Short Communication
Intrapleural Epinephrine Irrigation for Massive Malignant Hemothorax Pei-Ming Huang1
Nai-Kuan Chou1
Tzu-Hsin Lin2
1 Department of Surgery, National Taiwan University Hospital and
National Taiwan University College of Medicine, Taipei, Taiwan 2 Department of Traumatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
Chiung-Nien Chen1 Address for correspondence Chiung-Nien Chen, MD, PhD, Department of Surgery, National Taiwan University Hospital, No. 7, Chung-Shan S. Rd, Taipei 100, Taiwan (e-mail: [email protected]).
Abstract
Keywords
► intrapleural treatment ► hemothorax ► malignancy
Massive malignant hemothorax (MMH) is a rare and serious complication encountered in the field of oncology and can be life threatening. It is often difficult and complex to manage. Herein, we present cases of four patients who had MMH and in whom a hemothorax was successfully stopped via continuous intrapleural irrigation with epinephrine (5-mg epinephrine/1,000-mL normal saline, infused at 100 mL/h) instead of a conventional surgical approach. Although no patient deaths were attributed to intractable bleeding, two deaths were related to multiple organ failure. Despite the limited number of cases, this method was a convenient, effective, and inexpensive alternative to open surgical or thoracoscopic drainage for MMH.
Introduction Massive malignant hemothorax (MMH) is a rare and serious complication encountered in the field of oncology and can lead to respiratory insufficiency and cardiac distress. The most common symptoms include chest pain, dyspnea, and hemoptysis. Hemopneumothorax that develops soon after metastasis to the lung indicates an unfavorable prognosis.1 Although hemothorax has been recognized as a clinical entity for centuries, the management of MMH remains a medical challenge because of the associated multiple organ failure and the difficulty in performing the surgical procedures required for its treatment. Occasionally, a bleeding source may not be apparent during surgery; thus, ligation or electrocautery of the bleeding source may not be sufficient to stop the bleeding. This study presents a simple procedure for control of the acute deterioration in patients with a cancer-related massive hemothorax.
Case Presentation In total, four consecutive adult cancer patients with MMH, unrelated to catheterization problems or trauma, were enrolled and treated by intrapleural irrigation with epinephrine
received July 12, 2014 accepted after revision October 20, 2014
(5-mg epinephrine/1,000-mL normal saline, infused at 100 mL/h) between July 2009 and July 2011. All patients met the criteria of having a rapid accumulation of a pleural hematoma and a shift of the mediastinal structures, recognizable by bedside imaging. The patients with MMH were initially managed by simultaneous replacement of blood volume and drainage of the hemothorax with a chest tube thoracostomy. All patients were also treated with 500 mg of tranexamic acid, systemic antifibrinolytic therapy with every 8 hours, by intravascular injection to control the bleeding. In general, for all cases, the indication for performing the intrapleural epinephrine irrigation was failure of above management. Daily anteroposterior chest radiographs were obtained during the intrapleural irrigation with epinephrine for all four patients (►Fig. 1A, B). ►Table 1 shows the patients’ demographics and outcomes with the intrapleural epinephrine irrigation approach. Surgical intervention, specifically, video-assisted thoracoscopic surgery was performed in the first case. Intrapleural irrigation with epinephrine was performed in this patient because of failure to control the refractory bleeding after surgery. After pleural epinephrine irrigation, the bleeding was controlled in these four patients. After irrigation, oxygen saturation temporarily increased in all patients. Moreover, there
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1396658. ISSN 0171-6425.
Downloaded by: National University of Singapore. Copyrighted material.
Thorac Cardiovasc Surg
Huang et al.
Fig. 1 (A) Chest X-ray shows left lung field haziness due to malignant hemothorax. (B) Follow-up chest X-ray reveals state of being improved lung field after intrapleural epinephrine irrigation.
were no specific findings of blood clot accumulation in any patient after irrigation. Although the in-hospital mortality was high (three of the four patients), no patient deaths were attributable to intractable bleeding and two deaths were related to multiple organ failure.
Discussion Massive hemothorax is associated with significant morbidity and mortality. The etiology of malignant hemothorax is unclear. Some of the complications are related to the primary disease and some are related to a previous history of chest needle aspiration. Sources of a hemothorax have been reported to be caused by hemorrhage from tumor vessels or spontaneous rupture of the systemic circulation.2,3 The prognosis of malignancy-associated hemothorax continues to be extremely poor. Awareness and perhaps predictability of this rare complication are important for early diagnosis, intervention, and possibly improved overall survival. Thoracentesis is often performed to diagnose infections and to exclude the presence of complicated parapneumonic effusions.4 Pleural biopsy confirms the diagnosis of pleural involvement in patients with a history of malignancy. Furthermore, these patients are often critically ill, such as cancer-related cachexia or lung metastasis, so they might not be surgical candidates for hemothorax. Therefore, drainage of the hemorrhage may be more suitable for improvement of the patient’s clinical status. We also detail a simple procedure for control of the acute deterioration in patients with metastatic malignant disease by the local irrigation of the intrapleural space with epinephrine. Pleural lavaged streams of epinephrine through the drain tube increase the augmented opportunity of hemostasis. Drainage of hemothorax allows for the apposition of the visceral and parietal pleura, which aids hemostasis. Besides, epinephrine irrigation could flush the blood clots. Clamping a chest tube does not decrease a hemorrhage and can further worsen gas Thoracic and Cardiovascular Surgeon
exchange.5 Initiation of treatment of MMH with potent antifibrinolytic drugs resulted in a reduction in bleeding and of transfusion requirements. Recombinant activated factor VII is one of the drugs with proven efficacy in counteracting intractable hemorrhage in various scenarios. A combination of oral and intrapleural tranexamic acid to treat patients with this severe complication has also been reported.6 This report demonstrates another therapeutic choice for controlling MMH. Intrapleural irrigation with epinephrine facilitates vasoconstriction of bleeding sources and enhances the ability of hemostatic agents to control bleeding in an even and thorough manner.5 In this study, all the refractory MMH patients’ bleeding was successfully controlled via continuous intrapleural irrigation with epinephrine administration, instead of conventional surgical electrocautery. Other systemic side effects of epinephrine, such as hypertension and tachycardia, were not observed in our patients. As cancer patients are critically ill and frequently have coexisting conditions, 50% of our patients had multiple organ failure. Regardless of the success of the aforementioned method in controlling the acute hemorrhage, 75% of patients succumbed to their likely lethal disease. Should rescue treatment be offered to all patients with uncontrolled metastatic malignant disease or to a selective approach of a subset of patients? We contemplate longevity of life is not synonymous with “quality of life” in this situation. Before performing definitive surgical treatment for hemothorax, pleural lavaged streams of epinephrine could be a good selection based on our experiences. However, some hemothoraces (in patients with great vessel or organ rupture or with massive postoperative hemothorax) require immediate, definitive surgical intervention. Therefore, pleural epinephrine irrigation ought not to be continuously used if bleeding does not stop or decrease. Of a subset of patients at risk of hemothorax, most patients are likely to benefit from this technique, but those with catastrophic bleed should not
Downloaded by: National University of Singapore. Copyrighted material.
Intrapleural Epinephrine Irrigation for Malignant Hemothorax
References 1 Hihara T, Furumoto N, Kakishita M. Hemopneumothorax due
2
Right Abbreviations: F, female; M, male; PEEP, positive end-expiratory pressure.
Peritoneum Colon cancer 48 4
M
Left Spine, spleen, liver, stomach, peritoneum 50 3
F
Cervical cancer
Left/right 27 d later Brain, spine, pleura Multiple myeloma 52 2
M
Left Spines, lung, liver Coccygeal chordoma 51 1
F
Funding/Support This study has not been supported by any funding.
4
5
6
7
8
9
to pulmonary metastasis with malignant hemangioendothelioma: CT and pathological findings. Radiat Med 1988;6(5): 213–215 Catena F, Bianchi R, Ansaloni L, Pinna AD. Hemothorax caused by rupture of a primitive thoracic leiomyosarcoma of the thoracic aorta: description of a case and literature review. J Thorac Cardiovasc Surg 2008;135(3):688–689 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):234–236 Dominguez J, Sancho C, Escalante E, Morera JR, Moya JA, Bernat R. Percutaneous treatment of a ruptured intercostal aneurysm presenting as massive hemothorax in a patient with type I neurofibromatosis. J Thorac Cardiovasc Surg 2002;124(6):1230–1232 Huang PM, Ko WJ, Tsai PR, et al. Aggressive management of massive hemothorax in patients on extracorporeal membrane oxygenation. Asian J Surg 2012;35(1):16–22 De Boer WA, Koolen MG, Roos CM, Ten Cate JW. Tranexamic acid treatment of hemothorax in two patients with malignant mesothelioma. Chest 1991;100(3):847–848 Schweigert M, Beron M, Dubecz A, Stadlhuber R, Stein H. Videoassisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly. Thorac Cardiovasc Surg 2012;60(7):474–479 Solaini L, Prusciano F, Solaini L, Carletti M. Video-assisted thoracoscopic surgery for postoperative hemothorax. Thorac Cardiovasc Surg 2011;59(8):475–478 Schroeter T, Bittner H, Subramanian S, Hänsig M, Mohr F, Borger M. Life-threatening hemothorax resulting from lung hernia after minimally invasive mitral valve surgery. Thorac Cardiovasc Surg 2011;59(4):252–254
Thoracic and Cardiovascular Surgeon
Downloaded by: National University of Singapore. Copyrighted material.
Survival No 2 Nonintubated oxygen support
54
Expired due to cardiopulmonary failure No 1 Nonintubated oxygen support
5
Expired due to sepsis No 1 Intubated with PEEP support
51
Expired due to cardiopulmonary failure No 6 2d Non-intubated oxygen support
Complications Postoperative hospital stay (d) Pleural irrigation duration (d) Patient status Sites of hemothorax Distant metastasis organ Underlying cancer
be treated by this technique. The technique is simple and perhaps worthwhile for those critically ill patients who in pre-catastrophic event are thought to have the possibility of a productive future existence. Massive hemothorax and continual bleeding with unstable hemodynamics are indications for further surgical intervention, especially if conventional treatment has failed. For the treatment of retained hemothorax, VATS or thoracotomy is the favored for evacuation and adequate hemothorax drainage.7–9 Because the acute hemothorax is typically unexpected, predicting the patient’s postintervention “quality of life” may be next to impossible—an ethical dilemma for those practitioners faced with this emergency, that is, “primum non nocere.” Despite the limited case number and the survival result in this study, continuous intrapleural irrigation with epinephrine was a convenient, effective, and inexpensive alternative to open surgical or thoracoscopic drainage in these four cases.
3
Age (y)
Sex
Huang et al.
Conflicts of Interest All the authors have no conflicts of interest to disclose.
Patient
Table 1 Demographics of four patients with malignant hemothorax treated by intrapleural epinephrine irrigation
Follow-up (mo)
Intrapleural Epinephrine Irrigation for Malignant Hemothorax
Intrapleural Epinephrine Irrigation for Massive Malignant Hemothorax Pei-Ming Huang1
Nai-Kuan Chou1
Tzu-Hsin Lin2
1 Department of Surgery, National Taiwan University Hospital and
National Taiwan University College of Medicine, Taipei, Taiwan 2 Department of Traumatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
Chiung-Nien Chen1 Address for correspondence Chiung-Nien Chen, MD, PhD, Department of Surgery, National Taiwan University Hospital, No. 7, Chung-Shan S. Rd, Taipei 100, Taiwan (e-mail: [email protected]).
Abstract
Keywords
► intrapleural treatment ► hemothorax ► malignancy
Massive malignant hemothorax (MMH) is a rare and serious complication encountered in the field of oncology and can be life threatening. It is often difficult and complex to manage. Herein, we present cases of four patients who had MMH and in whom a hemothorax was successfully stopped via continuous intrapleural irrigation with epinephrine (5-mg epinephrine/1,000-mL normal saline, infused at 100 mL/h) instead of a conventional surgical approach. Although no patient deaths were attributed to intractable bleeding, two deaths were related to multiple organ failure. Despite the limited number of cases, this method was a convenient, effective, and inexpensive alternative to open surgical or thoracoscopic drainage for MMH.
Introduction Massive malignant hemothorax (MMH) is a rare and serious complication encountered in the field of oncology and can lead to respiratory insufficiency and cardiac distress. The most common symptoms include chest pain, dyspnea, and hemoptysis. Hemopneumothorax that develops soon after metastasis to the lung indicates an unfavorable prognosis.1 Although hemothorax has been recognized as a clinical entity for centuries, the management of MMH remains a medical challenge because of the associated multiple organ failure and the difficulty in performing the surgical procedures required for its treatment. Occasionally, a bleeding source may not be apparent during surgery; thus, ligation or electrocautery of the bleeding source may not be sufficient to stop the bleeding. This study presents a simple procedure for control of the acute deterioration in patients with a cancer-related massive hemothorax.
Case Presentation In total, four consecutive adult cancer patients with MMH, unrelated to catheterization problems or trauma, were enrolled and treated by intrapleural irrigation with epinephrine
received July 12, 2014 accepted after revision October 20, 2014
(5-mg epinephrine/1,000-mL normal saline, infused at 100 mL/h) between July 2009 and July 2011. All patients met the criteria of having a rapid accumulation of a pleural hematoma and a shift of the mediastinal structures, recognizable by bedside imaging. The patients with MMH were initially managed by simultaneous replacement of blood volume and drainage of the hemothorax with a chest tube thoracostomy. All patients were also treated with 500 mg of tranexamic acid, systemic antifibrinolytic therapy with every 8 hours, by intravascular injection to control the bleeding. In general, for all cases, the indication for performing the intrapleural epinephrine irrigation was failure of above management. Daily anteroposterior chest radiographs were obtained during the intrapleural irrigation with epinephrine for all four patients (►Fig. 1A, B). ►Table 1 shows the patients’ demographics and outcomes with the intrapleural epinephrine irrigation approach. Surgical intervention, specifically, video-assisted thoracoscopic surgery was performed in the first case. Intrapleural irrigation with epinephrine was performed in this patient because of failure to control the refractory bleeding after surgery. After pleural epinephrine irrigation, the bleeding was controlled in these four patients. After irrigation, oxygen saturation temporarily increased in all patients. Moreover, there
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1396658. ISSN 0171-6425.
Downloaded by: National University of Singapore. Copyrighted material.
Thorac Cardiovasc Surg
Huang et al.
Fig. 1 (A) Chest X-ray shows left lung field haziness due to malignant hemothorax. (B) Follow-up chest X-ray reveals state of being improved lung field after intrapleural epinephrine irrigation.
were no specific findings of blood clot accumulation in any patient after irrigation. Although the in-hospital mortality was high (three of the four patients), no patient deaths were attributable to intractable bleeding and two deaths were related to multiple organ failure.
Discussion Massive hemothorax is associated with significant morbidity and mortality. The etiology of malignant hemothorax is unclear. Some of the complications are related to the primary disease and some are related to a previous history of chest needle aspiration. Sources of a hemothorax have been reported to be caused by hemorrhage from tumor vessels or spontaneous rupture of the systemic circulation.2,3 The prognosis of malignancy-associated hemothorax continues to be extremely poor. Awareness and perhaps predictability of this rare complication are important for early diagnosis, intervention, and possibly improved overall survival. Thoracentesis is often performed to diagnose infections and to exclude the presence of complicated parapneumonic effusions.4 Pleural biopsy confirms the diagnosis of pleural involvement in patients with a history of malignancy. Furthermore, these patients are often critically ill, such as cancer-related cachexia or lung metastasis, so they might not be surgical candidates for hemothorax. Therefore, drainage of the hemorrhage may be more suitable for improvement of the patient’s clinical status. We also detail a simple procedure for control of the acute deterioration in patients with metastatic malignant disease by the local irrigation of the intrapleural space with epinephrine. Pleural lavaged streams of epinephrine through the drain tube increase the augmented opportunity of hemostasis. Drainage of hemothorax allows for the apposition of the visceral and parietal pleura, which aids hemostasis. Besides, epinephrine irrigation could flush the blood clots. Clamping a chest tube does not decrease a hemorrhage and can further worsen gas Thoracic and Cardiovascular Surgeon
exchange.5 Initiation of treatment of MMH with potent antifibrinolytic drugs resulted in a reduction in bleeding and of transfusion requirements. Recombinant activated factor VII is one of the drugs with proven efficacy in counteracting intractable hemorrhage in various scenarios. A combination of oral and intrapleural tranexamic acid to treat patients with this severe complication has also been reported.6 This report demonstrates another therapeutic choice for controlling MMH. Intrapleural irrigation with epinephrine facilitates vasoconstriction of bleeding sources and enhances the ability of hemostatic agents to control bleeding in an even and thorough manner.5 In this study, all the refractory MMH patients’ bleeding was successfully controlled via continuous intrapleural irrigation with epinephrine administration, instead of conventional surgical electrocautery. Other systemic side effects of epinephrine, such as hypertension and tachycardia, were not observed in our patients. As cancer patients are critically ill and frequently have coexisting conditions, 50% of our patients had multiple organ failure. Regardless of the success of the aforementioned method in controlling the acute hemorrhage, 75% of patients succumbed to their likely lethal disease. Should rescue treatment be offered to all patients with uncontrolled metastatic malignant disease or to a selective approach of a subset of patients? We contemplate longevity of life is not synonymous with “quality of life” in this situation. Before performing definitive surgical treatment for hemothorax, pleural lavaged streams of epinephrine could be a good selection based on our experiences. However, some hemothoraces (in patients with great vessel or organ rupture or with massive postoperative hemothorax) require immediate, definitive surgical intervention. Therefore, pleural epinephrine irrigation ought not to be continuously used if bleeding does not stop or decrease. Of a subset of patients at risk of hemothorax, most patients are likely to benefit from this technique, but those with catastrophic bleed should not
Downloaded by: National University of Singapore. Copyrighted material.
Intrapleural Epinephrine Irrigation for Malignant Hemothorax
References 1 Hihara T, Furumoto N, Kakishita M. Hemopneumothorax due
2
Right Abbreviations: F, female; M, male; PEEP, positive end-expiratory pressure.
Peritoneum Colon cancer 48 4
M
Left Spine, spleen, liver, stomach, peritoneum 50 3
F
Cervical cancer
Left/right 27 d later Brain, spine, pleura Multiple myeloma 52 2
M
Left Spines, lung, liver Coccygeal chordoma 51 1
F
Funding/Support This study has not been supported by any funding.
4
5
6
7
8
9
to pulmonary metastasis with malignant hemangioendothelioma: CT and pathological findings. Radiat Med 1988;6(5): 213–215 Catena F, Bianchi R, Ansaloni L, Pinna AD. Hemothorax caused by rupture of a primitive thoracic leiomyosarcoma of the thoracic aorta: description of a case and literature review. J Thorac Cardiovasc Surg 2008;135(3):688–689 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):234–236 Dominguez J, Sancho C, Escalante E, Morera JR, Moya JA, Bernat R. Percutaneous treatment of a ruptured intercostal aneurysm presenting as massive hemothorax in a patient with type I neurofibromatosis. J Thorac Cardiovasc Surg 2002;124(6):1230–1232 Huang PM, Ko WJ, Tsai PR, et al. Aggressive management of massive hemothorax in patients on extracorporeal membrane oxygenation. Asian J Surg 2012;35(1):16–22 De Boer WA, Koolen MG, Roos CM, Ten Cate JW. Tranexamic acid treatment of hemothorax in two patients with malignant mesothelioma. Chest 1991;100(3):847–848 Schweigert M, Beron M, Dubecz A, Stadlhuber R, Stein H. Videoassisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly. Thorac Cardiovasc Surg 2012;60(7):474–479 Solaini L, Prusciano F, Solaini L, Carletti M. Video-assisted thoracoscopic surgery for postoperative hemothorax. Thorac Cardiovasc Surg 2011;59(8):475–478 Schroeter T, Bittner H, Subramanian S, Hänsig M, Mohr F, Borger M. Life-threatening hemothorax resulting from lung hernia after minimally invasive mitral valve surgery. Thorac Cardiovasc Surg 2011;59(4):252–254
Thoracic and Cardiovascular Surgeon
Downloaded by: National University of Singapore. Copyrighted material.
Survival No 2 Nonintubated oxygen support
54
Expired due to cardiopulmonary failure No 1 Nonintubated oxygen support
5
Expired due to sepsis No 1 Intubated with PEEP support
51
Expired due to cardiopulmonary failure No 6 2d Non-intubated oxygen support
Complications Postoperative hospital stay (d) Pleural irrigation duration (d) Patient status Sites of hemothorax Distant metastasis organ Underlying cancer
be treated by this technique. The technique is simple and perhaps worthwhile for those critically ill patients who in pre-catastrophic event are thought to have the possibility of a productive future existence. Massive hemothorax and continual bleeding with unstable hemodynamics are indications for further surgical intervention, especially if conventional treatment has failed. For the treatment of retained hemothorax, VATS or thoracotomy is the favored for evacuation and adequate hemothorax drainage.7–9 Because the acute hemothorax is typically unexpected, predicting the patient’s postintervention “quality of life” may be next to impossible—an ethical dilemma for those practitioners faced with this emergency, that is, “primum non nocere.” Despite the limited case number and the survival result in this study, continuous intrapleural irrigation with epinephrine was a convenient, effective, and inexpensive alternative to open surgical or thoracoscopic drainage in these four cases.
3
Age (y)
Sex
Huang et al.
Conflicts of Interest All the authors have no conflicts of interest to disclose.
Patient
Table 1 Demographics of four patients with malignant hemothorax treated by intrapleural epinephrine irrigation
Follow-up (mo)
Intrapleural Epinephrine Irrigation for Malignant Hemothorax
