunt trauma (86%). Chest tubes were in the pleural space in 84% of cases. Most of the chest tubes (72%) were inserted in the resuscitation room. In the overall analysis, we found a significant trend (p=0.017) for longer hospital stay in patients without targeted chest tubes positions. Out-of-hospital chest tube insertion required higher replacement rates than resuscitation room insertions (57.1 vs 2.8%, p= <0.001). Conclusion: Patients with malposition of emergency chest tube according to CT were not associated with worse outcomes as most of the complications resolved spontaneously. Outof- hospital chest tube insertions were associated with higher replacement rates compared to resuscitation room chest tube insertion. HRCT helps to identify any other lung injury/ involvement along with ICD malposition. [ABSTRACT FROM AUTHOR]

ARDS in general and severe COVID ARDS (CARDS) is particularly associated with high rates of barotrauma. Two cases with severe CARDS developed bilateral pneumothorax with persistent air leak (PAL). Conservative management with prolonged chest tube drainage did not help in PAL resolution and both patients continued to be on high‐end ventilatory support. The course was further complicated by the presence of septic shock. The 1st patient was taken up for a challenging procedure after spending 23 days on the mechanical ventilator. Diagnostic pleuroscopy revealed left‐sided bullae and a surgical staple bullectomy was done. The right side showed a large bronchopleural fistula (BPF) on pleuroscopy, which was occluded using a customized endobronchial silicone blocker (CESB, described in 2018). This led to the reduction and finally, resolution of the bilateral PAL with subsequent removal of chest drains and weaning off the ventilator and oxygen. The second patient was managed with 2 CESB devices for occlusion of RUL anterior and posterior segment fistulae, followed by chest drain removal. These cases highlight effective out‐of‐the‐box multimodality treatment using a combination of interventional pulmonary techniques and surgical stapling for a life‐threatening bilateral PAL secondary to CARDS. [ABSTRACT FROM AUTHOR]

Objective: In this study, we aimed to determine whether plasma calcium level and C-reactive protein albumin ratio (CAR) as well as other demographic and hematological markers are related in predicting severe bleeding after coronary artery bypass grafting (CABG). Methods: A total of 227 adult patients who underwent CABG at our hospital between December 2021 and June 2022 were prospectively studied. Total amount of chest tube drainage was evaluated within the first 24 hours postoperatively or until the patient was re-explored for bleeding. The patients were divided into two groups — Group 1, patients with low amount of bleeding (n=174), and Group 2, patients with severe bleeding (n=53). Univariate and multivariate regression analyzes were performed to determine independent parameters related to severe bleeding within the first 24 hours after surgery. Results: When the groups were compared in terms of demographic, clinical, and preoperative blood parameters; cardiopulmonary bypass time and serum C-reactive protein (CRP) levels were found to be significantly higher in Group 2 compared to the low bleeding group. In addition, lymphocytes, hemoglobin, calcium, albumin, and CAR were found to be significantly lower in Group 2. In multivariate analysis, calcium, albumin, CRP, and CAR were found to be independent predictors of significant association with excessive bleeding. A cut-off value of 8.7 (94.3% sensitivity and 94.8% specificity) for calcium and 0.155 (75.4% sensitivity and 80.4% specificity) for CAR predicted excessive bleeding. Conclusion: Plasma calcium level, CRP, albumin, and CAR can be used to predict severe bleeding after CABG [ABSTRACT FROM AUTHOR]

Background: Pleural empyema, marked by pus accumulation around the lungs, presents a formidable clinical challenge. Current trends emphasize anatomy-guided approaches, leveraging advanced imaging and minimally invasive techniques. This shift recognizes the significance of precise anatomical localization for tailored interventions, promising improved outcomes. Objective: This study aimed to find out the anatomy-guided approaches for pleural empyema and Outcomes of Surgical versus non-surgical treatment of pleural empyema. Methodology: The current retrospective cohort research was conducted at LRH on hospitalized patients with empyema who received treatment on a regular schedule between January 2021 and 2023. The present retrospective cohort analysis was conducted in a single location using anatomy-guided approaches by surgery (VATS & open thoracotomy decortication techniques) and non-surgical (medical & chest tubes drainage with or without fibrin lytic drugs) treatments related to thoracic surgery/General surgery and respiratory medicine wards. The statistical test instrument used was the independent t-test on demographic data. Results: out of 130 patients, the cure rate was 27 % (n=35), while the death rate was 0.3% (n=1). A VATS decortication was performed on 13 out of 149 individuals who were judged to be in Stage II. The technique was turned into an open procedure when the findings revealed a 0% success rate with decortication after thoracotomy. Patients who had thoracotomy decortication got a cure rate of 96.4%, and there were two deaths out of the 113 patients. N=2 (1.8%) required an open window thoracostomy due to an untreated empyema, whereas four (3.5%) required thoracoplasty. The patients treated with tube thoracostomy and chest incision decortication had total hospitalization durations of 15.4 ± 2.1 and 6.2 ± 1.8 days (P < 0.001). Accordingly, 98.2% and 27.1% were the success rates for surgical and nonsurgical therapies. Conclusion: Thoracotomy decortication treatment is generally the first rank choice with more excellent success rates than non-surgical approaches because of the advanced stages of empyema in our patients. However, these days, most research reports on the efficaciousness of non-surgical and VATS care of empyema. [ABSTRACT FROM AUTHOR]

Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the 'safe zone' of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation. [ABSTRACT FROM AUTHOR]

Background: Tracheobronchial injury (TBI) is a rare but potentially life-threatening trauma that requires prompt diagnosis and treatment. We present a case in which a patient with COVID-19 infection was successfully treated for a TBI through surgical repair and intensive care with extracorporeal membrane oxygenation (ECMO) support. Case presentation: This is the case of a 31-year-old man transported to a peripheral hospital following a car crash. Tracheal intubation was performed for severe hypoxia and subcutaneous emphysema. Chest computed tomography showed bilateral lung contusion, hemopneumothorax, and penetration of the endotracheal tube beyond the tracheal bifurcation. A TBI was suspected; moreover, his COVID-19 polymerase chain reaction screening test was positive. Requiring emergency surgery, the patient was transferred to a private negative pressure room in our intensive care unit. Due to persistent hypoxia and in preparation for repair, the patient was started on veno-venous ECMO. With ECMO support, tracheobronchial injury repair was performed without intraoperative ventilation. In accordance with the surgery manual for COVID-19 patients in our hospital, all medical staff who treated this patient used personal protective equipment. Partial transection of the tracheal bifurcation membranous wall was detected and repaired using 4-0 monofilament absorbable sutures. The patient was discharged on the 29th postoperative day without postoperative complications. Conclusions: ECMO support for traumatic TBI in this patient with COVID-19 reduced mortality risk while preventing aerosol exposure to the virus. [ABSTRACT FROM AUTHOR]

Pleural empyema often requires surgical intervention; however, surgical invasiveness should be minimized. We utilized the modified Claget procedure as an alternative to thoracoplasty for acute pleural empyema with a dead space. The procedure was performed as follows: first, 500 mg of kanamycin and 500,000 units of polymyxin sulfate dissolved in 10–100 ml saline was instilled intrapleurally via tube thoracostomy. The chest tube was clamped overnight and then removed. The modified Clagett procedure might be effective for acute pleural empyema with a dead space without pulmonary or bronchopleural fistula. We report our successful experience of performing modified Clagett procedure for pleural empyema with a dead space, through a detailed case presentation. [ABSTRACT FROM AUTHOR]

Introduction: A debate currently exists regarding the efficacy of pigtail catheters vs chest tubes in the management of thoracic trauma. This meta-analysis aims to compare the outcomes of pigtail catheters vs chest tubes in adult trauma patients with thoracic injuries. Methods: This systematic review and meta-analysis were conducted using PRISMA guidelines and registered with PROSPERO. PubMed, Google Scholar, Embase, Ebsco, and ProQuest electronic databases were queried for studies comparing the use of pigtail catheters vs chest tubes in adult trauma patients from database inception to August 15th, 2022. The primary outcome was the failure rate of drainage tubes, defined as requiring a second tube placement or VATS, unresolved pneumothorax, hemothorax, or hemopneumothorax requiring additional intervention. Secondary outcomes were initial drainage output, ICU-LOS, and ventilator days. Results: A total of 7 studies satisfied eligibility criteria and were assessed in the meta-analysis. The pigtail group had higher initial output volumes vs the chest tube group, with a mean difference of 114.7 mL [95% CI (70.6 mL, 158.8 mL)]. Patients in the chest tube group also had a higher risk of requiring VATS vs the pigtail group, with a relative risk of 2.77 [95% CI (1.50, 5.11)]. Conclusions: In trauma patients, pigtail catheters rather than chest tubes are associated with higher initial output volume, reduced risk of VATS, and shorter tube duration. Considering the similar rates of failure, ventilator days, and ICU length-of-stay, pigtail catheters should be considered in the management of traumatic thoracic injuries. Study Type: Systematic Review and meta-analysis. [ABSTRACT FROM AUTHOR]

Introduction: Thoracic esophageal perforation (TEP) remains a therapeutic challenge that carries with it a high mortality. Because of its rare occurrence and management is complex, most patients are referred to higher level of care. Management is variable, ranging from a stent placement to an esophagectomy. Unfortunately, stent capabilities may not be readily available and the different surgical approaches can be complex, time-consuming, and demanding on a septic patient. Given these challenges, we conceived a simple 6-step (1) Antibiotics, (2) Suture the cervical esophagus with a 0- chromic, (3) Suture the abdominal esophagus with a 3-0 chromic, (4) Insert nasogastric tube above the sutured cervical esophagus, (5) Support nutrition with a jejunostomy, and (6) Tubes (placement of bilateral chest tubes). Methods: Six consecutive septic patients with TEP who underwent an ASSIST approach were evaluated. On day 14, patients were taken to the OR for an esophagogastroduodenoscopy to open the cervical and hiatal esophageal closure. Patients then underwent a repeat barium swallow prior to resuming per oral (PO) intake. Results: Sepsis resolved in all patients. One patient died of advanced cirrhosis. None of the living patients required additional surgery and all resumed a normal diet. Conclusions: The "ASSIST" method is a viable option for managing septic patients with thoracic esophageal perforation. This novel approach does not require a high level of technical expertise and conceivably be performed by most centers without the need for immediate transfer to specialized facilities. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to compare the clinical effects of lobectomy and sublobar resection in the treatment of lung metastasis and to analyse the factors affecting patient prognosis. Methods: A retrospective analysis was performed on the clinical data of patients with pulmonary metastasis who underwent thoracic surgery at the Affiliated Cancer Hospital of Xinjiang Medical University between March 2010 and May 2021. Results: A total of 165 patients who underwent pulmonary metastasectomy (PM) for lung metastasis met the inclusion criteria. Compared with the lobectomy group, the sublobar resection group had shorter operation time for pulmonary metastases (P < 0.001), lower intraoperative blood loss (P < 0.001), lower drainage volume on the first day after surgery (P < 0.001), lower incidence of prolonged air leak (P = 0.004), shorter drainage tube indwelling time (P = 0.002), and shorter postoperative hospital stay (P = 0.023). Multivariate analysis showed that sex (95% confidence interval (CI), 0.390–0.974; P = 0.038), disease‐free interval (DFI) (95% CI, 1.082–2.842; P = 0.023), and postoperative adjuvant therapy (95% CI, 1.352–5.147; P = 0.004) were independent influencing factors of disease‐free survival of patients who underwent PM. DFI (95% CI, 1.062–3.894; P = 0.032) and preoperative carcinoembryonic antigen (CEA) level (95% CI, 1.420–5.163; P = 0.002) were independent factors influencing the overall survival of patients in this group. Conclusion: Sublobar resection provides a safe and effective treatment option for patients with pulmonary metastasis on the premise of ensuring resection of lung metastasis R0. Female sex, longer DFI, the use of postoperative adjuvant therapy and a lower preoperative CEA level were all favourable prognostic factors. [ABSTRACT FROM AUTHOR]

Congenital pulmonary airway malformation (CPAM) is a very rare phenomenon subject to malignant transformation that requires surgical resection. In an asymptomatic 10-year-old girl, we identified a single cystic and consolidated lesion on computed tomography. This incidental finding was confined to anterior segment of lung in right upper lobe (RUL). Uniportal video-assisted thoracoscopic surgery (VATS) served to successfully achieve anterior segmentectomy, without chest tube placement. The surgical specimen confirmed features of CPAM, also showing acute and chronic inflammation with abscess formation. Once the surgical mainstay for such lesions, open lobectomy is now under challenge by thoracoscopic technique, port-reduction methods, and a lung-preserving strategy. Herein, we have shown uniportal VATS anatomical resection of right anterior pulmonary segment to be a viable option for a 10-year-old child with CPAM confined to a single lung segment. [ABSTRACT FROM AUTHOR]

Background The management of intraoperative bleeding during thoracoscopic lobectomy is challenging, especially for non-experienced surgeons. We evaluated intraoperative bleeding in relation to learning curve of thoracoscopic lobectomy, the strategies to face it, the outcomes, and the target case number for gaining the technical proficiency. Methods This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy for lung cancer. Based on cumulative sum analysis, patients were divided into early and late experience groups, and the differences on surgical outcomes, with particular focus on vascular injury, were statistically compared. Results Eight-three patients were evaluated. Cumulative sum charts showed a decreasing of operative time, blood loss, and hospital stay after the 49th, the 43th, and the 39th case, respectively. Early (n = 49) compared with late experience group (n = 34) was associated with higher conversion rate (p = 0.08), longer operative time (p <0.0001), greater blood loss (p <0.0001), higher transfusion rate (p = 0.01), higher postoperative air leak rate (p = 0.02), longer chest tube stay (p <0.0001), and hospitalization (p <0.0001). Six patients (7%) had intraoperative bleeding during early phase of learning curve, successfully treated by thoracoscopy in four cases. Patients with vascular injury (n = 6) compared with control group (n = 77) presented a longer operative time (p = 0.003), greater blood loss (p = 0.0001), and higher transfusion rate (p = 0.001); no significant differences were found regarding postoperative morbidity (p = 0.57), length of chest tube stay (p = 0.07), and hospitalization (p = 0.07). Conclusion Technical proficiency was achieved after 50 procedures. All vascular injuries occurred in the early phase of learning curve; they were safely managed, without affecting surgical outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Draining the chest cavity with 2 tubes is a common practice among thoracic surgeons. This research was conducted in Addis Ababa from March 2021 to May 2022. A total of 62 patients were included. STUDY DESIGN: This study was conducted to investigate the superiority of either single or double tube insertion after decortication. Patients were randomized in a ratio of 1:1. In group A, 2 tubes were inserted; in group B, single 32F tubes were inserted. Statistical analyses were performed using Statistical Package for Social Sciences version 27.0, Student’s t test and Pearson chi-square test. RESULTS: The age range of patients was 18 to 70 years, with a mean of 44 ± 14.4434 years; the male to female ratio was 2.9:1. The dominant underlying pathologies were tuberculosis and trauma (45.2% vs 35.5%); the right side was more involved (62.3%). Drain output was 1,465 ± 1,887.9751 mL in group A vs 1,018 ± 802.5662 mL in group B (p value = 0.00001); the duration of drains was 7.5498 ± 11.3137 days in group A vs 3.8730 ± 1.4142 days in group B (p value = 0.000042). The degree of pain was 2.6458 ± 4.2426 vs 2.000 ± 2.1213 in group A and group B, respectively (p value = 0.326757). The length of hospital stay was 21.5818 ± 11.9791 days in group A vs 13.6091 ± 6.2048 days in group B (p value = 0.00001). Group A had air leak of 90.3% vs 74.2% in group B; subcutaneous emphysema was 9.7% in group A and 12.9% in group B. There was no fluid recollection, and no patients required tube reinsertion. CONCLUSIONS: The placement of a single tube after decortication is effective in reducing drain output, time of drain, and hospital stay. There was no association with pain, and there was no effect on other endpoints. [ABSTRACT FROM AUTHOR]

We presented the case of an adult patient with hyper‐IgE syndrome (HIES) who was admitted acutely with a large hydropneumothorax from lung consolidation, a bronchopleural fistula and pleural infection. He has had recurrent pulmonary and skin infections since childhood and longstanding pneumatoceles. He was treated with systemic antibiotics and chest tube drainage. Administration of two doses of low‐dose intrapleural therapy (1 mg tissue plasminogen activator and 5 mg deoxyribonuclease) allowed complete evacuation of his residual loculated pleural fluid, aided resolution of his infection without provoking a significant air leak and avoided the need for surgery. [ABSTRACT FROM AUTHOR]

BackgroundNearly every child undergoing congenital heart surgery has chest tubes placed intraoperatively. Center variation in removal practices and impact on outcomes has not been well described. This study evaluated variation in chest tube management practices and outcomes across centers.MethodsThe study included patients undergoing any of 10 benchmark operations from June 2017 to May 2018 at participating Pediatric Acute Care Cardiology Collaborative (PAC3) and Pediatric Cardiac Critical Care Consortium (PC4) centers. Clinical data from PC4 centers were merged with chest tube data from PAC3 centers. Practices and outcomes were compared across centers in univariate and multivariable analysis.ResultsThe cohort included 1029 patients (N = 9 centers). Median chest tube duration varied significantly across centers for 9 of 10 benchmark operations (all P ≤ .03), with a "model" center noted to have the shortest duration for 9 of 10 operations (range, 27.9% to 87.4% shorter duration vs other centers across operations). This effect persisted in multivariable analysis (P < .0001). The model center had higher volumes of chest tube output before removal (median, 8.5 mL/kg/24 h [model] vs 2.2 mL/kg/24 h [other centers]; P < .001], but it did not have higher rates of chest tube reinsertion (model center 1.3% vs 2.1%; P = .59) or readmission for pleural effusion (model center 4.4% vs 3.0%; P = .31), and had the shortest length of stay for 7 of 10 operations.ConclusionsThis study suggests significant center variation in chest tube removal practices and associated outcomes after congenital heart surgery. Best practices used at the model center have informed the design of an ongoing collaborative learning project aimed at reducing chest tube duration and length of stay.

Introduction: South Africa's significant burden of trauma and respiratory disease requires the regular need for intercostal drain (ICD) insertion. ICD misplacement is associated with significant complications. The aim of this study was to assess ICD insertion site accuracy and the factors affecting accuracy by Emergency Department doctors. Methods: This was a prospective, observational simulation-based study. Prior to participant admission, pertinent thoracic structures were marked on two simulated patients using an invisible marker which could only be seen using ultraviolet light. One by one, study participants were then asked to place a sticker on each side of each patient's chest to indicate where they would insert an ICD. Sticker placements were photographed under ultraviolet light. Placement sites were compared according to the most appropriate and accurate position for insertion (within the area superior to the 6th rib, posterior to pectoralis major and 1cm anterior to the mid-axillary line) as well as the British Thoracic Society's ‘triangle of safety’. Comparisons of accuracy were made between participant rank (junior vs senior doctor), participant experience, simulated patient BMI category and placement side. Results: Insertion site was accurate in 47% of placements and within the ‘triangle of safety’ in 51% of placements. Improved accuracy was associated with greater participant experience (61% vs. 37%, p

Abstract Background Pleural infection is an infection of the pleural space that is usually treated with antibiotics and source control. Chest tube insertion is the most popular and widely used drainage technique. We typically attempt to place the tube at the bottom of the thoracic cavity to consider the effects of gravity; however, the effectiveness of this practice is not well-defined. Therefore, we aimed to examine whether the position of the tip of the thoracic tube affects treatment failure in patients with pleural infection. Methods In this retrospective observational study, patients with pleural infection who underwent thoracic tube insertion were divided into two groups: those with the tip of the tube positioned below the 10th thoracic vertebra at the level of the diaphragm (lower position group) and those with the tip placed above the 9th thoracic vertebra (upper position group). We compared whether the position of the tube tip affected treatment failure. Stabilized inverse probability treatment weights (SIPTW) were used to balance the baseline characteristics between the groups. Treatment failure showed a composite outcome of hospital death, referral to surgeons for surgery, and additional chest tube insertion. Results Among the 87 patients, 41 and 46 patients were in the lower and upper groups, respectively. No significant difference was observed in the composite outcomes between the groups (46.3% vs. 54.3%, P = 0.596). There was also no significant difference in the composite outcome between both groups after adjusting for SIPTW (52.3% vs. 68.8%, P = 0.286). Conclusions There were no significant differences in the treatment failure in this study addressing pleural infection treatment, in which the drain tip position was stratified by the 9th and 10th thoracic vertebrae. The position of the tip of the thoracic tube may not be important for pleural infection treatment providing that it is in the thoracic cavity. Trial registration The participants were registered retrospectively.

Background: Retained hemothorax is a serious problem that can lead to empyema or fibro-thorax. Evacuation of the retained hemothorax is commonly performed via open thoracotomy. This randomized study was conducted to represent our center's expertise with this issue, we compared the outcomes of video-assisted thoracoscopic surgery (VATS) against open thoracotomy in managing post-traumatic retained clotted hemothorax. Methods: This prospective randomized research was conducted on sixty cases with posttraumatic remaining clots of at least 500 ml or at least one-third of haemothorax that cannot be evacuated by a chest tube after 72 h of first intervention, as detected by computed tomography imaging who underwent open thoracotomy or VATS in the management of posttraumatic retained clotted hemothorax. Cases were allocated to equal groups; group A: cases who underwent VATS and group B: cases who underwent open thoracotomy. Results: Preoperative intercostal chest tube (ICT) placement period was insignificantly different between the two groups. Group A had a significantly lesser post-operative amount of ICT drainage, and ICT was removed after significantly fewer days than in group B (P value < 0.001). Post-operatively, the numerical rating scale (NRS) was significantly higher at post-extubation and 6 h after extubation in group B than group A (P value < 0.05) and was insignificantly different between both groups the next morning, after chest tube removal and before discharge. group A had statistically better NRS versus group B (P value < 0.001). Wound infection incidence was significantly less in group A compared to group B (P value = 0.025); the incidence of air leak was insignificantly different between both groups. Group A has significantly shorter hospitalization than group B (P value < 0.001). Wound infection and empyema in outcases were insignificantly different between both groups (P value = 0.492). Cases in group A returned to normal activity earlier than group B (P value < 0.001). Conclusions: VATS in managing posttraumatic retained hemothorax was a more effective, well-tolerated, and reliable intervention that can be easily utilized for managing posttraumatic retained hemothorax in comparison to open thoracotomy. [ABSTRACT FROM AUTHOR]

Background and aim: Chest tube removal (CTR) can cause severe acute pain which is usually described by patients as a painful experience. This study compared the effects of cold compress, transcutaneous electrical nerve stimulation (TENS), and combined cold compress-TENS on CTR-associated pain among patients with coronary artery bypass grafting (CABG). Methods: This randomized controlled trial was conducted in 2018–2019 using a double-blind four-group design. Participants were 120 patients with CABG selected from Shafa hospital, Kerman, Iran, and randomly allocated to a cold compress, a TENS, a combined cold compress-TENS, and a placebo group (compress with room temperature) and TENS with an off TENS device. Each participant received the intervention for 15 min immediately before CTR. CTR-associated pain was assessed before, during, immediately after, and 15 min after CTR. Data were analyzed using the SPSS program (v. 22.0) at a significance level of less than 0.05. Results: The data of 29 participants in the placebo group, 26 in the TENS group, 30 in the cold compress group, and 26 in the combined cold compress-TENS group was gathered. Baseline demographic and clinical characteristics and pain intensity scores of participants had no statistically significant differences among all four groups (P > 0.05). The mean score of pain intensity in all groups was at its highest level during CTR and gradually decreased afterwards, but this pain intensity reduction in the compress-TENS group was significantly greater than other groups (P < 0.001). Conclusion: Combined cold compress-TENS is more effective than separate cold compress and TENS in reducing CTR-associated pain among patients with CABG. Therefore, non-pharmacological methods such as combined cold compress-TENS are recommended for managing CTR-associated pain. [ABSTRACT FROM AUTHOR]

Background: Thymoma is associated with autoimmune diseases. Myasthenia gravis is frequently associated with thymoma, but cases of thymoma complicated by alopecia areata are very rare. In this report, we present a case of thymoma associated with alopecia areata, but without Myasthenia gravis. Case presentation: A 60-year-old woman had a complaint of rapid progression of alopecia areata. A hair follicular biopsy was performed, which showed the infiltration of CD8-positive lymphocytes. She was prescribed topical steroids for 2 months prior to surgery, but her hair loss was not improved. Screening computed tomography showed a mass in the anterior mediastinum, which was suspected to be a thymoma. Myasthenia gravis was ruled out because she had no relevant symptoms or physical findings, and no anti-acetylcholine receptor antibodies were detected in serum. We performed a transsternal extended thymectomy based on a diagnosis of thymoma Masaoka stage I, without myasthenia gravis. Pathological examination showed Type AB thymoma, Masaoka stage II. The chest drainage tube was removed on postoperative day 1, and the patient was discharged on postoperative day 6. The patient has continued topical steroids and showed improvement 2 months postoperatively. Conclusions: Although alopecia areata is a rare complication in thymoma cases without myasthenia gravis, thoracic surgeons need to keep this condition in mind because alopecia reduces the patient's quality of life. [ABSTRACT FROM AUTHOR]

Objective: to determine the validity of the Global Leadership Initiative on Malnutrition (GLIM) against the Patient Generated-Subjective Global Assessment (PG-SGA) as a gold standard tool in malnutrition diagnosis, and to assess the impact of malnutrition diagnosed using GLIM and PG-SGA on the clinical outcomes of patients with esophageal squamous carcinoma (ESCC) resection. Methods: we prospectively analyzed 182 patients with ESCC who underwent radical esophagectomy at Zhongshan Hospital, Xiamen University, between October 2018 and December 2019. Preoperative malnutrition was diagnosed using GLIM and PG-SGA, and the postoperative clinical outcomes, including postoperative complications, postoperative chest tube indwelling time, length of stay and total hospitalization cost, were recorded. The association between the prevalence of malnutrition defined by the two tools and postoperative clinical outcomes was evaluated. Results: among the 182 ESCC patients, the incidence of malnutrition before surgery was 58.2 % and 48.4 % defined by PG-SGA and GLIM, respectively. GLIM and PG-SGA had good consistency in nutritional assessment of ESCC patients (k = 0.628, p < 0.001). Malnourished patients had higher TNM stages and older ages (all p < 0.05). Patients with malnutrition as assessed by PG-SGA and GLIM had a higher incidence of postoperative complications, a longer indwelling time of chest tube after esophagectomy, longer hospital length of stay, and higher hospitalization costs than patients with good nutrition (p < 0.001). Comparing the predictive efficiency of postoperative complications, the sensitivity of PG-SGAand GLIM-defined malnutrition were 81.6 % and 79.6 %, the specificity were 50.4 % and 63.2 %, the Youden index were 0.320 and 0.428, and the Kappa value were 0.110 and 0.130, respectively. The areas under ROC curve of PG-SGA- and GLIM-defined malnutrition and postoperative complications were 0.660 and 0.714, respectively. Conclusions: this study indicates the effectiveness of malnutrition diagnosed according to GLIM and PG-SGA in predicting postoperative clinical outcomes among patients with ESCC. Compared with PG-SGA, GLIM criteria can better predict postoperative complications of ESCC. Follow-up analysis of postoperative long-term survival is needed to explore the association between different assessment tools and postoperative long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

We report a 35‐year‐old woman who presented with dyspnoea and chest pain for 1 week. High‐resolution computed tomography (HRCT) thorax revealed bilateral pneumothoraces with diffuse lung cysts. Bilateral intercostal chest tubes were inserted, and there was a persistent air leak (PAL) bilaterally. We performed an autologous blood patch pleurodesis (ABPP) for the left PAL. For the right PAL, she underwent a successful right video‐assisted thoracic (VATS) surgery, wedge biopsy, and surgical pleurodesis. Histopathology examination confirmed the diagnosis of lymphangioleiomyomatosis (LAM). The left pneumothorax recurred. An indwelling pleural catheter (Rocket® IPC™; Rocket Medical plc; WASHINGTON) was inserted and the patient was discharged after 1 day with an atrium pneumostat (Pneumostat™; Atrium Medical Corporation, Hudson, NH, USA) chest drain valve. The patient was initiated on Sirolimus 2 mg daily. The left PAL resolved at 6 weeks. This case highlights the benefit of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL. [ABSTRACT FROM AUTHOR]

Background: Emergency department (ED) overcrowding is a public health crisis that affects patient care quality. Space management in the ED can affect patient flow dynamics and clinical practice. We proposed a novel design of the "emergency procedure zone" (EPZ). The purpose of the EPZ was to provide an isolated area for clinical practice and procedure teaching, to ensure a secure area with adequate equipment and monitors, and safeguard patient privacy and safety. This study aimed to analyze the impact of the EPZ on procedural practice and patient flow dynamics. Methods: This study was conducted at the ED of a tertiary teaching hospital in Taiwan. Data were collected from 1 March 2019 to 31 August 2020 (pre-EPZ period) and from 1 November 2020 to 30 April 2022 (post-EPZ period). Statistical analyses were performed using IBM SPSS Statistics software. This study focused on the number of procedures and length of stay in the emergency department (LOS-ED). Variables were analyzed using the chi-square test and Mann–Whitney U test. Statistical significance was defined as p < 0.05. Results: There were 137,141 (pre-EPZ period) and 118,386 (post-EPZ period) ED visits recorded during this period. The post-EPZ period showed a significant increase in central venous catheter insertion, chest tube or pigtail placement, arthrocentesis, lumbar puncture, and incision and drainage procedures (p < 0.001). For patients who were directly discharged from the ED, the post-EPZ period also had a higher percentage of ultrasound studies performed in the ED and a shorter LOS-ED for patients who were directly discharged from the ED (p < 0.001). Conclusions: The establishment of an EPZ in the ED has a positive impact on procedural efficiency. The EPZ improved diagnosis and disposition efficiency, shortened the length of stay, and provided benefits such as improved management, patient privacy, and teaching opportunities. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the utility of immediate post-procedure computed tomography (IPP-CT) and routine one-hour chest radiography (1HR-CXR) for detecting and managing pneumothorax in patients undergoing computed tomography (CT)-guided percutaneous lung biopsy. Materials and methods: All CT-guided percutaneous lung biopsies performed between May 2014 and August 2021 at a single institution were included. Data from 275 procedures performed on 267 patients (147 men; mean age: 63.5 ± 14.1 years; range 18–91 years) who underwent routine 1HR-CXR were reviewed. Incidences of pneumothorax and procedure-related complications on IPP-CT and 1HR-CXR were recorded. Associated variables, including tract embolization methods, needle diameter/type, access site, lesion size, needle tract distance, and number of biopsy samples obtained were analyzed and compared between groups with and without pneumothorax. Results: Post-procedure complications included pneumothorax (30.9%, 85/275) and hemoptysis (0.7%, 2/275). Pneumothorax was detected on IPP-CT and 1HR-CXR in 89.4% (76/85) and 100% (85/85), respectively. A chest tube was placed in 4% (11/275) of the cases. In 3.3% (9/275) of the cases, delayed pneumothorax was detected only on 1HR-CXR, but no patient in this group necessitated chest tube placement. The incidence of pneumothorax was not significantly different between tract embolization methods (p = 0.36), needle diameters (p = 0.36) and types (p = 0.33), access sites (p = 0.07), and lesion sizes (p = 0.88). On logistic regression, a lower biopsy sample number (OR = 0.49) was a protective factor, but a longer needle tract distance (OR = 1.16) was a significant risk factor for pneumothorax. Conclusion: Following CT-guided percutaneous lung biopsy, pneumothorax detected on IPP-CT strongly indicates persistent pneumothorax on 1HR-CXR and possible chest tube placement. If no pneumothorax is identified on IPP-CT, follow-up 1HR-CXR may be required only for those who develop symptoms of pneumothorax. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery guidelines in China recommend early ambulation within 24 h after surgery. The aims of this audit were to investigate the early ambulation of patients with lung cancer under thoracoscopic surgery, and to explore the influence of different ambulation time on postoperative rehabilitation of patients. Methods: Using observational study method, observe and record of 226 cases under the thoracoscope surgery early ambulation of patients with lung cancer. Data collected included postoperative bowel movements, chest tube extubation time, length of hospital stay, postoperative pain and the incidence of postoperative complications. Results: The time of first ambulation was (34.18 ± 17.18) h, the duration was (8.26 ± 4.62) min, and the distance was (54.94 ± 46.06) m. The time of first postoperative defecation, the time of chest tube extubation and the length of hospital stay were significantly shortened in patients who ambulate within 24 h, and the pain score on the third day after surgery was decreased, and the incidence of postoperative complications was reduced, with statistical significance (P < 0.05). Conclusion: Early ambulation within 24 h after thoracoscopic surgery for lung cancer patients can promote the recovery of intestinal function, early removal of chest tube, shorten the length of hospital stay, relieve pain, reduce the incidence of complications, and facilitate the rapid recovery of patients. [ABSTRACT FROM AUTHOR]

Background: Surgical approach is the most effective treatment for primary spontaneous pneumothorax. The two most widely adopted surgical methods are mechanical abrasion and apical pleurectomy, in addition to bullectomy. We performed a systematic review and meta-analysis to examine which technique is superior in treating primary spontaneous pneumothorax. Methods: PubMed, MEDLINE and EMBASE databases were searched for studies published between January 2000 to September 2022 comparing mechanical abrasion and apical pleurectomy for treatment of primary spontaneous pneumothorax. The primary outcome was pneumothorax recurrence. Secondary outcomes included post-operative chest tube duration, hospital length of stay, operative time and intra-operative of blood loss. Results: Eight studies were eligible for inclusion involving 1,613 patients. There was no difference in the rate of pneumothorax recurrence between pleural abrasion and pleurectomy (RR: 1.34; 95% CI: 0.94 to 1.92). However, pleural abrasion led to shorter hospital length of stay (MD: -0.25; 95% CI: -0.51 to 0.00), post-operative chest tube duration (MD: -0.30; 95% CI: -0.56 to -0.03), operative time (MD: -13.00; 95% CI -15.07 to 10.92) and less surgical blood loss (MD: -17.77; 95% CI: -24.36 to -11.18). Conclusion: Pleural abrasion leads to less perioperative patient burden and shorter hospital length of stay without compromising the rate of pneumothorax recurrence when compared to pleurectomy. Thus, pleural abrasion is a reasonable first choice surgical procedure for management of primary spontaneous pneumothorax. [ABSTRACT FROM AUTHOR]

Aims A catastrophic side effect of retroperitoneal perforation after ERCP is the development of pneumothorax. Due to this fatal unexpected complication, clinicians and gastrointestinal specialists should observe the patients regarding ERCP by proper physical examination. Patient & Methods The patient was a 52-year-old woman with CBD stone who underwent surgery for severe abdominal pain after ERCP, but because of her general condition deterioration after surgery and the evidence of pneumothorax in chest x-ray, she underwent chest tube insertion and tissue debridement of necrotic tissue. Findings Pancreatitis is a common complication post-ERCP; However, it tends to be right-sided or bilateral, while in our case, the pneumothorax involves the left side. This scarcity seems to be as a result of the adhesions between the retroperitoneum and anterior aortic sheath as an anatomic barrier. Conclusion Post-ERCP pneumothorax can occur in different pathophysiological ways, but the most important step in this regard is to identify this ominous complication and take appropriate treatment as soon as possible. [ABSTRACT FROM AUTHOR]

Pneumothorax (PTX) is a life-threatening condition that overdiagnosis could result in increases in mortality and morbidity of patients. A-71-year old man was admitted due to multiple trauma. In the examination, there were some abrasions all over his body including his thorax. There were no decreases in respiratory sounds in auscultation but he had little right hemithorax r ib tenderness. In his CXR, there was a suspected pleural visceral line. Due to the inconsistency in physical exam and radiologic findings we decided to take a chest CT-scan before the insertion of the chest tube that indicated no PTX for him and the suspected visceral line was skin fold of a permacath for hemodialysis. Several conditions could mimic findings of PTX in CXR that every physician should know and pay attention to them besides special attention to the history taking and physical examination to reduce the morbidity of patients. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study is to determine the effects of milking and suction methods on maintaining drain patency following cardiac surgery in paediatric patients. Methods: This was a randomized controlled trial. The patients were assigned to three groups (suction method, milking method, and control group) between July 2018 and December 2019. Results: The most frequent medical diagnoses were tetralogy of Fallot (34.4%, n = 31) and ventricular septal defect (14.4%, n = 13). Heart rate may increase unless a method was chosen to maintain drain patency (F: 4.450, p = 0.003); suction (F: 0.528 p = 0.781) and milking (F: 2.281 p = 0.070) methods did not significantly increase the heart rate. The use of a manipulation method for maintaining drain patency maintained stability of the blood pressure values and did not affect haemodynamic stability, oxygen saturation, and body temperature. There was no statistically significant difference within and among the groups (p > 0.05) in relation to the volume of bleeding between admission until the sixth hour, although there was greater bleeding with the milking method (2.67 ± 15.30 ml) and less bleeding (−5.00 ± 23.30) with the suction method. Conclusion: The milking and suction methods used to maintain drain patency can be employed and will assist with maintaining the stability of the patient within the first critical 6 h. Further studies need to be conducted in order to clarify that the recommendations can be generalized to all children with congenital heart disease. Summary statement: What is already known about this topic? Manipulation methods are employed to prevent drain blockage after cardiac surgery.Milking and suction methods are frequently used.There is a limited amount of research‐based evidence to support nursing management for these methods of preventing blockage in chest and mediastinal drains. What this paper adds? Manipulation methods could be used, especially for patients to maintain stability in the first critical six hours after surgery, and they do not harm the hemodynamic process.The milking method used to maintain drain patency in paediatric patients after cardiac surgery can be considered less preferred because it causes an increase in the amount of bleedingThe suction method can be preferred because it reduces the amount of bleeding in the critical early post‐operative period. The implication of this paper: Findings can support decision‐making over the method to be used to maintain drain patency, decided by the treating team in a multidisciplinary manner. [ABSTRACT FROM AUTHOR]

Background: Small‐bore chest tube (SBCT) placement via modified Seldinger technique is a commonly performed invasive procedure for treatment of pleural effusion and pneumothorax. When performed suboptimally, it may lead to serious complications. Validated checklists are central to teaching and assessing procedural skills and may result in improved health care quality. In this paper, we describe the development and content validation of a SBCT placement checklist. Methods: A literature review across multiple medical databases and seminal textbooks was performed to identify all publications describing procedural steps involved in SBCT placement. No studies were identified that involved systematic development of a checklist for this purpose. After the first iteration of a comprehensive checklist (CAPS) based on literature review was developed, the modified Delphi technique involving a panel of nine multidisciplinary experts was used to modify it and establish its content validity. Results: After four Delphi rounds, the mean expert‐rated Likert score across all checklist items was 6.85 ± 0.68 (out of 7). The final, 31‐item checklist had a high internal consistency (Cronbach's alpha = 0.846) with 95% of the responses (by nine experts across 31 checklist items) being a numerical score of 6 or 7. Conclusions: This study reports the development and content validity of a comprehensive checklist for teaching and assessing SBCT placement. For purposes of demonstrating construct validity, this checklist should next be studied in the simulation and clinical setting. [ABSTRACT FROM AUTHOR]

Background: Drainless minimally invasive video-assisted thoracoscopic surgery (VATS) has improved perioperative outcomes and has become the standard of care for many thoracic procedures. Objectives: This study aimed to assess safety and perioperative outcomes of omitting chest tube drainage after VATS among eligible selected patients Methods: This study included 48 patients eligible for VATS and fulfilling the inclusion and exclusion criteria of omitting chest tube drain where, they were randomly allocated into two groups: Group-I (Drainless group) included 24 patients undergoing VATS with intra operative omitting of chest tube drains after an air leakage test and group-II (Drainage group) that included 24 patients undergoing VATS with conventional treatment using standard chest tube drainage. Results: Omitting chest tube drainage improved the median of operation time (116.0 minutes), average post-operative pain score per day (1.66) and shortened median of postoperative duration of hospital stay (1.0 days) among patients in drainless group-I compared to 139 minutes, 4.8 and 3.5 days among patient in drainage group-II (P<0.001) respectively. Uniportal VATS procedure, VATS sympathectomy, male sex, younger age and non-smoking habits in eligible selected patients with omitting chest tube drainage among them expressed significantly the lowest postoperative pain score, shortest postoperative duration of hospital stay and the least operation time with minimal risk of perioperative complications compared to drainage group-II (P<0.01). Conclusions: Omitting chest tube drainage after VATS is feasible in eligible selected patients and improved its efficacy, safety and perioperative outcomes (postoperative pain, hospital stay length, and the risk of perioperative complications). [ABSTRACT FROM AUTHOR]

Objective: We aimed to determine the rate of complications associated with autologous costal cartilage graft harvest for pediatric laryngotracheal reconstruction (LTR). Secondarily, we sought to identify risk factors associated with the harvest of autologous costal cartilage, as well as evaluate management strategies. Data Sources: An electronic database search of Ovid MEDLINE, Ovid EMBASE, and PubMed was completed for articles pertaining to complications in autologous costal cartilage harvest for pediatric LTR. Review Methods: This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) 2020 guidelines. The study characteristics, operative information, and patient demographics were collected. The data concerning postoperative complications, risk factors, and management strategies were collected and analyzed for patterns. Results: A total of 31 manuscripts representing 745 patients were included for analysis. The reported donor site complications included pneumothorax (n = 13, 1.74%), pleural tear (n = 5, 0.67%), infection (n = 8, 1.07%), and scar‐related problems (n = 2, 0.26%). There were no reported cases of seroma, persistent pain, or chest wall deformity. Only five studies discussed the management of donor site complications, with intervention in 11 (39.28%) patients including chest tube drainage and steroid injection. Conclusion: There is significant variability in the literature regarding complication rates in autologous costal cartilage harvest for pediatric LTR. The incidence of major postoperative complications is low and supports the use of autologous costal cartilage as graft material for pediatric LTR. Level of Evidence: NA. [ABSTRACT FROM AUTHOR]

Catamenial pneumothorax is a rare primary spontaneous pneumothorax associated with the menstrual phase and is the most common manifestation of thoracic endometriosis syndrome. We report a case of a 32‐year‐old woman with a history of endometriosis who presented to the emergency ward with a chief complaint of dyspnea and right‐sided chest pain, and a chest X‐ray showed a right pneumothorax. Initial management was by placing a chest tube to expand the right lung. The patient underwent a video‐assisted thoracoscopy and talc pleurodesis, during which we found multiple perforations in the tendinous part of the diaphragm. A partial resection of the tendinous part of the diaphragm was done. Our review indicated that primary spontaneous pneumothorax in women should be suspected as catamenial pneumothorax due to thoracic endometriosis. The gold standard procedure for diagnosis and treatment is surgery. Hormonal therapy is an effective choice to prevent and reduce post‐operative recurrence. [ABSTRACT FROM AUTHOR]

Background: After open or thoracoscopic lung biopsy, it is common to leave a chest tube as a postoperative drain that is typically removed on the first or second postoperative day. Standard technique is to apply an occlusive dressing at the site of chest tube removal using gauze and some form of tape. Methods: We reviewed the charts of children who underwent thoracoscopic lung biopsy at our institution for the past 9 years, many of whom left the operating room with a chest tube. When the tube was removed, the site was dressed, based on attending surgeon preference, with either cyanoacrylate tissue adhesive (Dermabond®; Ethicon, Cincinnati, OH) or a standard dressing with gauze and transparent occlusive adhesive dressing. Endpoints included wound complications and need for a secondary dressing. Results: Of 134 children who underwent thoracoscopic biopsy, 71 (53%) were given a chest tube. Chest tubes were removed at bedside in standard manner after a mean of 2.5 days. In 36 (50.7%) cyanoacrylate was used and in 35 (49.3%) a standard occlusive gauze dressing was used. No patient in either group suffered a wound dehiscence or needed a rescue dressing. There were no wound-related complications or surgical site infections in either group. Conclusion: Cyanoacrylate dressings are effective for closure of chest tube drain sites and appear to be safe. They might also save patients from having to deal with a bulky bandage and the discomfort of having a strong adhesive removed from their surgical site. [ABSTRACT FROM AUTHOR]

Purpose: To study the role of prolonged prophylactic antibiotic therapy (PAT) in the prevention of Inter-costal drain (ICD) related infectious complications in patients with Blunt Trauma Chest (BTC). Methods: Patients of age 15 years and above with BTC requiring ICD were included. Patients with penetrating chest injuries, associated injuries/illnesses requiring antibiotic administration, need for mechanical ventilation, known pulmonary disease or immuno-compromised status and need for open thoracotomy were excluded. 120 patients were randomized equally to two groups; no prolonged PAT group (Group A) and prolonged PAT group (group B). Both group patients received one shot of injectable antibiotic prior to ICD insertion. Primary outcome measure was comparison of ICD related infectious complications (pneumonia, empyema and SSI) and secondary outcome measures included the duration of ICD, Length of Hospital stay (LOS) and in-hospital mortality in both the groups. Results: Infectious complications (pneumonia, empyema and SSI) were seen in only one patient in antibiotic group, and none in no antibiotic group (p value = 0.500). Other complications such as post ICD pain scores, respiratory failure requiring ventilatory support, retained hemothorax or recurrent pneumothorax, did not show any statistical difference between both groups. Also, no significant difference was seen in both the groups in terms of mean duration of ICD (p value = 0.600) and LOS (p value = 0.259).m Conclusion: Overall prevalence of ICD related infectious complications are low in BTC patients. Definitive role of prolonged prophylactic antibiotics in reducing infectious complications and other associated co morbidities in BTC patients with ICDs could not be established. Trial registry details: Clinical Trial Registry, India (Trial registered at ctri.nic.in/clinical trials/login.php, number REF/2019/021704 dated 18/10/2019). [ABSTRACT FROM AUTHOR]

Purpose: Emergency and trauma physicians typically rely on anatomic landmarks to determine the proper intercostal space for emergent tube thoracostomy. However, physicians using this technique select a potentially dangerous insertion site too inferior in nearly one-third of cases, which have the potential to result in subdiaphragmatic puncture. We investigated a point-of-care ultrasound (POCUS) thoracic "Quick Look" procedure as a technique to allow visualization of underlying structures to avoid tube misplacement. Methods: We performed an observational study of adult emergency department patients and their treating physicians. The patient's emergency physician was asked to rapidly identify and mark a hypothetical tube thoracostomy insertion site on the patient's chest wall. An ultrasound fellow then performed a POCUS thoracic "Quick Look" exam with a phased-array probe placed directly over the marked site. Over one regular respiratory cycle, the identification of standard lung pattern was considered a negative scan whereas visualization of the diaphragm with underlying liver or spleen was considered a positive scan. Time for completion of the "Quick Look" scan was measured and inter-rater reliability was determined through image review by a single, blinded ultrasound director. Results: Seventy-six thoracic "Quick Look" scans were performed on patient subjects, of which 17% (13/76, 95%CI 8–26%) were positive. The average time for performing the "Quick Look" exam was 43 s (95%CI 30–57). Inter-rater reliability of the thoracic "Quick Look" was excellent (κ = 0.95). Conclusion: Thoracic "Quick Look" exams performed at mock chest tube insertion sites demonstrated potentially dangerous insertions in 17% of the cases. POCUS thoracic "Quick Look" may be a rapid and reliable technique that improves safety when placing an emergent chest tube. [ABSTRACT FROM AUTHOR]

Parapneumonic effusion is defined as the accumulation of pleural fluid associated with lung infection/pneumonia. Parapneumonic effusions can be uncomplicated or complicated. They are caused by the spread of infection and inflammation to the pleural space, and can develop into empyema thoracis—frank pus in the pleural space. Chest radiograph and thoracic ultrasound are the key imaging modalities for the diagnosis of parapneumonic effusion. Management aims are reducing inflammation and bacteria in the pleural cavity, and enabling full lung expansion. Broad-spectrum intravenous antibiotics, with the addition of chest tube drainage and fibrinolytic therapy for larger collections, are the mainstays of management. This article provides a clear, evidence-based and structured approach to the assessment and management of parapneumonic effusion/ empyema thoracis in children and young people. [ABSTRACT FROM AUTHOR]

Audience: This case is targeted to emergency medicine residents of all levels. Introduction: Shortness of breath (SOB) is one of the top ten most common chief complaints seen in the Emergency Department, accounting for close to 10% of presenting complaints.1 An acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a frequent culprit, accounting for roughly 15.4 million visits and 730,000 hospitalizations per year.2 The diagnosis of treatment of mild to moderate AECOPD can be relatively uncomplicated; however, multiple factors can increase the complexity of management and pose additional challenges that the emergency physician (EP) must be prepared for. Severe AECOPD can necessitate the need for both Non-invasive positive pressure ventilator (NIPPV) such as bi-level positive airway pressure (BiPAP) as well as emergent intubation. Furthermore, managing the ventilator settings in patients with an AECOPD is far from routine, requiring an intricate understanding of pulmonary physiology.3 Educational Objectives: By the end of this simulation, learners will be able to (1) assess for causes of severe shortness of breath, (2) manage severe COPD exacerbation by administering appropriate medications, (3) identify worsening clinical status and initiate NIPPV, (4) assess the causes of hypoxia after establishing endotracheal intubation and, (5) identify indication for needle decompression and perform chest tube thoracostomy. Educational Methods: This simulation was conducted with a high-fidelity mannequin with a separate low fidelity chest tube mannequin that allowed for hands-on practice placing a chest tube. A total of 16 PGY-1 residents participated in the simulated patient encounter. Research Methods: Following the simulation and debrief session, all residents were sent a Likert scale survey via surveymonkey.com to assess the educational quality of the simulation. The survey contained the following questions; 1) Overall, this simulation was realistic and could represent a patient presentation in the Emergency Department, 2) Overall, the case contained complexity that challenged me as a learner, 3) This case helped to expand my medical knowledge, 4) I feel more confident in diagnosing and treating AECOPD, 5) I feel more confident in recognizing the indications for NIPPV and intubation, 6) This simulation offered an opportunity to improve my procedural skills, 7) I feel more confident in setting up the ventilator, 8) I feel more confident in addressing ventilator alarms. Results: Following the simulation and debrief session, all the participants (n=16), were provided a survey to assess the educational quality of the simulation. There were a total of 12 respondents and a hundred percent of them agreed or strongly agreed that the case contained complexity that challenged them. All of the respondents agreed that the simulation case was realistic and that the case helped expand their medical knowledge. Furthermore, all the learners agreed or strongly agreed that the case helped them in improving their procedural skills. Discussion: This case combines a mixture of high fidelity and medium fidelity components to encompass both clinical knowledge and procedural skills. This case is effective in expanding beyond the basic approach to managing an AECOPD patient and forces learners to address clinical deterioration, escalate airway interventions, manage ventilator settings, and address ventilator alarms, including placement of a chest tube. Residents commented that this case was very realistic and particularly challenging because it highlighted gaps in their clinical knowledge and procedural skills. Residents were most challenged by identifying when to escalate care as well as how to manage ventilator settings in AECOPD patients. Topics: Acute exacerbation COPD, intubation, positive pressure ventilation, ventilator alarms, chest tube thoracostomy. [ABSTRACT FROM AUTHOR]

Background: Muscle-sparing thoracotomy (MST) has been proposed as an alternative to standard posterolateral thoracotomy (sPLT) for elective thoracic procedures with limited use in urgent thoracotomies. Objectives: The aim of this study was to compare the results of sPLT and MST during urgent thoracotomy for the treatment of chest trauma. Methods: This case series study included patients who underwent urgent thoracotomies within the first 48 hours of admission for treatment of chest trauma, from January 2019 to July 2022. Patients were divided into two groups: sPLT and MST groups. In addition, the MST group was divided into partial (pMST) or complete (cMST). Results: Seventy-five out of 1400 patients with chest trauma (5.3%) underwent urgent thoracotomy, and 30 of them (40%) had MST. Compared with the sPLT group, the MST group had a lower abbreviated injury scale (AIS) of the thoracic region, with a significant difference (4.09 ± 0.66 versus 3.77 ± 0.72, P = 0.052). There was no significant difference between the two groups with regard to the duration of tube drainage, ICU stay, hospital stay, and postoperative complications. The length of hospital stay was shorter in the MST group with no statistically significant difference (14.30 ± 3.01 vs. 15.5 ± 2.48, P = 0.08). The extent of MST, whether partial or complete, had no significant effect on postoperative outcomes. Conclusions: If it does not impede access or chest exposure, MST can be performed with early recovery and therefore a shorter hospital stay than sPLT. [ABSTRACT FROM AUTHOR]