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Mediastinal tube placement in children with pneumomediastinum: hemodynamic changes and description of technique
K M Turlapati1, R M Spear, B M Peterson
1Department of Critical Care, Children's Hospital and Health Center, San Diego, CA 92123, USA.
Insights
Percutaneous mediastinal tube insertion safely and effectively drains pneumomediastinum in children, leading to immediate hemodynamic improvement. This simple bedside technique offers rapid decompression and continuous drainage for pediatric patients.
Area of Science:
- Pediatric Critical Care Medicine
- Thoracic Surgery
- Medical Device Technology
Background:
- Pneumomediastinum, or air in the mediastinum, can cause significant hemodynamic compromise in pediatric patients.
- Mechanically ventilated children are particularly susceptible to pneumomediastinum.
- Effective and safe drainage strategies are crucial for managing this condition.
Purpose of the Study:
- To detail the technique for percutaneous mediastinal tube insertion.
- To evaluate the hemodynamic response to mediastinal tube placement.
- To assess the complication rate associated with this procedure in children.
Main Methods:
- A combined retrospective and prospective study involving 25 mechanically ventilated children with pneumomediastinum.
- Review of medical records and chest radiographs for 15 retrospective patients.
- Prospective collection of hemodynamic data in 10 consecutive patients undergoing mediastinal tube placement.
- Detailed description of the subxyphoid insertion technique using a pericardiocentesis catheter and connection to continuous suction.
Main Results:
- Mediastinal tube placement significantly reduced the size of the mediastinal air column (mean change -1.6 cm, p < .001).
- Hemodynamic improvements observed included increased systolic blood pressure (16 mm Hg, p = .007), diastolic blood pressure (11 mm Hg, p = .005), mean arterial pressure (12 mm Hg, p = .005), and cardiac index (34% increase).
- No complications such as bleeding, cardiac puncture, or infection were reported.
Conclusions:
- Percutaneous mediastinal tube drainage is a safe and effective method for managing pneumomediastinum in children.
- The procedure leads to rapid and significant hemodynamic improvement.
- This simple bedside technique facilitates continuous drainage and can be performed safely in pediatric intensive care units.
Objective:
To describe the technique, hemodynamic response, and complication rate after the insertion of a percutaneous mediastinal tube for drainage of pneumomediastinum.
Design:
A combined retrospective and prospective study in mechanically ventilated children with pneumomediastinum.
Setting:
Multidisciplinary pediatric intensive care unit at a children's hospital.
Patients:
The medical records and chest radiographs of 25 (15 retrospective and 10 prospective) patients who had placement of a mediastinal tube for drainage of pneumomediastinum from 1990 to 1995 were reviewed. Hemodynamic data were collected prospectively in the ten consecutive children from January 1994 to April 1995.
Intervention:
Mediastinal tube placement: The subxyphoid area was cleansed with povidone-iodine and draped. An 18-gauge, thin-walled introducer needle was inserted 1 to 2 cm below the xyphoid process at an angle of 20 degrees from the anterior abdominal wall, directed at the substernal space. Either a 9-Fr or 11-Fr pericardiocentesis catheter was inserted over a wire and advanced to the third intercostal space. The catheter was secured and connected to 10 cm H2O suction, using a standard thoracostomy tube drainage device.
Measurements And Main Results:
The size of the mediastinal air column on a lateral chest radiograph was measured before and after placement of the mediastinal tube. The mean change in the size of the mediastinal air column was -1.6 cm (median -1.5, p < .001). In the ten prospective patients, hemodynamic data were recorded immediately before and after placement of a mediastinal tube from previously placed arterial and central venous pressure catheters. The mean hemodynamic changes after the mediastinal tube placement were: heart rate -4 beats/min (median = -1, p = .14); systolic blood pressure 16 mm Hg (median = 10, p = .007); diastolic blood pressure 11 mm Hg (median = 11, p = .005); mean arterial pressure 12 mm Hg (median = 8, p = .005); and central venous pressure -2 mm Hg (median = -1, p = .04). In four patients with pulmonary artery thermodilution catheters, the mean increase in cardiac index immediately following placement of the mediastinal tube was 34%. No complications, including bleeding, cardiac puncture, or infection occurred.
Conclusions:
These findings suggest that hemodynamic compromise commonly accompanies pneumomediastinum in children. Decompression of the mediastinal space and drainage of the pneumomediastinum, using this simple bedside technique for continuous drainage, can be performed rapidly and safely in children, resulting in immediate hemodynamic improvement, and allowing for continuous drainage.