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Balloon Foley catheter compression as a treatment for intercostal vessel bleeding
Injury, Int. J. Care Injured 42 (2011) 958–959
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Technical Note
Balloon Foley catheter compression as a treatment for intercostal vessel bleeding Bao Fei Chao a, Ying Jian Jian a, He Zhe Hao a, Sun Li b, Hu Jian a,*, Pan Hui a, Yan Yun Hai a a b
Department of Thoracic Surgery, First Hospital, College of Medicine, Zhejiang University, No. 79, Qingchun Road, Hangzhou 310003, Zhejiang, China School of Medicine, Hangzhou Normal University, Hangzhou 310036, China
A R T I C L E I N F O
Article history: Accepted 9 May 2011
Introduction Iatrogenic and non-iatrogenic causes may contribute to intercostal vessel injury; the most common iatrogenic aetiology is thoracostomy and thoracentesis, especially for patients having coagulation disorders (e.g., hepatocirrhosis, liver transplantation and haematopathy). Non-iatrogenic injuries include secondary intercostal vessel injury, such as chest-wall sharp-instrument injury, autogenous haemorrhage of angioma and costal fracture. There are a variety of manoeuvres that can be used in the management of intercostal vessel bleeding. These include chest tube drainage, thoracotomy and endovascular embolisation.1–3 Balloon-compression technique is an effective and immediate treatment option that can readily be implemented by clinical practitioners with minimal training. It can be a life-saving intervention, especially in low-resource settings where surgical facilities may not be available. Here, we describe and recommend a non-surgical technique of using the balloon Foley catheter to manage intercostal vessel injury. Technique The first patient, a 52-year-old male, had a delayed haemorrhage after thoracostomy. Persistent haemorrhage occurred during the next 48 h. We therefore decided to perform a thoracotomy to control the bleeding. Unfortunately, during the general anaesthesia, the patient suffered a cardiac arrest. After cardiopulmonary resuscitation, he then had a very high risk of mortality if the planned thoracotomy was continued. Because the cause of haemorrhage was believed to be from the intercostal vessels, we decided to use a 20-F balloon Foley catheter to replace the chest tube (Fig. 1). When the catheter tip was positioned within the thoracic cavity, the balloon was inflated with 20 ml water and withdrawn against the chest wall to compress the injured vessel
* Corresponding author. Tel.: +86 571 87236770; fax: +86 571 86995818. E-mail address: [email protected] (H. Jian). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.05.009
(Fig. 2). This technique quickly stopped the patient’s haemorrhage. Meanwhile, the Foley catheter can be used for drainage. The procedure was successful, and no bleeding was found and the drainage kept unblocked. The patient was discharged in 3 days. The second patient, a 46-year-old male, was admitted for thoracic bleeding due to sharp-instrument injury, which was highly suspected an intercostal vessel bleeding. To manage bleeding, we decided to apply this new technique. Whilst placing a 24-F Foley catheter, we noticed that the amount of bleeding was obviously reduced, suggestive of intercostal vessel bleeding. The drainage amount was 1500 ml in the first 3 h. After that, there was no more drainage. The computed tomography (CT) scan showed no pleural effusion. The result of this new procedure was satisfactory and the patient was discharged on the 4th hospital day.
Discussion The well-known technique to control bleeding is to apply direct pressure to the injured vessel. Foley catheter balloon compression is a well-recognised technique employed to arrest haemorrhage from penetrating wounds. There are other case reports of successful control of neck wounds, liver trauma and retroperitoneal haemorrhage using balloon catheter tamponade,4–6 whereas reports of management of the intercostal vessel bleeding with balloon catheter compression are limited. Based on the same principles, we developed a new technique to manage intercostal vessel bleeding using a balloon Foley catheter. In our case, such therapeutic effect is found to be reliable and instant, avoiding surgical trauma. As long as diagnosis is clear, it is practical and convenient when it is applied to management of intercostal vessel bleeding. Based on our experience, this new technique has the following advantages: First, compression with balloon is the classical haemostatic method, which is practical and effective, avoiding surgical trauma, making it suitable for those patients who cannot tolerate the operation. Meanwhile, the Foley catheter can be used for draining gas and fluid7 to observe the haemostatic effect directly. Second, this technique is simple and inexpensive. Patients tolerate the soft and flexible Foley catheter very well. Hence, it is suitable to be extended in basic medical care units and it can even be used as the preoperative haemostatic method. Finally, in the case of multiple rib fracture and flail chest, chest wall will be fixed by drawing with the balloon urinary catheter. However, ongoing bleeding at a rate of 200–300 ml h 1 after Foleycatheter placement is also proposed to be an indication for chest exploration.8
[(Fig._1)TD$IG]
B.F. Chao et al. / Injury, Int. J. Care Injured 42 (2011) 958–959
959
We acknowledge that the Foley catheter may have certain limitations. Can we convert the urinary catheter into a balloon chest catheter? Here are some presumptions: (1) balloon applanation may enlarge the contact area to reinforce the haemostatic effect; (2) make a special L-shape between the inner part of the catheter and the stem to avoid injuring the lung; meanwhile, it can improve the drainage effect; and (3) the chestwall fixing technique affects haemostasis. Here, we list four plans to address this issue: draw and stitch the catheter on the skin; draw and fix with the lock catch; fix by drawing with a force, such as a saline bottle weighing about 300 g; and, finally, use dualballoon fixation at both sides of the chest wall; (4) design the catheter with X-ray-observable features for better observation; and (5) add a flushing pipe to help remove blood clots from the chest cavity. Meanwhile, it can be used as the passage for an endoscope to explore the chest cavity.9 In summary, the technique we describe here has the advantage of being an immediate and effective method in stopping intercostal vessel bleeding, avoiding the need for emergent surgery. Foleycatheter balloon compression is a useful adjunct in the management of selective patients with intercostal vessel bleeding. We hope that our results will encourage further use of this technique. Conflict of interest Fig. 1. The balloon was inflated with 10–20 ml water.
[(Fig._2)TD$IG]
There is no conflict of interest. Acknowledgements The authors have no relevant financial relationship and no commercial interests. The study has not received any financial support. The authors would like to thank Azmatrustam for critically reviewing the article. References 1. Chemelli AP, Thauerer M, Wiedermann F, et al. Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries. J Vasc Surg 2009;49(6):1505–13. 2. Kessel B, Alfici R, Ashkenazi I, et al. Massive hemothorax caused by intercostal artery bleeding: selective embolization may be an alternative to thoracotomy in selected patients. Thorac Cardiovasc Surg 2004;52(4):234–6. 3. Paci M, Ferrari G, Annessi V, et al. The role of diagnostic VATS in penetrating thoracic injuries. World J Emerg Surg 2006;1:30. 4. Seligman JY, Egan M. Balloon tamponade: an alternative in the treatment of liver trauma. Am Surg 1997;63(11):1022–3. 5. Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for lifethreatening hemorrhage in penetrating neck trauma. World J Surg 2006;7:1265–8. 6. Davidson Sr AT. Direct intralumen balloon tamponade: a technique for the control of massive retroperitoneal hemorrhage. Am J Surg 1978;136(3):393–4. 7. Ben-Nun A, Best LA. A simple method of using a Foley catheter to drain pleural effusion. Surg Today 2008;38(8):769–70. 8. Meredith JW, Hoth JJ. Thoracic trauma: when and how to intervene. Surg Clin North Am 2007;87:95–118. 9. Wang ZT, Wang LM, Li S, et al. Electronic endoscope insertion into a thoracic drainage tube is a new technique in the treatment and diagnosis of pleural diseases. Surg Endos 2009;23(7):1671–3.
Fig. 2. The balloon was withdrawn against the chest wall to tamponade the injured vessel.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Technical Note
Balloon Foley catheter compression as a treatment for intercostal vessel bleeding Bao Fei Chao a, Ying Jian Jian a, He Zhe Hao a, Sun Li b, Hu Jian a,*, Pan Hui a, Yan Yun Hai a a b
Department of Thoracic Surgery, First Hospital, College of Medicine, Zhejiang University, No. 79, Qingchun Road, Hangzhou 310003, Zhejiang, China School of Medicine, Hangzhou Normal University, Hangzhou 310036, China
A R T I C L E I N F O
Article history: Accepted 9 May 2011
Introduction Iatrogenic and non-iatrogenic causes may contribute to intercostal vessel injury; the most common iatrogenic aetiology is thoracostomy and thoracentesis, especially for patients having coagulation disorders (e.g., hepatocirrhosis, liver transplantation and haematopathy). Non-iatrogenic injuries include secondary intercostal vessel injury, such as chest-wall sharp-instrument injury, autogenous haemorrhage of angioma and costal fracture. There are a variety of manoeuvres that can be used in the management of intercostal vessel bleeding. These include chest tube drainage, thoracotomy and endovascular embolisation.1–3 Balloon-compression technique is an effective and immediate treatment option that can readily be implemented by clinical practitioners with minimal training. It can be a life-saving intervention, especially in low-resource settings where surgical facilities may not be available. Here, we describe and recommend a non-surgical technique of using the balloon Foley catheter to manage intercostal vessel injury. Technique The first patient, a 52-year-old male, had a delayed haemorrhage after thoracostomy. Persistent haemorrhage occurred during the next 48 h. We therefore decided to perform a thoracotomy to control the bleeding. Unfortunately, during the general anaesthesia, the patient suffered a cardiac arrest. After cardiopulmonary resuscitation, he then had a very high risk of mortality if the planned thoracotomy was continued. Because the cause of haemorrhage was believed to be from the intercostal vessels, we decided to use a 20-F balloon Foley catheter to replace the chest tube (Fig. 1). When the catheter tip was positioned within the thoracic cavity, the balloon was inflated with 20 ml water and withdrawn against the chest wall to compress the injured vessel
* Corresponding author. Tel.: +86 571 87236770; fax: +86 571 86995818. E-mail address: [email protected] (H. Jian). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.05.009
(Fig. 2). This technique quickly stopped the patient’s haemorrhage. Meanwhile, the Foley catheter can be used for drainage. The procedure was successful, and no bleeding was found and the drainage kept unblocked. The patient was discharged in 3 days. The second patient, a 46-year-old male, was admitted for thoracic bleeding due to sharp-instrument injury, which was highly suspected an intercostal vessel bleeding. To manage bleeding, we decided to apply this new technique. Whilst placing a 24-F Foley catheter, we noticed that the amount of bleeding was obviously reduced, suggestive of intercostal vessel bleeding. The drainage amount was 1500 ml in the first 3 h. After that, there was no more drainage. The computed tomography (CT) scan showed no pleural effusion. The result of this new procedure was satisfactory and the patient was discharged on the 4th hospital day.
Discussion The well-known technique to control bleeding is to apply direct pressure to the injured vessel. Foley catheter balloon compression is a well-recognised technique employed to arrest haemorrhage from penetrating wounds. There are other case reports of successful control of neck wounds, liver trauma and retroperitoneal haemorrhage using balloon catheter tamponade,4–6 whereas reports of management of the intercostal vessel bleeding with balloon catheter compression are limited. Based on the same principles, we developed a new technique to manage intercostal vessel bleeding using a balloon Foley catheter. In our case, such therapeutic effect is found to be reliable and instant, avoiding surgical trauma. As long as diagnosis is clear, it is practical and convenient when it is applied to management of intercostal vessel bleeding. Based on our experience, this new technique has the following advantages: First, compression with balloon is the classical haemostatic method, which is practical and effective, avoiding surgical trauma, making it suitable for those patients who cannot tolerate the operation. Meanwhile, the Foley catheter can be used for draining gas and fluid7 to observe the haemostatic effect directly. Second, this technique is simple and inexpensive. Patients tolerate the soft and flexible Foley catheter very well. Hence, it is suitable to be extended in basic medical care units and it can even be used as the preoperative haemostatic method. Finally, in the case of multiple rib fracture and flail chest, chest wall will be fixed by drawing with the balloon urinary catheter. However, ongoing bleeding at a rate of 200–300 ml h 1 after Foleycatheter placement is also proposed to be an indication for chest exploration.8
[(Fig._1)TD$IG]
B.F. Chao et al. / Injury, Int. J. Care Injured 42 (2011) 958–959
959
We acknowledge that the Foley catheter may have certain limitations. Can we convert the urinary catheter into a balloon chest catheter? Here are some presumptions: (1) balloon applanation may enlarge the contact area to reinforce the haemostatic effect; (2) make a special L-shape between the inner part of the catheter and the stem to avoid injuring the lung; meanwhile, it can improve the drainage effect; and (3) the chestwall fixing technique affects haemostasis. Here, we list four plans to address this issue: draw and stitch the catheter on the skin; draw and fix with the lock catch; fix by drawing with a force, such as a saline bottle weighing about 300 g; and, finally, use dualballoon fixation at both sides of the chest wall; (4) design the catheter with X-ray-observable features for better observation; and (5) add a flushing pipe to help remove blood clots from the chest cavity. Meanwhile, it can be used as the passage for an endoscope to explore the chest cavity.9 In summary, the technique we describe here has the advantage of being an immediate and effective method in stopping intercostal vessel bleeding, avoiding the need for emergent surgery. Foleycatheter balloon compression is a useful adjunct in the management of selective patients with intercostal vessel bleeding. We hope that our results will encourage further use of this technique. Conflict of interest Fig. 1. The balloon was inflated with 10–20 ml water.
[(Fig._2)TD$IG]
There is no conflict of interest. Acknowledgements The authors have no relevant financial relationship and no commercial interests. The study has not received any financial support. The authors would like to thank Azmatrustam for critically reviewing the article. References 1. Chemelli AP, Thauerer M, Wiedermann F, et al. Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries. J Vasc Surg 2009;49(6):1505–13. 2. Kessel B, Alfici R, Ashkenazi I, et al. Massive hemothorax caused by intercostal artery bleeding: selective embolization may be an alternative to thoracotomy in selected patients. Thorac Cardiovasc Surg 2004;52(4):234–6. 3. Paci M, Ferrari G, Annessi V, et al. The role of diagnostic VATS in penetrating thoracic injuries. World J Emerg Surg 2006;1:30. 4. Seligman JY, Egan M. Balloon tamponade: an alternative in the treatment of liver trauma. Am Surg 1997;63(11):1022–3. 5. Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for lifethreatening hemorrhage in penetrating neck trauma. World J Surg 2006;7:1265–8. 6. Davidson Sr AT. Direct intralumen balloon tamponade: a technique for the control of massive retroperitoneal hemorrhage. Am J Surg 1978;136(3):393–4. 7. Ben-Nun A, Best LA. A simple method of using a Foley catheter to drain pleural effusion. Surg Today 2008;38(8):769–70. 8. Meredith JW, Hoth JJ. Thoracic trauma: when and how to intervene. Surg Clin North Am 2007;87:95–118. 9. Wang ZT, Wang LM, Li S, et al. Electronic endoscope insertion into a thoracic drainage tube is a new technique in the treatment and diagnosis of pleural diseases. Surg Endos 2009;23(7):1671–3.
Fig. 2. The balloon was withdrawn against the chest wall to tamponade the injured vessel.