Ann Thorac Surg 2003;78:705-707
© 2003 The Society of Thoracic Surgeons
Case report
Autologous salvaged blood transfusion in spontaneous hemopneumothorax
Kazuhiro Sakamoto, MDa*,
Takahiro Ohmori, MDa,
Hidefumi Takei, MDa,
Kimiatsu Hasuo, MDa,
Yasushi Rino, MDa,
Yoshinori Takanashi, MDa
a First Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan
Accepted for publication June 19, 2003.
* Address reprint requests to Dr Sakamoto, First Department of Surgery, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004 Japan.
e-mail: saka784-lj{at}infoseek.jp
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Abstract
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Spontaneous hemopneumothorax (SHP) is a rare clinical entity, and an emergent operation due to continuous bleeding or hypovolemic shock is at times necessary. Although allogeneic blood transfusions are urgently required for significant blood loss, autologous blood transfusions can also be considered in patients with SHP. We herein report two cases of successful autologous blood transfusions using blood in the pleural space, decreasing or obviating the need for allogeneic blood transfusion.
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Introduction
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Spontaneous hemopneumothorax (SHP) is a rare clinical entity, which tends to occur in relatively young men. Sometimes allogeneic blood transfusions are needed in SHP due to continuous bleeding or hypovolemic shock. In most cases of SHP, an emergent operation is needed for hemostasis of the ongoing hemorrhage. In recent years, a thoracoscopic approach has become one of the treatments for SHP as a less invasive surgery [1–3]. For many years, autologous blood transfusion has been widely accepted to avoid risks of allogeneic blood transfusion as a lifesaving therapy for hemorrhagic shock [4]; however, autologous blood transfusion adopted as a treatment for SHP has not been previously reported. Over a 7-month period of time, two patients presented with SHP. We successfully applied autologous blood transfusion combined with thoracoscopic operation in these two patients.
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Case reports
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Patient 1
A 44-year-old man was emergently admitted with sudden onset of right-sided chest pain and shortness of breath. Physical examination revealed a blood pressure of 66/50 mm Hg and a pulse of 124 beats per minute with hypovolemic shock. A complete blood count (CBC) showed a hemoglobin of 10.3 g/dL. Portable chest radiograph in the supine position demonstrated a right-sided pneumothorax with fluid in the right pleural space (Fig 1). A chest tube was placed into the pleural space, resulting in immediate drainage of 1,000 mL of blood. We performed fluid resuscitation followed by emergent thoracoscopy. Thoracoscopic examination revealed a large amount of fresh blood and coagulated blood totaling about 1,200 mL in the pleural space. The blood was collected by the cell-saving device system (Haemonetics Cell Saver System 5; Haemonetics Corp, Braintree, MA) from the pleural space and the chest drainage bottle. A total of 1,700 mL of blood was collected in the cell-saving device system and 850 mL of blood was used for reinfusion during the operation. Bleeding from a ruptured aberrant vessel in the apex of the chest wall was found. Hemostasis was obtained by endoscopic loop ligation of the bleeding vessel. A ruptured bulla was also recognized, and resected by endostaplers. The patient received 400 mL of allogeneic blood transfusion for hypotension before the autologous blood transfusion. Postoperatively, the patient's hemoglobin level was 11.0 g/dL. The chest tube was removed on the first postoperative day and he was uneventfully discharged on the second postoperative day.
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Fig 1. Chest roentgenogram at spine position. Right-sided pneumothorax with pleural fluid is observed.
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Patient 2
A 30-year-old man was emergently admitted with sudden onset of left-sided chest pain and shortness of breath. He had received chest drainage for left-sided pneumothorax one month before admission. Physical examination revealed a systolic blood pressure of 80 mm Hg and a pulse of 116 beats per minute due to hypovolemic shock. A CBC showed hemoglobin of 10.9 g/dL. Chest radiograph demonstrated a left-sided pneumothorax with an air-fluid level in the left pleural space (Fig 2). A chest tube was placed into the pleural space, resulting in immediate drainage of 1,250 mL of blood. Emergent thoracoscopy was conducted. The blood from the chest tube drainage container was collected by the cell-saving device system and 600 mL of blood was transfused before the operation. Thoracoscopic examination revealed a small amount of unclotted blood in the pleural space. Bleeding from a ruptured aberrant vessel in the apex of the chest wall was found. Hemostasis was obtained by endoscopic loop ligation of the vessel. A ruptured bulla was also recognized, and resected by endostaplers. The patient did not require allogeneic blood transfusion. Postoperatively, the patient's hemoglobin level was 12.6 g/dL. The chest tube was removed on the first postoperative day and he was uneventfully discharged on thesecond postoperative day. Both patients had no postoperative recurrences 16 months (patient 1) and 9 months (patient 2) after operation, respectively.
Comment
Spontaneous hemopneumothorax involves the accumulation of air and blood within the pleural space in the absence of trauma or other obvious causes. The three mechanisms of bleeding in SHP are: (1) a torn adhesion between the parietal and visceral pleura [5]; (2) rupture of vascularized bullae [2]; and (3) rupture of aberrant vessels between the parietal pleura and bullae, which are thought to be one type of adhesion [2]. Systemic blood pressure in the vessels combined with the negative intrapleural pressure might also aggravate and prolong the bleeding, resulting in massive blood loss into the pleural space [1]. It occasionally leads to shock due to massive intrapleural bleeding and(or) intrapleural tension. In addition to chest tube insertion, aggressive fluid resuscitation or blood transfusion followed by surgical intervention should be indicated.
On the other hand, allogeneic blood transfusion has some risks such as transmission of blood-borne diseases, blood transfusion reactions, and exposure to foreign antigens [6]. To avoid these risks, autologous blood transfusion has been used for various operations. Autologous blood transfusion has been successfully used as a lifesaving therapy for hypovolemic shock for many years [4], and the usefulness of autologous blood transfusion has been shown in the field of blunt and penetrating injuries [7, 8]. However, autologous blood transfusion adopted as a treatment for SHP has not been previously reported. One of the potential complications of autologous blood transfusion is bacterial contamination. The contamination may be caused by airborne contaminants that either fall or are pulled into the operative field by air currents created by suction tubes of the cell conservation device or the manipulation of the salvaged blood before reinfusion [9]. The chance of bacterial contamination in SHP patients may be low, because the pleural space is a closed space. Another potential complication of autologous blood transfusion is coagulopathy. However, there is now wide experience in the use of cell concentration devices such as the cell-saving device system that washed and concentrated salvaged blood and no significant coagulopathy has been noted [6]. Blood drained from a SHP is relatively uncontaminated, easily collected, and frequently does not clot because of defibrinogenation by the pleura [4]. Autologous blood transfusion for SHP seems feasible and may decrease or obviate the need for allogeneic blood transfusion with its attendant risks. Use of autologous blood transfusion should be considered in SHP patients.
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References
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Abstract
Introduction
