When should an intercostal chest drain (ICD) be removed in a patient with traumatic hemothorax?

Timing of Intercostal Drain Removal in Traumatic Hemothorax

Remove the intercostal chest drain when drainage is ≤200-300 mL per 24 hours, there is no active air leak, and chest radiograph confirms complete lung re-expansion with satisfactory evacuation of pleural fluid. 1

Essential Pre-Removal Criteria

Before removing any chest drain in traumatic hemothorax, you must confirm all of the following:

• Drainage volume below threshold for 24 hours: ≤200-300 mL/24 hours is the standard threshold 1
• No active air leak: The drain should not be bubbling 1
• Complete lung re-expansion: Confirmed on chest radiograph 1
• Non-purulent fluid character: Ensure drainage is serous, not infected 1

Drainage Volume Thresholds

The specific volume criteria are well-established:

• Standard threshold: Drainage ≤200-300 mL/24 hours for most clinical scenarios 1
• Alternative threshold: Some evidence supports safe removal at <300 mL/24 hours compared to waiting for <100 mL/24 hours 2
• Maximum drainage duration: If drainage remains high but the drain has been in place for >7-14 days, consider removal to reduce infection risk 2

Clinical Decision Algorithm

Follow this stepwise approach:

1. At 24-48 hours post-insertion: Assess drainage volume, check for air leak, obtain chest radiograph 1

2. If drainage >300 mL/24 hours: Continue drainage and reassess daily; consider repeat imaging to evaluate for ongoing bleeding or residual collection 1

3. If drainage ≤200-300 mL/24 hours AND no air leak AND lung fully expanded: Remove the drain 1

4. If excessive drainage persists >48-72 hours: Consider alternative interventions rather than continued drainage alone 1

Important Caveats and Pitfalls

Never clamp a bubbling chest drain as this could convert a simple pneumothorax into a life-threatening tension pneumothorax 1. This is particularly relevant in traumatic hemopneumothorax where both blood and air may be present.

Prolonged drainage increases infection risk: Drains should be removed as early as possible once criteria are met to reduce surgical site infections and length of hospital stay 2. The risk of empyema increases with prolonged drainage time.

Residual hemothorax considerations: While drain position and intrapleural length do not significantly affect the frequency of residual hemothorax 3, inadequate drainage can lead to retained blood, which may cause lung collapse and empyema 3. If residual hemothorax is suspected after drain removal, consider intrapleural fibrinolytic therapy rather than prolonged drainage 1.

Tube Size Considerations

Small bore drains (10-14F) are as effective as large bore tubes (20-24F) and allow the same removal criteria while improving patient comfort 1. Even for traumatic hemothorax, recent evidence suggests that 16F tubes are sufficient for managing hemothorax developed more than 24 hours after injury 4, though traditional teaching recommends 28-36F for acute traumatic hemothorax 5.

Complex Cases Requiring Specialist Referral

Refer to a respiratory physician or thoracic surgeon if:

• Persistent air leak exceeding 48 hours 1
• Failure of lung to re-expand despite adequate drainage 1
• Ongoing hemorrhage requiring thoracotomy (typically indicated by initial drainage >1,500 mL or continued bleeding causing hemodynamic instability) 6