Pleural Cavity Irrigation for Hemothorax

To reduce risk of retained hemothorax and need for secondary intervention by defining the indications, timing, and method for tube thoracostomy with pleural cavity irrigation for hemothorax.

Blunt or penetrating trauma patients with hemothorax requiring tube thoracostomy.

At time of tube thoracostomy for hemothorax, if the patient has stable hemodynamics, pleural cavity irrigation should be performed under sterile conditions as described below.

1. Tube thoracostomy performed using standard technique under sterile conditions with preprocedural IV cefazolin (or clindamycin if PCN-allergic) administered. Size of chest tube selected based on attending surgeon discretion
2. Sterile suction tubing (with/without Yankauer) introduced into chest tube and with gentle manipulation of tube, thoracic cavity is evacuated of as much hemothorax as possible
   a. Abnormal hemodynamics or evacuation of >1500 ml blood warrants consideration of operative intervention
3. 1L NS attached with IV tubing in sterile fashion to chest tube Luer lock (see figure 1)
4. Chest tube and pleur-evac elevated above level of patient to allow drainage of saline by gravity into pleural cavity (see figure 2)
5. Chest tube and pleur-evac placed below level of patient to allow drainage of saline by gravity into the pleur-evac.
   Chest tube connected to chest tube drainage system at -20 mmHg for at least 24 hours

1. Sterile 60ml Toomey syringe (with plunger removed) attached to chest tube – tube is stabilized at chest wall and syringe is held above chest level
2. Assistant incrementally pours 500 ml warm saline through syringe/tube and into the thoracic cavity
3. Sterile suction tubing (with/without Yankauer) is reinserted and thoracic cavity is evacuated
4. Repeat steps 3-5 with additional 500 ml warm saline
5. Chest tube connected to chest tube drainage system at -20 mmHg for at least 24 hours

Al Tannir AH, Biesboer EA, Golestani S, et al. Thoracic Cavity Irrigation Prevents Retained Hemothorax and Decreases Surgical Intervention in Trauma Patients. J Trauma Acute Care Surg. Published online March 25, 2024. doi:10.1097/TA.0000000000004324

Kugler NW, Carver TW, Milia D, Paul JS. Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis. J Trauma Acute Care Surg. 2017;83(6):1136-1141. doi:10.1097/TA.0000000000001700

Kugler NW, Carver TW, Paul JS. Thoracic irrigation prevents retained hemothorax: a pilot study. J Surg Res. 2016;202(2):443-448. doi:10.1016/j.jss.2016.02.046

Ramanathan R, Wolfe LG, Duane TM. Initial suction evacuation of traumatic hemothoraces: a novel approach to decreasing chest tube duration and complications. Am Surg. 2012;78(8):883-887.

Savage SA, Cibulas GA 2nd, Ward TA, Davis CA, Croce MA, Zarzaur BL. Suction evacuation of hemothorax: A prospective study. J Trauma Acute Care Surg. 2016;81(1):58-62. doi:10.1097/TA.0000000000001099

McLauchlan N, Ali A, Beyer CA, et al. Percutaneous thoracostomy with thoracic lavage for traumatic hemothorax: a performance improvement initiative. Trauma Surg Acute Care Open. 2024;9(1):e001298. Published 2024 Feb 29. doi:10.1136/tsaco-2023-001298