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Author: Omid Zad, MD

Antibiotic prophylaxis in eCPR

Prophylactic Antibiotic Use in Adult Cardiac Arrest Patients Receiving Emergent ECMO (eCPR)

Written by Omid Zad, MD on . Posted in Zad Talk. No Comments on Prophylactic Antibiotic Use in Adult Cardiac Arrest Patients Receiving Emergent ECMO (eCPR)

Introduction

Extracorporeal Membrane Oxygenation (ECMO) is an advanced life support therapy utilized in critical care medicine to provide temporary circulatory and respiratory support for patients with severely compromised cardiac and/or pulmonary function.1 In the context of cardiac arrest, the rapid deployment of ECMO, termed extracorporeal cardiopulmonary resuscitation (eCPR), aims to restore systemic perfusion and improve survival rates in patients who do not respond to conventional resuscitation efforts.2 While ECMO offers a crucial bridge to recovery, it inherently carries a significant risk of infection. The establishment of the ECMO circuit necessitates the insertion of large-bore cannulas into major blood vessels, a procedure that, particularly in the emergent setting of cardiac arrest, may be conducted under less than ideal sterile conditions, thereby increasing the potential for microbial contamination at the insertion site. Furthermore, the ECMO circuit itself, involving invasive cannulas that breach the skin’s natural protective barrier, provides a direct pathway for pathogenic microorganisms to enter the bloodstream.4 The complexity of care for patients on ECMO often involves multiple additional invasive interventions, such as central venous catheters for medication administration and arterial lines for hemodynamic monitoring, which further elevate the susceptibility to hospital-acquired infections.4 This report aims to critically evaluate the current recommendations and available evidence regarding the use of prophylactic antibiotics in adult patients who experience cardiac arrest and are emergently placed on ECMO. It will specifically address the concerns arising from the potentially semi-sterile nature of cannula insertion during eCPR and the implications of prolonged ECMO support on infection risk.

The urgent need to establish circulatory support during eCPR might sometimes necessitate a more rapid cannulation procedure, potentially with less stringent adherence to sterility protocols compared to elective ECMO initiation. This reality could contribute to a higher initial risk of infections at the cannula insertion sites. Additionally, patients who survive the initial cardiac arrest and are supported by ECMO often require prolonged treatment, sometimes lasting for days or even weeks.1 This extended duration of ECMO support, with indwelling cannulas and other invasive devices, progressively increases the cumulative risk of various nosocomial infections, extending beyond just the initial insertion site.

Current Guidelines on Prophylactic Antibiotics in ECMO

The Extracorporeal Life Support Organization (ELSO) provides guidelines for the management of patients receiving ECMO. Current ELSO recommendations generally advise against the routine use of antimicrobial prophylaxis in ECMO patients to prevent infections, beyond the standard periprocedural antibiotic administration.7 This stance is primarily based on the observation that retrospective studies investigating the efficacy of routine prophylactic antibiotics after ECMO cannulation have not consistently demonstrated a clear benefit in improving patient outcomes.9 ELSO guidance suggests the administration of only standard periprocedural antimicrobial prophylaxis, which is typically a single dose given shortly before the procedure to prevent surgical site infections from skin commensals.9

While ELSO offers various guidelines covering different aspects of ECMO support, including specific guidelines for adult and pediatric eCPR 10, the provided research material does not detail a specific recommendation within these guidelines regarding routine antibiotic prophylaxis in the eCPR setting. It is noted that ELSO has developed in-depth guidelines for ECMO in COVID-19 patients 10, which likely include detailed infection prevention and control strategies tailored to that specific patient population. However, the applicability of these COVID-19-specific recommendations to the broader population of non-COVID eCPR patients requires careful consideration of the differing risk factors and clinical contexts.

The rationale behind ELSO’s discouragement of routine antibiotic prophylaxis in ECMO patients stems from the inconsistent findings of retrospective studies, which have failed to demonstrate a consistent improvement in patient outcomes with this practice.9 Furthermore, there are significant concerns about the potential for routine antibiotic use to promote the development of antibiotic resistance, a critical issue in the management of critically ill patients who are already at high risk of infection with multidrug-resistant organisms.11

The lack of a specific ELSO recommendation either endorsing or opposing routine prophylactic antibiotics in eCPR suggests that the general guidance for ECMO patients should be applied. However, the unique circumstances and potential risks associated with eCPR, such as the possibility of less than ideal sterile conditions during emergent cannulation, might necessitate a more nuanced approach at the individual institutional level. Each center should consider its local infection rates, prevalent pathogens, and patient risk factors when developing protocols for infection prevention in eCPR patients.

Evidence for Prophylactic Antibiotics in eCPR Patients

The evidence regarding the effectiveness of prophylactic antibiotics in ECMO patients, including those undergoing eCPR, is varied and often conflicting. A nationwide cohort study conducted in Japan by Kondo et al. 14 analyzed a large database of patients receiving ECMO and found that the administration of prophylactic antibiotics (specifically cephalosporins or glycopeptides) within the first two days of ECMO initiation was associated with a reduction in in-hospital mortality and a lower incidence of nosocomial pneumonia. However, this study had several limitations, including the fact that it did not specifically focus on patients who underwent eCPR and the definition of prophylaxis included antibiotic administration up to 48 hours after ECMO initiation, which might blur the line between true prophylaxis and early empirical treatment.13 Additionally, the study did not provide detailed information on the specific antibiotic agents used, their dosages, or the duration of treatment.

In contrast, a systematic review published in 2016, which evaluated 11 studies on antibiotic prophylaxis in ECMO patients, concluded that infection rates were generally similar regardless of prophylaxis use, and the two studies that directly compared outcomes with and without prophylaxis found no benefit from routine antibiotic administration.7 The review also noted the heterogeneity of causative infectious organisms, which did not support a clear rationale for any specific prophylactic strategy.

However, a more recent retrospective study specifically focused on patients undergoing eCPR found a potential benefit of prophylactic antibiotics with coverage against Pseudomonas aeruginosa.3 This study observed that patients who received prophylactic antibiotics with Pseudomonas coverage within 72 hours after eCPR had a significantly lower incidence of nosocomial infections, particularly ventilator-associated pneumonia (VAP), where Pseudomonas was a common pathogen. The antibiotics with Pseudomonas coverage used in this study included ceftazidime, cefepime, ciprofloxacin, levofloxacin, and meropenem.20 This finding suggests that in the eCPR population, where VAP is a frequent complication and Pseudomonas is often implicated, targeted prophylaxis might be beneficial.

A systematic review from 2024, encompassing three studies with a large number of ECMO participants, indicated that prophylactic antibiotics were associated with a reduction in mortality, the risk of infections, and complications such as acute kidney injury and diarrhea.18 However, the authors of this review also emphasized the need for further prospective research and the development of tailored, ECMO-specific bundles to optimize infection prevention strategies.

The available evidence presents a complex picture. While some studies, particularly the large Japanese cohort and the eCPR-specific study on Pseudomonas coverage, suggest potential benefits of prophylactic antibiotics in certain contexts, the overall evidence is not robust enough to support a universal recommendation for routine use in all adult patients receiving eCPR. The heterogeneity in study designs, patient populations, antibiotic regimens, and outcome measures contributes to the conflicting findings.

Table 1: Summary of Key Studies Investigating Prophylactic Antibiotics in ECMO

Study Author and YearStudy DesignPatient PopulationInterventionComparison GroupMain Findings
Kondo et al., 2021Retrospective CohortAdults (general ECMO)Cephalosporin or glycopeptide within 2 days of ECMONo antibioticsReduced in-hospital mortality and nosocomial pneumonia associated with prophylaxis.
Systematic Review, 2016Systematic ReviewAdults, Children, Neonates (general ECMO)Various prophylactic antibiotic regimensNo prophylaxisNo benefit from routine antibiotic prophylaxis in most patients; heterogeneous causative organisms.
PMC10774957, 2023Retrospective CohortAdults (eCPR)Prophylactic antibiotics with Pseudomonas coverageNo prophylaxisLower incidence of nosocomial infections, particularly VAP, associated with Pseudomonas coverage within 72 hours of eCPR.
Systematic Review, 2024Systematic ReviewAdults (general ECMO)Various prophylactic antibiotic regimensNo prophylaxisProphylactic antibiotics associated with reduced mortality, infections, and complications, but calls for more prospective research.

IV. Rationale Against Routine Prophylaxis and Considerations for Antimicrobial Stewardship

The routine use of prophylactic antibiotics in ECMO patients carries significant potential risks. One of the most concerning is the increased likelihood of developing antibiotic resistance among both the patient’s own flora and the pathogens responsible for subsequent infections.1 This can lead to infections that are more difficult to treat and may require the use of broader-spectrum antibiotics, further exacerbating the problem of resistance. Additionally, antibiotic prophylaxis can disrupt the normal microbial balance in the body, potentially leading to opportunistic infections such as Clostridioides difficile infection.11 Patients may also experience direct drug toxicities or other adverse side effects from the prophylactic antibiotics themselves.12 Furthermore, the fear of missing an infection in this complex patient population can sometimes lead to the overdiagnosis of ECMO-associated infections (EAIs), resulting in the prolonged use of broad-spectrum antibiotics, which further contributes to the risks of resistance and C. difficile infection.11

Given these potential harms and the limited evidence of clear benefit for routine prophylaxis in ECMO, the principles of antimicrobial stewardship are of paramount importance in this vulnerable patient population.1 Antimicrobial stewardship aims to optimize antibiotic use to improve patient outcomes while minimizing the development of resistance. In the context of eCPR, this means avoiding unnecessary antibiotic exposure unless there is strong evidence to support its use in a specific situation.1 If prophylactic antibiotics are considered, the choice of agent should be carefully tailored based on the local microbiology and antibiotic resistance patterns prevalent in the institution.11 It is also crucial to regularly review and revise antibiotic protocols based on local infection data and emerging resistance trends.11

The potential for routine antibiotic prophylaxis to promote antibiotic resistance likely outweighs the uncertain benefits, especially in the absence of robust evidence. This highlights the critical need for a judicious approach to antibiotic use in ECMO patients, prioritizing antimicrobial stewardship to protect both individual patients and the broader healthcare system from the consequences of antibiotic resistance.

Potential Role of Targeted Prophylaxis in Specific Subgroups or Settings

While ELSO generally advises against routine antibiotic prophylaxis in ECMO patients, there might be specific patient characteristics or procedural factors that could warrant consideration for a more targeted approach in the eCPR setting. Immunocompromised patients, for instance, may be at a higher baseline risk of infection.1 ELSO guidelines acknowledge that prophylaxis might be considered in immunocompromised individuals.13 However, the specific definition of immunocompromised in this context and the optimal prophylactic regimen remain unclear and require careful clinical judgment.

ELSO also mentions patients with a prolonged open chest, often encountered after cardiac surgery, as a potential indication for prophylactic antibiotics.7 This scenario is less directly applicable to eCPR unless the cannulation was performed via an open chest approach, which is less common than percutaneous insertion.

Regarding procedural factors, central cannulation has been suggested to potentially carry a higher risk of certain infections compared to peripheral cannulation.1 However, current guidelines do not differentiate prophylaxis recommendations based on the site of cannulation, and further evidence is needed to determine if targeted prophylaxis is warranted in patients undergoing central cannulation for eCPR.

Although emergent cannulation during eCPR might theoretically be associated with a higher risk of infection due to potentially less controlled sterile conditions, current guidelines do not distinguish prophylaxis recommendations based on the urgency of the procedure. The decision to consider targeted prophylaxis in specific subgroups of eCPR patients should be based on a comprehensive assessment of the individual patient’s risk factors, the specific circumstances of their cardiac arrest and resuscitation, and the local epidemiology of infections in the ECMO unit.

Importance of Infection Prevention and Control Measures

Comprehensive infection prevention and control measures are paramount in reducing the risk of nosocomial infections in ECMO patients and are likely more impactful than routine antibiotic prophylaxis. Meticulous adherence to aseptic techniques during ECMO cannulation and the ongoing care of cannula insertion sites are fundamental.1 Implementing standardized cannula site care bundles, adapted from principles used for central line-associated bloodstream infection (CLABSI) prevention, has shown significant success in reducing infection rates.5 These bundles typically focus on standardizing the use of antimicrobial dressings, ensuring strict aseptic techniques during dressing changes and line access, optimizing cannula securement to prevent movement and disruption of the insertion site, performing daily antimicrobial patient bathing, and addressing environmental factors to minimize contamination risks.31

Routine monitoring of cannula insertion sites for any signs of infection, such as erythema, purulent drainage, or localized tenderness, is essential.1 Maintaining a low threshold to obtain cultures from blood and insertion sites when infection is suspected allows for early identification of pathogens and timely initiation of appropriate treatment.1 Efforts should also be made to avoid maintaining ECMO treatment for longer than absolutely necessary, as prolonged duration of support is a well-established risk factor for infection.1 Other important infection control practices include the use of needleless hubs at all connections in the ECMO circuit to reduce the risk of contamination 4, the routine disinfection of ECMO system parts with chlorhexidine 4, and ensuring frequent hand hygiene by all healthcare personnel involved in the care of the patient.4

The experience of centers that have implemented comprehensive infection prevention bundles has demonstrated remarkable success in significantly reducing bloodstream infections in ECMO patients.31 These success stories underscore the effectiveness of a multi-faceted approach that focuses on meticulous care practices and standardized protocols to minimize the risk of infection.

Considerations for Antibiotic Regimens if Prophylaxis is Used

If, despite the general lack of strong evidence, a clinician decides to use prophylactic antibiotics in an adult patient receiving eCPR, the choice of antibiotic regimen should be carefully considered. The Japanese cohort study mentioned the use of cephalosporins or glycopeptides within the first two days of ECMO initiation.14 However, the specific agents, dosages, and durations were not detailed in the provided snippets. The eCPR study suggesting a benefit of Pseudomonas coverage did not specify a particular regimen but mentioned classes of antibiotics that have activity against Pseudomonas, including ceftazidime, cefepime, ciprofloxacin, levofloxacin, and meropenem.20 It is important to note that any consideration of these agents for prophylaxis should be guided by the local antibiogram, which provides information on the susceptibility patterns of common pathogens in a specific institution. Patient-specific factors, such as allergies and prior antibiotic exposure, should also be taken into account. One study 25 reported on the development of a standardized antimicrobial prophylaxis regimen for ECMO patients based on their institutional experience, but the specific details of this regimen are not available in the provided material.

It is crucial to emphasize that there is no universally recommended antibiotic regimen for prophylactic use in eCPR patients, and any decision to use prophylaxis should be made on an individualized basis, considering the potential benefits and risks in the context of the specific clinical situation and local microbiological data. Furthermore, it is important to acknowledge the significant challenges associated with antibiotic dosing in ECMO patients due to the pharmacokinetic and pharmacodynamic alterations that can occur with ECMO support.30 Factors such as increased volume of distribution, altered drug clearance, and potential sequestration of antibiotics within the ECMO circuit can affect drug levels and efficacy. Therefore, if prophylactic antibiotics are used, ensuring therapeutic levels is important, and in cases of suspected or confirmed infection, therapeutic drug monitoring may be warranted.

Table 2: Antibiotics with Pseudomonas aeruginosa Coverage Mentioned in eCPR Study

Antibiotic NameClass of Antibiotic
CeftazidimeCephalosporin
CefepimeCephalosporin
CiprofloxacinFluoroquinolone
LevofloxacinFluoroquinolone
MeropenemCarbapenem

VIII. Conclusion and Recommendations

In summary, the current evidence regarding the use of prophylactic antibiotics in adult patients receiving emergent ECMO for cardiac arrest (eCPR) is not robust enough to support a routine recommendation. While a large retrospective study suggested a potential benefit of early antibiotic administration in ECMO patients in general, and a study focused on eCPR indicated that prophylactic antibiotics with Pseudomonas aeruginosa coverage might reduce nosocomial infections, the overall evidence remains limited and often conflicting. The Extracorporeal Life Support Organization (ELSO) generally recommends against routine antimicrobial prophylaxis in ECMO patients, citing the lack of clear patient outcome benefit and concerns about promoting antibiotic resistance.

Given the absence of strong evidence supporting routine prophylaxis and the significant risks associated with widespread antibiotic use, a nuanced approach is warranted. While routine prophylactic antibiotics are not recommended for all adult patients receiving eCPR, there might be specific contexts or patient subgroups where targeted prophylaxis could be considered. For instance, based on the findings of a study focused on eCPR, prophylactic antibiotics with coverage against Pseudomonas aeruginosa within the first 72 hours of ECMO initiation might be considered, especially in institutions with a high prevalence of Pseudomonas VAP. However, this decision should be made with caution and in the context of local antibiograms and a thorough assessment of the individual patient’s risk factors. Patients with known immunocompromising conditions might also warrant consideration for targeted prophylaxis, although specific regimens and durations require further investigation.

The cornerstone of reducing ECMO-associated infections in eCPR patients should be the meticulous implementation and consistent adherence to comprehensive infection prevention bundles. These bundles, adapted from best practices for CLABSI prevention, should focus on standardized protocols for cannula insertion and maintenance, including aseptic techniques, antimicrobial dressings, cannula securement, and routine site monitoring. Furthermore, strict adherence to antimicrobial stewardship principles is crucial to minimize unnecessary antibiotic use and mitigate the development of antibiotic resistance.

Future research should focus on conducting prospective, well-designed studies to evaluate the efficacy of targeted prophylactic strategies in specific subgroups of eCPR patients. Identifying patient and procedural factors that are associated with a higher risk of infection could help to refine prophylactic approaches and optimize infection prevention strategies in this complex and critically ill population.

Reference

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Sodium Bicarbonate

Bicarb: Not Always the Quick Fix

Written by Omid Zad, MD on . Posted in Zad Talk. No Comments on Bicarb: Not Always the Quick Fix

Acidosis is a critical condition in which there is an excess of acid in the body fluids, causing a decrease in blood pH (normally 7.35–7.45). This can lead to significant physiological disturbances and requires careful diagnosis and management. Broadly, acidosis is classified into two main types: metabolic and respiratory.

Types of Acidosis

  1. Metabolic Acidosis
    • Anion Gap Acidosis: Caused by the buildup of organic acids such as lactate (e.g., lactic acidosis), ketoacids (e.g., diabetic ketoacidosis), or toxins (e.g., methanol, ethylene glycol).
    • Non-Anion Gap Acidosis: Occurs when bicarbonate is lost (e.g., through the gastrointestinal tract or kidneys) or when hydrochloric acid is added to the system.
  2. Respiratory Acidosis
    • Develops due to hypoventilation, resulting in the accumulation of carbon dioxide (CO₂). Elevated CO₂ levels lower blood pH, leading to acidemia.

Mechanism of Action of Bicarbonate

Sodium bicarbonate (NaHCO₃) is a buffer that helps neutralize excess acid. When administered, it dissociates into sodium (Na⁺) and bicarbonate (HCO₃⁻). The bicarbonate ions bind with hydrogen ions (H⁺) to form carbonic acid (H₂CO₃), which the body converts into water (H₂O) and carbon dioxide (CO₂). The CO₂ is then exhaled through the lungs, helping to raise blood pH.

Indications for Bicarbonate Use

  1. Severe Metabolic Acidosis
    • Sodium bicarbonate is recommended when arterial blood pH is ≤ 7.0. The primary objective is to raise the pH to a safer level (around 7.2) to reduce the harmful effects of extreme acidemia.
  2. Lactic Acidosis with Acute Kidney Injury (AKI)
    • According to the Surviving Sepsis Campaign, endorsed by the Society of Critical Care Medicine, sodium bicarbonate may improve outcomes in patients with severe metabolic acidemia (pH ≤ 7.2) who also have AKI (AKIN stage 2 or 3). Studies suggest a survival benefit in this subgroup.
  3. Drug Intoxications
    • Sodium bicarbonate is also beneficial for certain drug overdoses, including sodium channel blockers or salicylates, where urine alkalinization enhances the elimination of the toxin.

Contraindications and Cautions

  • Lactic Acidosis Secondary to Hypoperfusion
    • Routine use of bicarbonate in lactic acidosis caused by poor tissue perfusion (e.g., immediately after cardiac surgery) is not generally recommended. Research indicates no meaningful improvement in hemodynamic status or reduction in vasopressor requirements. The Surviving Sepsis Campaign advises against using bicarbonate if pH ≥ 7.15.
  • Respiratory Acidosis
    • In respiratory acidosis, giving bicarbonate can increase CO₂ production. Since patients with respiratory acidosis already have difficulty exhaling CO₂, bicarbonate therapy can worsen the condition by raising the ventilatory burden.

Potential Adverse Effects

  • Hypernatremia
  • Hypocalcemia
  • Metabolic alkalosis if overcorrected,
  • Reduced myocardial contractility and vasomotor tone, which can further compromise circulation.


Special Focus: Lactic Acidosis Post-Cardiac Surgery

When lactic acidosis follows cardiac surgery, it is frequently tied to hypoperfusion and tissue hypoxia. The main therapeutic approach should be to restore adequate tissue perfusion and oxygenation. Sodium bicarbonate may be considered only in severe acidemia (pH ≤ 7.0) if its potential benefits outweigh the risks. Administration should be gradual, with close monitoring of blood gases and electrolytes to avoid complications like metabolic alkalosis and shifts in serum electrolytes.

Conclusion

Sodium bicarbonate is a powerful tool in the management of severe metabolic acidosis, particularly when the blood pH is below 7.0 or in patients with coexisting acute kidney injury (AKI). However, its role in lactic acidosis secondary to hypoperfusion and respiratory acidosis is generally limited or not recommended, mainly because it may not offer any real benefits and can potentially worsen the patient’s condition. As always, it is crucial to address the root cause of the acid-base disturbance—be it improving tissue perfusion in shock states or enhancing ventilation in respiratory failure—while using sodium bicarbonate judiciously.

Join the Conversation

What is your thoughts on using sodium bicarbonate? Do you have an ICU protocol or guidelines in your facility to monitor the use of sodium bicarbonate? We’d love to hear from you. Your insights can help us all continue to grow and learn together.

  1. Bicarbonate Therapy in Severe Metabolic Acidosis. Sabatini S, Kurtzman NA. Journal of the American Society of Nephrology : JASN. 2009;20(4):692-5. doi:10.1681/ASN.2007121329.
  2. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Evans L, Rhodes A, Alhazzani W, et al. Critical Care Medicine. 2021;49(11):e1063-e1143. doi:10.1097/CCM.0000000000005337.
  3. Lactic Acidosis and the Role of Sodium Bicarbonate: A Narrative Opinion. Rudnick MR, Blair GJ, Kuschner WG, Barr J. Shock (Augusta, Ga.). 2020;53(5):528-536. doi:10.1097/SHK.0000000000001415.
  4. A Review of Bicarbonate Use in Common Clinical Scenarios. Wardi G, Holgren S, Gupta A, et al. The Journal of Emergency Medicine. 2023;65(2):e71-e80. doi:10.1016/j.jemermed.2023.04.012.
  5. Is There a Role for Sodium Bicarbonate in Treating Lactic Acidosis From Shock? Boyd JH, Walley KR. Current Opinion in Critical Care. 2008;14(4):379-83. doi:10.1097/MCC.0b013e3283069d5c.
  6. Acid-Base Disorders in the Critically Ill Patient. Achanti A, Szerlip HM. Clinical Journal of the American Society of Nephrology : CJASN. 2023;18(1):102-112. doi:10.2215/CJN.04500422.
  7. Sodium Bicarbonate Therapy in Patients With Metabolic Acidosis. Adeva-Andany MM, Fernández-Fernández C, Mouriño-Bayolo D, Castro-Quintela E, Domínguez-Montero A. TheScientificWorldJournal. 2014;2014:627673. doi:10.1155/2014/627673.
  8. Lactic Acidosis: Current Treatments and Future Directions. Kraut JA, Madias NE. American Journal of Kidney Diseases : The Official Journal of the National Kidney Foundation. 2016;68(3):473-82. doi:10.1053/j.ajkd.2016.04.020.
Hemothorax CXR

Small-Bore vs. Large-Bore Chest Tubes: Does Size Really Matter for Hemothorax and Pleural Effusions?

Written by Omid Zad, MD on . Posted in Zad Talk. No Comments on Small-Bore vs. Large-Bore Chest Tubes: Does Size Really Matter for Hemothorax and Pleural Effusions?

When it comes to placing a chest tube—also known as a thoracostomy tube—to manage hemothorax or pleural effusion, traditional teaching has often defaulted to the phrase “bigger is better.” For years, large-bore tubes (often around 36-40 French) were considered the gold standard, especially in trauma settings, because the logic went something like this: A bigger tube removes fluid or blood more quickly and effectively, prevents clots from forming inside, and reduces the chance of complications down the road. But medicine is always evolving, and several recent studies have challenged this long-standing belief. Increasingly, evidence suggests that small-bore chest tubes (often in the range of 14 French or even smaller) can be just as effective as their bulkier counterparts.

So, is it time to reconsider the “bigger is better” mantra? Let’s take a look at the science and see what the evidence-based medicine of today tells us about choosing a tube size for hemothorax and pleural effusions, both in trauma and malignant disease settings.

The Rationale Behind Smaller Tubes

Before diving into the research, let’s talk about why smaller chest tubes are even on the table. Large-bore chest tubes are not exactly fun. They can be painful to insert and can cause discomfort for the patient while they remain in place. Smaller tubes, being narrower, can be placed using less invasive techniques, often under local anesthesia and with imaging guidance. They’re more comfortable for patients, potentially reduce pain, and can be easier to manage. And if they’re just as effective at draining fluid or blood, then why wouldn’t we choose the more patient-friendly option?

This is precisely what researchers and clinicians have been asking themselves over the last decade. The following studies shed some light on this debate.

Evidence in Traumatic Hemothorax

Inaba et al. (2012)1

In trauma, the longstanding tradition was big tubes all the way. The fear: if you don’t clear blood quickly, you risk clots, retained hemothorax, infection, and possibly the need for additional interventions. But a prospective study by Inaba and colleagues challenged this assumption. Published in The Journal of Trauma and Acute Care Surgery (2012), this study examined patients with traumatic hemothorax who were managed with either small-bore (28-32 Fr) or large-bore (36-40 Fr) chest tubes. The results might surprise you.

Inaba’s team found no significant difference in key clinical outcomes between the two groups. Retained hemothorax rates? About the same. Need for additional tube placement? Similar. Major invasive procedures down the line? No major difference. In short, the study concluded that when it comes to draining blood from a traumatic hemothorax, small-bore tubes appeared to be just as effective as large-bore tubes.

Lyons et al. (2024)2

If one study nudges the door open, a systematic review and meta-analysis can swing it wide open. A recent analysis by Lyons and colleagues (2024) pooled data from multiple studies looking at small-bore (≤14 Fr) vs. large-bore (≥20 Fr) thoracostomy for traumatic hemothorax. Their findings support Inaba’s: there were no significant differences in failure rates, mortality, or complication rates between the two approaches. The message is consistent: small-bore tubes can get the job done just as well in trauma scenarios, and they may carry the added benefits of being less invasive and more comfortable.

Evidence in Pleural Effusion

We’ve seen what happens in trauma, but what about non-traumatic pleural effusions, such as those caused by malignancy? Here, there’s often more time for planning and less of a chaotic emergency environment. In these settings, patient comfort and quality of life considerations are paramount. If small-bore tubes can provide equal efficacy, that’s a big deal for patients living with conditions like metastatic cancer.

Thethi et al. (2018)3

A meta-analysis by Thethi and colleagues in Journal of Thoracic Disease (2018) looked specifically at the efficacy of pleurodesis in malignant pleural effusions. Pleurodesis is a procedure that seals the pleural space to prevent fluid from re-accumulating. If small-bore tubes couldn’t drain the fluid effectively in the first place or caused more complications, pleurodesis would be less successful. The results? No significant difference in the success of pleurodesis or complication rates between small and large chest tubes. This means that patient comfort does not have to be sacrificed for effectiveness.

Parulekar et al. (2001)4

Even going back over two decades, researchers like Parulekar and colleagues were noticing that small-bore catheters worked just as well as large-bore chest tubes for draining and sclerotherapy of malignant pleural effusions. They found no significant differences in outcomes. If the data was pointing in that direction then, and more recent studies continue to confirm it, we may safely conclude that size often doesn’t dictate success.

Why Are Smaller Tubes Just as Effective?

It might seem counterintuitive that a smaller-diameter tube could handle thick fluids or clots as well as a larger one. After all, bigger tubes have more lumen space. But as it turns out, good technique and proper management may matter more than raw diameter.

For hemothorax, the traditional fear was that smaller tubes might clot more easily. While intuitively this might make sense, the actual data doesn’t strongly support that concern. Instead, as long as the tube is positioned correctly and managed appropriately—with potential adjuncts such as fibrinolytics when needed—small tubes can drain blood effectively.

In the case of malignant effusions, the fluid is often less viscous than acute blood. Small-bore tubes have a much easier time draining these fluids. Additionally, many malignant effusions are managed with an indwelling pleural catheter system that allows the patient to drain fluid at home. These catheters are small-bore by design and have revolutionized comfort and quality of life for patients.

Considerations and Caveats

Of course, no one-size-fits-all approach works in medicine. There may be certain clinical scenarios where a large-bore tube is still preferred. For example, if you suspect a massive hemothorax with very thick or clotted blood, or if you anticipate needing to evacuate large volumes very quickly (such as in a hemodynamically unstable trauma patient), a larger tube might still offer some advantages. The immediate flow rate might be better, and it might help surgeons or acute care physicians feel more confident that they won’t need to replace the tube or intervene again shortly.

However, for many routine cases—particularly stable patients with smaller volumes or malignant effusions—small-bore tubes seem to do just fine. The key is that clinical judgment should guide the decision. Think about the patient’s hemodynamic status, the nature of the fluid, the urgency of drainage, and the patient’s overall comfort and quality of life.

Changing Practice and Perception

Medicine is often influenced by tradition. For many years, “this is how we’ve always done it” was the motto. But as evidence builds and we realize that our beliefs don’t always hold up under scrutiny, guidelines and practices evolve. Many trauma centers, intensivists and pulmonologists have begun to integrate smaller tubes into their algorithms, especially for stable patients or those with recurrent malignant effusions.

This shift is more than just academic. It’s about patient-centered care. Smaller tubes generally mean less pain, potentially less sedation, and overall a better experience. They can also be easier for nursing staff and families to manage. Smaller devices can mean smaller scars, both literal and figurative.

Take-Home Message

So, does size matter when it comes to chest tubes for hemothorax and pleural effusions? The growing body of literature says: not as much as we once thought. Studies like those by Inaba et al. and Lyons et al. support small-bore tubes in traumatic hemothorax, showing no disadvantages in outcomes. Meanwhile, Thethi et al. and Parulekar et al. highlight the effectiveness of small-bore chest tubes for malignant pleural effusions. All told, small-bore chest tubes have a strong track record in terms of drainage efficacy, complication rates, and patient comfort.

That doesn’t mean we toss large-bore tubes out the window. In certain emergent settings, when rapid evacuation of a large volume of blood is needed, large-bore tubes may remain the go-to. But for many other scenarios, small-bore tubes are a perfectly viable—and sometimes preferable—option. As always, clinical judgment and individualized patient care should guide the decision.

Join the Conversation

Have you seen small-bore chest tubes used in your practice? Do you have stories—successful or challenging—regarding their use in trauma or malignant effusions? What factors influence your decision to pick one size over another? Share your thoughts in the comments below! We’d love to hear from you. Your insights can help us all continue to grow and learn together.

  1. Does Size Matter? A Prospective Analysis of 28-32 Versus 36-40 French Chest Tube Size in Trauma. Inaba K, Lustenberger T, Recinos G, et al. The Journal of Trauma and Acute Care Surgery. 2012;72(2):422-7. doi:10.1097/TA.0b013e3182452444. ↩︎
  2. Small Versus Large-Bore Thoracostomy for Traumatic Hemothorax: A Systematic Review and Meta-Analysis. Lyons NB, Abdelhamid MO, Collie BL, et al. The Journal of Trauma and Acute Care Surgery. 2024;97(4):631-638. doi:10.1097/TA.0000000000004412. ↩︎
  3. Effect of Chest Tube Size on Pleurodesis Efficacy in Malignant Pleural Effusion: A Meta-Analysis of Randomized Controlled Trials. Thethi I, Ramirez S, Shen W, et al. Journal of Thoracic Disease. 2018;10(1):355-362. doi:10.21037/jtd.2017.11.134. ↩︎
  4. Use of Small-Bore vs Large-Bore Chest Tubes for Treatment of Malignant Pleural Effusions. Parulekar W, Di Primio G, Matzinger F, Dennie C, Bociek G. Chest. 2001;120(1):19-25. doi:10.1378/chest.120.1.19. ↩︎

Basic ECMO Nomenclature

Written by Omid Zad, MD on . Posted in ECMO, Medical Education. No Comments on Basic ECMO Nomenclature

  • ECLS (Extracorporeal life support): Is the support of cardiopulmonary function using an extracorporeal circuit. This requires a minimum of a pump and membrane lung.
    • ECMO (Extracorporeal membrane oxygenation): a system used for oxygenation and/or cardiac support. There are different support modes for ECMO. However, the 4 common modes are:
      • Venoarterial (VA ECMO): Venous drainage with systemic arterial return. This mode is used for cardiac ECMO. But it is also used for ECPR and ICSOR:
        • Extracorporeal cardiopulmonary resuscitation (ECPR): VA ECMO support started when ROSC cannot be achieved with conventional CPR.
        • Extracorporeal interval support for organ recovery (EISOR): VA ECMO support after cardiac death to maintain organ blood flow for organ transplant.
      • Venovenoarterial (VVA ECMO): venous drainage with simultaneous venous and systemic arterial return.
      • Venovenous (VV ECMO): venous drainage with venous return.
      • Venopulmonary (VP ECMO): venous drainage with pulmonary artery return.
    • ECCO2R (Extracorporeal carbon dioxide removal): system used for primary CO2 removal. This can be VV (VV ECCO2R) or AV (AV ECCO2R) mode. However, with the use of dual-lumen cannulas the AV mode is less commonly used for this type of support.
SystemSupport ModeConditionApplication
ECMOVA ECMOCardiac failureCardiac ECMO, ECPR, EISOR
VVA ECMOCardiorespiratory failureCardiac and respiratory ECMO
VV ECMORespiratory failureRespiratory ECMO
VP ECMORV/respiratory failureRespiratory ECMO
RV support
ECCO2RVV ECCO2RCO2 retentionLung Protection
AV ECCO2R
Extracorporeal life support nomenclature
CPT WRVU

ICU Point of Care Ultrasound (POCUS)

Written by Omid Zad, MD on . Posted in Critical Care Billing. No Comments on ICU Point of Care Ultrasound (POCUS)

HCPCS CodeDescriptionwRVUs
76942Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device, imaging supervision and interpretation)0.67
+76937Ultrasonic guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel latency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting.0.30
93308Echocardiography, transthoracic, real time with image documentation (2D) includes M-mode recording; when performed, follow up or limited study0.53
+93321Doppler Echocardiography, pulsed wave and/or continues wave with spectral display (List separately in addition to codes for 2D echocardiographic imaging); follow up or limited sutdy0.15
+93325Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)0.07