Chest Tube Removal in Simple Pneumothorax: Does Water-Seal Duration Matter?

Timing of chest tube (CT) removal after transition from suction to water-seal (WS) varies when treating traumatic simple pneumothoraces (PTXs). Longer periods of WS may identify slow-occurring PTXs reducing CT replacement, whereas shorter periods may expedite patient disposition and have associated cost savings. Prior studies support the need for an interval of WS. We compare durations of WS, looking at rates of CT reinsertion. A 10-year retrospective review on trauma patients with a simple PTX requiring a CT was performed. WS duration of 1 to 8 hours (short - SG) versus 18 to 36 hours (long - LG) were compared. Univariate analysis and multivariate logistic regression were used. Of the 2000 patient charts reviewed, 209 met the criteria, with 43 in the SG and 166 in the LG. Patient demographics and mechanism of injury were similar. There was no difference in CT replacement [6.9% (SG) vs 4.8% (LG), P 0.59]. Logistic regression revealed an increase in CT replacement if the patient ever had positive pressure ventilation (OR 4.1, CI 1.1-17, P 0.04) and if returned to suction from WS (OR 6.3, CI 1.2-28, P 0.03). Short intervals of WS do not increase CT reinsertion while decreasing the total time and morbidity associated with CT.

REBOA for the IVC? Resuscitative balloon occlusion of the inferior vena cava (REBOVC) to abate massive hemorrhage in retrohepatic vena cava injuries.

BACKGROUND: The use of resuscitative endovascular balloon occlusion as a maneuver for occlusion of the aorta is well described. This technique has life-saving potential in other cases of traumatic hemorrhage. Retrohepatic inferior vena cava (IVC) injuries have a high rate of mortality, in part, due to the difficulty in achieving total vascular isolation. The purpose of this study was to investigate the ability of resuscitative balloon occlusion of the IVC to control suprahepatic IVC hemorrhage in a swine model of trauma. METHODS: Thirteen swine were randomly assigned to control (seven animals) versus intervention (six animals). In both groups, an injury was created to the IVC. Hepatic inflow control was obtained via clamping of the hepatoduodenal ligament and infrahepatic IVC. In the intervention group, suprahepatic IVC control was obtained via a resuscitative balloon occlusion of the IVC placed through the femoral vein. In the control group, no suprahepatic IVC control was established. Vital signs, arterial blood gases, and lactate were monitored until death. Primary end points were blood loss and time to death. Lactate, pH, and vital signs were secondary end points. Groups were compared using the χ and the Student t test with significance at p < 0.05. RESULTS: Intervention group's time to death was significantly prolonged: 59.3 ± 1.6 versus 33.4 ± 12.0 minutes (p = 0.001); and total blood loss was significantly reduced: 333 ± 122 vs 1,701 ± 358 mL (p = 0.001). In the intervention group, five of the six swine (83.3%) were alive at 1 hour compared to zero of seven (0%) in the control group (p = 0.002). There was a trend toward worsening acidosis, hypothermia, elevated lactate, and hemodynamic instability in the control group. CONCLUSIONS: Resuscitative balloon occlusion of the IVC demonstrates superior hemorrhage control and prolonged time to death in a swine model of liver hemorrhage. This technique may be considered as an adjunct to total hepatic vascular isolation in severe liver hemorrhage and could provide additional time needed for definitive repair. LEVEL OF EVIDENCE: Therapeutic study, level II.

Permissive Hypotension: Potentially Harmful in the Elderly? A National Trauma Data Bank Analysis.

Permissive hypotension is a component of damage control resuscitation that aims to provide a directed, controlled resuscitation, while countering the "lethal triad." This principle has not been specifically studied in elderly (ELD) trauma patients (≥55 years). Given the ELD population's lack of physiologic reserve and risk of inadequate perfusion with "normal" blood pressures, we hypothesized that utilized a permissive hypotension strategy in ELD trauma patients would result in worse outcomes compared with younger patients (18-54 years). A retrospective review of National Trauma Data Bank reports from 2009 and 2010, identifying critically ill patients undergoing a "damage control laparotomy," was performed to determine the effect of age and systolic blood pressure on outcome. Logistic regression analysis, including evaluation of an interaction between age and admission blood pressure, was performed on mortality using admission demographics, physiology, injury severity, mechanism of injury, and in-hospital complications. Although there was a higher likelihood of death with greater age, lower admission systolic blood pressure, lower Glasgow Coma Score, increased injury severity score, and acute renal failure, a synergistic effect of age and blood pressure on mortality was not identified. Permissive hypotension appears to be a possible management strategy in ELD trauma patients.