Shed Pleural Blood from Traumatic Hemothorax Contains Elevated Levels of Pro-Inflammatory Cytokines.

PURPOSE: The autotransfusion of unwashed (or unprocessed) shed hemothorax blood (USHB) in trauma patients is widely assumed to be beneficial; however, the inflammatory potential of shed pleural blood has not been thoroughly studied. Since previous studies have documented marked changes in coagulation function of shed pleural blood, we hypothesized that its level of inflammatory cytokines would be elevated. METHODS: A prospective observational study of trauma patients in whom cytokine levels from USHB were compared to venous samples from healthy volunteers was conducted. Differences between the cytokine content of patient-derived samples were compared to those from healthy subjects. RESULTS: There was a statistically significant increase in pro-inflammatory cytokines (IL-6, IL-8, TNFα, GM-CSF), a pro-inflammatory Th-1 cytokine (IFNγ), and anti-inflammatory Th-2 cytokines (IL-4 and IL-10) in shed pleural blood over four hours when compared with samples from healthy controls (P <0.05). Cytokine levels in USHB are approximately 10- to 100-fold higher compared with healthy control venous samples. CONCLUSIONS: USHB, even collected within the accepted four-hour window, contains significantly elevated cytokine levels, suggesting the potential for deleterious effects from autotransfusion. Randomized trials are needed to determine the safety and efficacy of autotransfusion in trauma patients.

An experimental model of hemothorax autotransfusion: impact on coagulation.

BACKGROUND: Traumatic hemothorax (HTX) has been demonstrated to predictably contain low fibrinogen, low hematocrit, and low platelet counts. When analyzed on its own, shed HTX demonstrates coagulopathy. However, when mixed with normal pooled plasma (NPP) at physiologically relevant dilutions, HTX demonstrates accelerated coagulation. We hypothesize that when HTX is mixed with a patient's own plasma, the mixture will demonstrate hypercoagulability. The accelerated coagulation of this mixture would have important implications for the autotransfusion of HTX as a method of resuscitating a trauma patient. METHODS: Adult trauma patients from whom greater than 140 mL of HTX was evacuated within 1 hour of tube thoracostomy were included. HTX was sampled at 1 hour after evacuation, and a portion of the sample was centrifuged and stored as frozen plasma for later analysis. The remainder of the sample was analyzed (coagulation, hematology, electrolytes), and values were compared with concurrent venous values extracted via chart review. A citrate tube containing the patient's venous blood was additionally spun down and frozen for subsequent mixing study analysis. Coagulation was further evaluated by mixing serial dilutions of the previously frozen HTX with NPP. Additionally, the previously frozen HTX was mixed in serial dilutions with the previously frozen sample of patient plasma (PTP). RESULTS: Subjects (10) were enrolled based on inclusion criteria and collection of a discarded venous sample. In HTX samples analyzed alone, no thrombus was formed in any coagulation test (activated partial thromboplastin time [aPTT] > 180). The median aPTT value of PTP alone was 25.5. In 1-hour specimens mixed at a clinically relevant dilution of 1:4, HTX mixed with NPP had a mediana PTT value of 26.0, whereas HTX mixed with PTP had a median aPTT value of 21.7. Thus, the mixture of HTX + PTP demonstrated a statistically significantly lower aPTT than the mixture of HTX + NPP (P = 0.01). Additionally, the mixture of HTX and PTP shows a statistically significantly lower aPTT value than PTP alone (P = 0.03), indicating a hypercoagulable state. CONCLUSIONS: HTX demonstrates coagulopathy when analyzed independently, but is hypercoagulable when mixed with NPP or PTP. Furthermore, mixing studies show a statistically significantly lower aPTT when HTX is mixed with PTP versus HTX mixed with NPP. Thus, autotransfusion of HTX would likely produce a hypercoagulable state in vivo, and should not be used in place of other blood products to resuscitate a trauma patient. The autotransfusion of HTX may, however, be of use in a resource-limited environment where other blood products are not available.

A small amount can make a difference: a prospective human study of the paradoxical coagulation characteristics of hemothorax.

BACKGROUND: The evacuated hemothorax has been poorly described because it varies with time, it has been found to be incoagulable, and its potential effect on the coagulation cascade during autotransfusion is largely unknown. METHODS: This is a prospective descriptive study of adult patients with traumatic chest injury necessitating tube thoracostomy. Pleural and venous samples were analyzed for coagulation, hematology, and electrolytes at 1 to 4 hours after drainage. Pleural samples were also analyzed for their effect on the coagulation cascade via mixing studies. RESULTS: Thirty-four subjects were enrolled with a traumatic hemothorax. The following measured coagulation factors were significantly depleted compared with venous blood: international normalized ratio (>9 vs 1.1) (P < .001) and activated partial thromboplastin time (aPTT) (>180 vs 24.5 seconds) (P < .001). Mixing studies showed a dose-dependent increase in coagulation dilutions through 1:8 (P < .05). CONCLUSIONS: An evacuated hemothorax does not vary in composition significantly with time and is incoagulable alone. Mixing studies with hemothorax plasma increased coagulation, raising safety concerns.

[Treatment of post-traumatical coagulated hemothorax. Videothoracoscopy or open surgery].

Comparative estimation of videothoracic and open surgery efficacy in the treatment of post-traumatic coagulated hemothorax have been shown in 612 patients. According to the achieved results, effectiveness of videothoracoscopy (92.4%) is better than open surgeries. Apart from that, reduction in the hospitalization days (9.6 days compared to 11.5 days in open surgeries), frequency of complications (4.5% and 13.8%), traumatic intervention and rehabilitation time. All the patients alive. Best results are achieved using videothoracoscopical operations at the earliest in posttraumatic coagulated hemothorax.

Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood?

BACKGROUND: Autotransfusable shed blood has been poorly characterized in trauma and may have similarities to whole blood with additional benefits. METHODS: This was a prospective descriptive study of adult patients from whom ≥50 mL of blood was drained within the first 4 hours after chest tube placement. Pleural and venous blood samples were analyzed for coagulation, hematology, and electrolytes. RESULTS: Twenty-two subjects were enrolled in 9 months. The following measured coagulation factors of hemothorax were significantly depleted compared with venous blood: international normalized ratio (>9 in contrast to 1.1, P < .001), activated partial thromboplastin time (>180 in contrast to 28.5 seconds, P < .001), and fibrinogen (<50 in contrast to 288 mg/dL, P < .001). The mean hematocrit (26.4 in contrast to 33.9), (P = .003), hemoglobin (9.3 in contrast to 11.8 g/dL, P = .004), and platelet count (53 in contrast to 174 K/µL, P < .001) of hemothorax were significantly lower than venous blood. A hemothorax volume of 726 mL was calculated to be equivalent to 1 U of red blood cells. CONCLUSIONS: Hemothorax blood contains significantly decreased coagulation factors and has lower hemoglobin when compared with venous blood.

[Application of early videothoracoscopic pulmonary decortication in the treatment of an acute pleural empyema and suppurated clotted hemothorax].

There was presented the experience of performance of videothoracoscopic pulmonary decortications in 22 patients, suffering suppurated clotted hemothorax, and in 188--an acute pleural empyema. In 97.3% patients the cessation of purulent process and pulmonary volume restoration were achieved. Residual cavities with the pulmonary nonairtightness signs were revealed in 3 (1.4%) patients, the empyema recurrence--in 1 (0.5%), suppuration of the wound, made by thoracic port--in 1 (0.5%), all the patients are alive.

Central venous oxygen saturation, arterial base deficit, and lactate concentration in trauma patients.

Our object was to explore the usefulness of central venous oxygen saturation, arterial base deficit, and lactate concentration in the evaluation of trauma patients. In busy urban trauma centers, limited operating room availability may necessitate that certain hemodynamically stable patients experience some delay between diagnosis of injury and surgery. Because hemodynamic compromise may occur before operation is undertaken, some means of identifying those patients who have the most severe injuries or who are at greatest risk for hemodynamic instability would be useful. We prospectively studied 40 patients with operative truncal injuries admitted to the Cook County Trauma Unit, Chicago, to examine the usefulness of postresuscitation central venous oxygen saturation (ScvO2), arterial lactate concentration, and arterial base deficit in this regard. Preoperative hypotension occurred in 12.5 per cent of these initially stable patients. ScvO2 did not significantly correlate with any of the parameters of blood loss and severity of injury examined. However, both base deficit and lactate concentration correlated with transfusion requirements; in addition, base deficit correlated with trauma score, and lactate correlated with peritoneal shed blood volume. Our data suggest that, after resuscitation, arterial base deficit and lactate concentration may be better indicators of blood loss than is ScvO2.

Utility of C-reactive protein measurements for empyema diagnosis after pneumonectomy.

Serum C-reactive protein (CRP) levels were studied serially during the postoperative period in 151 consecutive patients who underwent pneumonectomy. Virtually all patients who had a simple postoperative course (115 of 120), as well as 9 patients who had a bronchial infection of the remaining lung, 3 with a pulmonary embolus, and 2 who suffered postoperative bleeding requiring reoperation, demonstrated a similar postoperative evolution in their CRP values: a rapid postoperative rise until a peak or a plateau (mean peak value, 132 +/- 25 mg/L) was reached within 3 to 6 days, followed by a progressive decline to a value of less than 75 mg/L on day 9, and less than 50 mg/L on day 12. Conversely, all 12 patients who suffered empyema postoperatively, as well as 3 patients with bacterial pneumonia, 1 patient with chylothorax, and 1 patient with inflammatory pericarditis, demonstrated either a markedly persistent elevation in their CRP values or a secondary rise in the levels which exceeded 100 mg/L. Because of the high sensitivity (100%) and specificity (91.4%) of the CRP levels in detecting postpneumonectomy empyema, we recommend the routine use of this measure. Furthermore, a low CRP value after pneumonectomy (less than 50 mg/L) may help in deciding whether to confidently discharge a patient from the hospital in the absence of empyema. The negative predictive value of this method was found to be 100%.

Tranexamic acid treatment of hemothorax in two patients with malignant mesothelioma.

Patients with malignant mesothelioma may present with hemothorax. We used a combination of oral and intrapleural tranexamic acid to treat two patients with this severe complication. Initiation of treatment with this potent anti-fibrinolytic drug resulted in rapid reduction of bleeding and of transfusion requirements.

Prehospital autotransfusion in life-threatening hemothorax.

Eighteen patients with life-threatening traumatic hemothorax received prehospital autotransfusion using a simple new device. During transfer to the hospital, they received 3.9 +/- 0.5 L of colloid fluid and 4.1 +/- 0.6 L of autotransfused blood, without anticoagulation. Hemorrhagic blood was not coagulable, had a hematocrit of 20 +/- 4 percent, few platelets, and low fibrinogen levels. Five patients died from irreversible hemorrhagic shock. Thirteen patients were alive upon admission to the hospital, underwent emergency surgery, and were discharged alive. During autotransfusion, hematocrit decreased from 24 +/- 3 to 19 +/- 3 percent, and systolic arterial pressure increased from 78 +/- 11 to 88 +/- 12 mm Hg. Upon admission to the hospital, platelet count was 90,800 +/- 21,400/cu mm, prothrombin time 48 +/- 3 percent, partial thromboplastin time 197 +/- 18 percent, plasma free hemoglobin levels 21 +/- 7 mg/100 ml, and serum potassium levels 3.6 +/- 0.5 mmol/L. No serious complication could be related to autotransfusion considered to be crucial to patients' survival. The preliminary results of this study suggest that autotransfusion might be developed in the prehospital setting since it appears simple and safe, and represents the only hope of survival for patients with life-threatening hemothorax.

Use of the Heimlich valve in a compact autotransfusion device.

A compact device which evacuates blood from a hemothorax and facilitates rapid autotransfusion was evaluated in dogs. Experimental hemothorax was established surgically by incising the internal mammary artery through a thoracotomy with the animals under general anesthesia. Postoperatively the blood was drained by one of two methods. In the Heimlich valve group (n = 5), blood was drained by a chest tube through a one-way flutter valve into a collapsible plastic bag. In the Sorenson group (n = 5), blood was drained by a chest tube into the Sorenson Autotransfusion System. Blood from these two groups was then autotransfused. In the control group (n = 5), the drained blood was not autotransfused. Results showed no statistical difference between the two autotransfusion groups in the volume of blood collected, circulating fibrinogen levels, platelet counts, stroma-free hemoglobin levels, prothrombin time, or 51Cr-labeled RBC survival. There was a significant drop in the circulating platelet count, which returned to normal by 24 hours, in both groups of dogs which were autotransfused. We conclude that autotransfusion of blood collected by a compact device which utilizes a Heimlich valve and requires no suction is similar to using the Sorenson Autotransfusion System. It may be safe to use the Heimlich valve to collect blood for autotransfusion in clinical situations, where its qualities of simplicity, portability and a minimum requirement for storage space are desirable.

[Coagulative and fibrinolytic properties of blood effused into the pleural cavity after lung surgery]. / Svertyvaiushchie i fibrinoliticheskie svoistva krovi, izlivsheisia v plevral'nuiu polost' posle operatsii na legkikh.

Coagulative properties of the blood and exudate accumulated in the pleural cavity following lung operations were studied. On the grounds of the studies of plasmin potential and active antiplasmin of the exudate a method of local fibrionolytic therapy of coagulated hemothorax with intrapleural injections of fibrinilysis activators was devised. Fibrinolytic therapy was applied in 106 patients, streptokinase preparations were injected to 28 of them.