[HSF] Management of Postop Clotted Hemothorax

Tea Acuff tacuff at swbell.net
Sun Apr 15 17:44:21 EDT 2007 

Funny how a single set of observations can withstand a cacophony of theory, Prasanna. Then again maybe the cacophonists won after all.
tea


----- Original Message ----
From: "rwmfglycar at aol.com" <rwmfglycar at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, April 15, 2007 4:52:54 PM
Subject: Re: [HSF] Management of Postop Clotted Hemothorax


Hal,
Years ago the number of patients with traumatic hemothorax due to stab wounds admitted to the ER of a hospital I worked in became overwhelming. The general surgeons and ER doctors adopted a policy of not inserting chest tubes. Instead the patient was observed for as long as needed to ensure stability and then discharged to the Physiotherapy out patient dept for breathing exercises. (It was an anomaly to me that this department did not find this load of patients for physiotherapy overwhelming. I guess that they treated them in groups. It was staffed by superb nonMD physiotherapists.) I was dubious about this policy but they did a quite good three month study that showed 90% with very good resolution and excellent functional status. Obviously this group of members of the Knife and Pistol club were different from the average patient  with a post cardiac surgery hemothorax and I would agree with Ed that cleaning out the chest early has much to recommend it.
However I used to see cases in which chest tube drainage for hemothorax had been done with poor resolution of the Xray appearance. The clinical test that I used to decide whether to do a surgical removal of clot was to place my hands on the rib cage, instruct the patient to take a deep breath and check the movement of the chest wall; those patients who, despite the Xray appearance, could expand the chest cage well, would all have satisfactory Xrays and air entry a month or two later. Those whose chest wall moved poorly on the side of the hemothorax generally came to exploration eventually. This led to the decision to adopt a policy to open the chest and clean it out immediately, whenever the patient could not produce a substantial expansion of the chest wall. (All of this was before the modern era of thoracoscopic surgery).
Streptokinase, by the way, never really worked that well. There might be some increase of a liquid coming out through the tube, but this was inconsistently related to an improvement in lung function.
Bob

-----Original Message-----
From: hgrmd at aol.com
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 15 Apr 2007 11:08 AM
Subject: Re: [HSF] Management of Postop Clotted Hemothorax


Ed,
  You're right.  Thanks.
Hal 

-----Original Message-----
From: ebender001 at charter.net
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 15 Apr 2007 11:01 AM
Subject: Re: [HSF] Management of Postop Clotted Hemothorax


Unlikely that hemolysis will occur any time soon. Adding strepto may lyse a 
little of the hemothorax, but it may also lyse the sealing clot on the bleeding 
point that caused the hemothorax. I have never seen streptokinase work for large 
collections. Case sounds like a long bypass run and it may have taken a little 
time for the coagulopathy to correct. Most of the time I have not found the 
source of the bleeding when I remotely re-explored, but sometimes I have. It has 
usually been some trivial problem that bled in the presence of a coagulopathy 
(pericardium, chest wall, IMA branch on the chest wall, sternal wire through a 
mammary branch or the mammary itself). I had one patient who developed a right 
hemothorax requiring exploration in whom I never opened the right pleura. I had 
pierced a mammary branch lateral to the open chest , missed the lung, but 
violated the pleural space. There was one other case of a Swan Ganz catheter 
through the lung parenchyma. 

The safest approach, and least detrimental to the post op length of stay, is to 
take the patient back, clean it out, and look for a source. But you already knew 
that. 

Ed Bender, MD 

On Apr 15, 2007, at 9:29 AM, hgrmd at aol.com wrote: 

> Dear Members, 
> Last Thursday, I operated on a 47 yo man with severe bicuspid > aortic 
stenosis, 5.2 cm ascending aorta with dilated sinuses, LAD > dz, and PAF. 
Interestingly, at age 6 he had an open aortic > valvotomy at Miami Children's. 
At his insistence, I did a biologic > Bentall with a 23mm Perimount sewn to a 
28mm Hemoshield, LIMA to > the LAD, and a cryomaze. Fresh off CPB, I noticed 
progression of > preop mild MR to 3+ MR. Hemodynamics were marginal, so I went 
back > in and repaired the mitral with a 26 mm Cosgrove. He then came off > 
easily, the post-CPB TEE showed no MR with an EF of 70%, didn't > seem to bleed, 
and was extubated the next day. Unfortunately, the > postop CXR revealed a 
sizable left hemothorax. It appeared to > occupy about half the chest. I placed 
a chest tube, but it really > didn't drain much. He currently is saturating well 
on 3 liters > nasal cannula. My question is: Does anyone have good experience > 
with instilling streptokinase or urokinase up the chest t
ube in > order to lyse 
> the clot? If so, what is the protocol.? Should I just take him > back and 
clean out the left side? 
> 
> Hal 
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