What to do for persistent hemothorax despite insertion of a 14 French (Fr) chest tube?

From the Guidelines

For persistent hemothorax despite insertion of a 14 French (Fr) chest tube, consider administering thrombolytic therapy via the chest tube.

Management of Persistent Hemothorax

• The use of chest tubes for managing hemothorax is a common practice, but the management of persistent hemothorax remains a challenge 1.
• Studies have shown that persistent, complex collections and organizing hemothoraces can be successfully treated with instillation of fibrinolytic agents 1.
• However, the evidence for routine use of fibrinolytics is limited, and more research is needed to establish its effectiveness 1.
• In cases of massive hemothorax, tube thoracostomy is recommended, and the drainage tube should be placed in the fourth/fifth intercostal space in the midaxillary line 1.
• For persistent hemothorax, percutaneous catheter drainage with administration of thrombolytic therapy may be a viable option, but it should be done with caution and careful monitoring 1.
• The decision to use thrombolytic therapy should be made on a case-by-case basis, taking into account the individual patient's condition and the potential risks and benefits of the treatment.
• It is essential to carefully evaluate the patient's response to the treatment and adjust the management plan accordingly.

From the Research

Management of Persistent Hemothorax

For patients with persistent hemothorax despite the insertion of a 14 French (Fr) chest tube, several options can be considered:

• Intrapleural fibrinolytic therapy to break down clots and adhesions 2
• Surgical exploration by VATS or thoracotomy if there is a large accumulation of blood (>1,500 ml) or ongoing production of >200 ml of blood per hour 2
• Placement of an additional chest tube or a larger chest tube, although the size of the chest tube may not affect the outcome 3
• Continued monitoring and conservative management, as some studies suggest that 14-Fr pigtail catheters can be as effective as larger chest tubes in draining traumatic hemothorax 4, 5, 6

Considerations for Chest Tube Size

The size of the chest tube may not be a significant factor in the management of traumatic hemothorax:

• Studies have shown that 14-Fr pigtail catheters can be as effective as larger chest tubes (28-40 Fr) in draining traumatic hemothorax 4, 5, 6
• The initial drainage output, tube duration, and failure rate were similar between 14-Fr pigtail catheters and larger chest tubes in some studies 4, 5, 6
• However, the choice of chest tube size may depend on the individual patient's condition and the surgeon's preference 3

Additional Interventions

In cases where conservative management is insufficient, additional interventions may be necessary:

• Surgical exploration by VATS or thoracotomy to prevent subsequent complications 2
• Intrapleural fibrinolytic therapy to break down clots and adhesions 2
• Placement of an additional chest tube or a larger chest tube to ensure adequate drainage 3