Role of Low-pressure Negative Pleural Suction in Patients With Thoracic Trauma - a Randomized Controlled Trial.

doi:10.21203/rs.3.rs-3942552/v1

Download PDF

Research Article

Role of Low-pressure Negative Pleural Suction in Patients With Thoracic Trauma - a Randomized Controlled Trial.

https://doi.org/10.21203/rs.3.rs-3942552/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 14 Jun, 2024

Read the published version in European Journal of Trauma and Emergency Surgery →

You are reading this latest preprint version

Background: Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function. It is a simple and life-saving procedure; nevertheless, it carries morbidity, even after its removal. Efforts have been made continuously to shorten the duration of ICD, but mostly in non-trauma patients. In this study, we evaluated the impact of negative pleural suction over the duration of ICD.

Methods: This study was a prospective randomized controlled interventional trial conducted at Level 1 Trauma Centre. Thoracic trauma patients with ICD, who met the inclusion criteria (sample size 70) were randomized into two groups, the first group with negative pleural suction up to -20 cm H2O, and the second group as conventional, i.e. ICD connected to underwater seal container only. The primary objective was to compare the duration of ICDs and the secondary objectives were the length of hospital stay and various complications of thoracic trauma.

Results: Duration of ICD was measured in median days with minimum & maximum days. For the negative suction group, it was 4 days (2-16 days); for the conventional group, it was also 4 days (2-17 days). There was also no significant difference among both groups in length of hospital stay.

Conclusion: The beneficial effect of negative pleural suction to ICD could not be demonstrated over the duration of ICD and hospital stay. In both groups, there was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema.

Level of evidence: Therapeutic Study, Level II

Thoracic Trauma

Haemothorax

Pneumothorax

ICD

Negative suction.

Unintentional and violence-related injuries take the lives of 4.4 million people worldwide each year and constitute nearly 8% of all deaths. Road traffic injuries (RTIs) are the leading cause of death for children and young adults aged 5–29 years [1]. Nearly 25% of traumatic deaths are due to thoracic trauma. Seatbelt use may be protective against serious injuries in patients with thoracic injury, unrestrained drivers in RTIs suffer a significant thoracic injury [2]. Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function [3]. ICD is the mainstay of treatment in 75–80% of patients, only 15 to 30% of penetrating thoracic trauma and less than 10% of blunt thoracic trauma necessitate surgical intervention [4]. ICD is a simple and life-saving procedure; nevertheless, it carries morbidity like pain, serous discharge, a sensation of foreign body, and the wound, even after its removal. However, thoracic trauma-related problems such as recurrent pneumothorax, retained haemothorax, persistent air leak, and empyema still happen in some patients even with ICDs. Retained haemothorax is reported in up to 20% of patients with thoracic trauma being managed with ICD [5]. It can be treated with a variety of interventions such as reinsertion of an ICD, intrapleural streptokinase instillation (IPSI), video-assisted thoracoscopic surgery (VATS), and thoracotomy. ICD care is critical in these patients and requires close monitoring. Carrying an ICD is very challenging for ambulatory patients because of the pain associated with it. Attempts have been made for a long time to shorten its duration. Negative suction has become popular for inducing pleurodesis and promoting quick closing of air leaks and haemothorax drainage. Most of the studies included patients who underwent lung resections or lobectomies with the primary objective of assessing the cessation of post-operative air leaks [6–9]. The main objective of this study was to evaluate the benefits of low-pressure negative pleural suction in patients with thoracic trauma in terms of the duration of ICD and incidence of complications such as recurrent pneumothorax, retained haemothorax, persistent air leak, empyema and length of hospital stay. We hypothesized that low-pressure negative suction would decrease the duration of ICD.

This prospective parallel designed randomized controlled trial with a 1:1 allocation ratio, was conducted at level I trauma center from 1st January 2021 to 30th November 2022. Patients who were admitted to the emergency department (ED) with thoracic trauma were managed as per the Advanced Trauma Life Support (ATLS) protocol and underwent chest x-ray and contrast-enhanced computed tomography (CECT) scan torso as adjuncts to primary survey and secondary survey, respectively, to establish a diagnosis of pneumothorax, haemothorax, or hemopneumothorax. Indications for ICD were respiratory distress with signs of hemothorax or pneumothorax either on e-FAST, CXR or CECT torso.

Patients in whom ICD had been placed, for traumatic pneumothorax (PTX), hemothorax (HTX), or hemopneumothorax (HPTX) were recruited in the study as per inclusion criteria such as age between 15–65 yrs., thoracic trauma (blunt/ penetrating/ both) patients after obtaining informed consent for the study. Exclusion criteria were pre-existing chronic pulmonary diseases, need for mechanical ventilator support, referred patients with ICDs already placed in previous hospitals, patients with air leak (> Grade 1), pregnancy, known coagulopathy, and malignancy. Ethical approval was obtained from the Institute ethics committee and this trial was also registered in the Clinical Trial Registry of India (CTRI) before recruitment of patients.

Randomization: The total number of cases of thoracic trauma patients with ICD reported to our center in the year 2020 was approximately 150. So, based on the duration of the study of 23 months, the sample size was calculated to be a total of 70, making 35 in each arm, keeping the alpha error at 5% and power at 80%. Randomization was done by the computer-generated block method, where each block consisted of 4 numbers thus making a total of 18 blocks. Each block contained 2 subjects from each group. Allocation concealment was achieved with sequentially numbered and sealed opaque envelopes. The researcher generated the random allocation sequence, the envelope was opened by the person not involved in the study and assigned participants into the groups. Patients were randomized into one of two groups: in Group I, the patient’s water seal drain was connected to the low-pressure (up to -20 cm H2O) negative suction; while in Group II, the Patient’s ICD was connected to only the underwater seal drainage system, i.e. conventional. All patients received paracetamol for analgesia which was supplemented by opioid analgesics and epidural analgesia in some of them. All patients were trained to do chest physical therapy, including deep breathing exercises and incentive spirometry. Patients were monitored clinically as per the institutional protocol. Chest X-rays (CXR) were obtained daily and at the time of discharge or removal of ICD. CXR findings and clinical parameters were noted for all the patients after removing the ICD. The treating physician decided on to when to remove the ICD.

The following clinic-radiological criteria were met before removing ICD: nonsanguinous output < 100 ml/day, no respiratory distress, no residual pneumothorax or hemothorax on Chest X-ray (CXR), and oxygen saturation > 95% on room air. Data were recorded on a predefined proforma, including demographic information, mechanism of injury, time to presentation, findings of primary survey, injury severity scores, and associated injuries. The primary outcome measure was the duration of ICD days. Secondary outcome measures were the incidence of complications (recurrent pneumothorax, retained haemothorax, persistent air leak, and empyema) and, a requirement of additional intervention (reinsertion of ICD, intrapleural instillation of streptokinase, VATS, or open thoracotomy).

Statistical analysis:

Data were analyzed by Stata 14 and presented in mean with Standard deviation (SD), median with interquartile range (IQR), and frequency (percentage). Continuous variables were compared by independent t-test (following a normal distribution) and Wilcoxon rank sum test (non-normal test). Categorical variables were compared by the chi-square test. An α error (p-value) of less than 0.05 was considered statistically significant. The endpoint of data recording was the discharge of the patient.

A total of 2791 acutely injured patients were admitted during the study period, out of which thoracic injuries consisted of 1034 (37%) patients. Out of 1034 patients, only 654 (63.2%) patients required ICD. Among the 654 patients, 584 (89.2%) patients did not meet the inclusion criteria due to various reasons (Fig. 1).

Finally, 70 patients with thoracic trauma were recruited to the study, randomized and allocated to two groups I and II. Based on e-FAST findings and pneumoscan findings, both groups were comparable, the difference between them was statistically insignificant (Table 1).

Table 1

Demographic Data and Baseline Characteristics
	Study (N = 35)	Control (N = 35)	p
Age (years), Mean±SD	38.6±12.85	39.2±15.52	0.84
Sex Male, n (%) Female, n (%)	31(88.57%) 4 (11.43%)	31(88.57%) 4 (11.43%)	0.9
ISS, Mean±SD	14.3±5.77	15±5.477	0.784
Mechanism of injury Blunt, n (%) Penetrating, n (%)	29(82.8%) 6 (17.2%)	28(80%) 7 (20%)	0.9
Arrival to ED Primary, n (%) Referred, n (%)	20 (57.1%) 15 (42.9%)	25(71.4%) 10(28.6%)	0.3
Initial triage Red, n (%) Yellow, n (%)	28 (80%) 7 (20%)	25(71.4%) 10(28.6%)	0.5
Positive CCT, n (%)	21 (60%)	23(65.7%)	0.8

On the evaluation of primary CXR in ED in the negative suction arm, 4 patients had haemothorax, 2 patients had pneumothorax, 11 patients had isolated rib fractures, and 18 patients had no findings, whereas, in the conventional arm, 4 patients had haemothorax, 7 patients had pneumothorax, 7 patients had isolated rib fractures and 17 patients had no findings. Both the groups were comparable, the difference was statistically insignificant (Table 1).

ICDs were placed mostly after the evaluation of CECT torso, in negative suction group which showed hemothorax in 8 patients, pneumothorax in 11 patients and hemopneumothorax in 16 patients, where as in conventional group, it was hemothorax in 7 patients, pneumothorax in 14 patients and hemopneumothorax in 14 patients too.

The majority of patients in both groups had a similar duration of ICD with a median of 4 days (p-value = 0.84) (Table 2).

Table 2

Descriptive analysis based on investigations on arrival in ED
	Study (N = 35)	Control (N = 35)	p
Positive eFAST	8(22.8%)	10(28.5%)	0.4
Positive pneumoscan	11(31.4%)	15(42.8%)	0.6
CXR finding HTX, n (%) PTX, n (%) Iso ribs, n (%)	4(11.4%) 2(5.7%) 11(31.5%)	4(11.4%) 7(20%) 7(20%)	0.6
CECT Torso finding HTX, n (%) PTX, n (%) HPTX, n (%) Ribs #,n (%)	8(22.86%) 11(31.43%) 16(31.43%) 27(77.14%)	7(20%) 14(40%) 14(40%) 28(80%)	0.9 0.6 0.9 0.9

Table 3

Comparison of outcome measures
	Study (n = 35)	Control (n = 35)	p
Duration of ICD (days), median (IQR)	4(2–16)	4(2–17)	0.823
Length of hospital stay(days), median (IQR)	4(2–27)	5(2–29)	0.478
Recurrent PTX, n (%)	2(5.71%)	2(5.71%)	0.9
Retained hemothorax, n (%)	5(14.29%)	3(8.57%)	0.71
Reinsertion of ICD, n (%)	6(17.14%)	5(15.7%)	0.9
STK needed, n (%)	1(2.86%)	0(0%)	0.9
VATS needed, n (%)	0(0%)	1(2.86%)	0.9
Thoracotomy needed, n (%)	3(8.6%)	2(5.7%)	0.9
Air leak, n (%)	0(0%)	0(0%)	0.9
empyema, n (%)	0(0%)	0(0%)	0.9

Thoracic trauma continues to be one of the most challenging cases for trauma surgeons to address comprehensively due to the high morbidity and mortality brought on by its complications [10]. The Majority of the studies done previously with negative suction with ICD were for lung resection surgeries and their primary objectives were to control air leaks [11–15]. Few other studies were conducted for primary spontaneous pneumothorax [16] and peripheral bronchopleural fistula [17]. Only a few studies were conducted in thoracic trauma patients [10, 18–20]. Unquestionably, patients in these studies were different from trauma patients in several ways, including age, pulmonary reserve, comorbidities, and the type of surgeries. No patients in our study had an ongoing air leak. Most of our cases, however, had pulmonary parenchymal wounds due to the nature of the trauma, as opposed to individuals who had pulmonary resections, which resulted in bronchial leaks. Still, there is no consensus about its use in trauma patients. Indications for ICD in our patients were hemopneumothorax, followed by pneumothorax and haemothorax. In most of the patients, if there was no respiratory distress, ICDs were placed after the CECT torso due to an early scan to evaluate the associated injuries.

Morales et al also reported a similar presentation [10]. In this study, the median duration of ICD was comparable between negative suction and conventional groups and it was 4 days (2–16 days) and 4 days (2–17 days) respectively. In a similar study by Morales et al in 110 patients with thoracic trauma, the median duration of ICD was 3 days (1–11 days) in the negative suction group and 3 days (1–16 days) in the conventional group [10]. There was no statistically significant difference between both cohorts. We also studied secondary interventions like reinserting ICD, instillation of STK, VATS, or thoracotomy for complications like recurrent pneumothorax or retained haemothorax etc. There was no statistically significant difference between both groups.

Majumdar et al., on the other hand, showed a statistically significant difference in the mean length of ICD between the groups: 7 days for the negative suction group and 12 days for the traditional group. The average length of hospital stay in the negative suction group was 8.97 days, while in the conventional group, it was 13.47 days. It was also significantly different between both groups. Mean hospital stay was lower in the negative suction group [19].

According to Muslim et al., the negative suction group's mean ICD length was 8.3 days, while the conventional group's was 12.6 days. The mean ICD duration was shorter in the negative suction group, indicating a statistically significant difference between the two groups. The average length of hospital stay in the negative suction group was 7.2 days, while in the conventional group, it was 12.4 days. Additionally, there was a notable difference between the two groups. The negative suction group had a shorter mean hospital stay [20].

In another similar study done on patients who underwent lung resection surgeries by Prokakis et al, in the negative suction group, the average ICD duration was 3.6 days, while in the conventional group, it was 3.4 days [14]. Among the two groups, there is no statistically significant difference. The negative suction group's mean length of stay was 11.2 days, while the conventional group's was 10.3 days. Among the two groups, there is no statistically significant difference. In the present trial, the median duration (with range) of hospital stay is taken to compare between negative suction and conventional group and it was 4 days (2–27 days) in the negative suction group and 4 days (2–29 days) in the conventional group respectively. There is no statistically significant difference among the two groups. For the maximum duration of hospital stay, other associated injuries were also taken into consideration. In a similar study by Morales et al over the 110 patients with thoracic trauma, the median duration of hospital stays (with range) was 3 days (1–14 days) in the negative suction group and 3 days (1–22 days) in the conventional group. There were no significant differences between both groups [10]. The median length of hospital stay was comparable among both studies. The maximum duration of hospital stay was lengthened due to associated injuries.

In this study, the total number of complications of thoracic trauma was 7 (20%) in the negative suction group, while it was 5 (14.2%) in the conventional group. It was comparable among both groups. In the negative suction group, 5 patients developed retained haemothorax, out of which 2 patients were managed with reinsertion of ICD alone, 1 patient required reinsertion of ICD with intrapleural streptokinase, 1 patient required thoracotomy even after reinsertion of ICD and 1 patient was directly managed with thoracotomy without reinsertion of ICD. There is a 12% incidence reported for retained hemothorax following trauma [21].

Two patients developed recurrent pneumothorax; both were managed with reinsertion of ICD. In the conventional group, 3 patients developed retained haemothorax, 1 patient was managed with reinsertion of ICD alone, 1 patient required VATS along with reinsertion of ICD, and 1 patient required thoracotomy with reinsertion of ICD. One patient required thoracotomy for surgical stabilization of rib fixation (SSRF). In a similar study by Morales et al on patients with thoracic trauma, the total number of complications was 6, all clotted haemothorax only in the negative suction group. Whereas the total number of complications was 7 in the conventional group, 6 patients developed clotted haemothorax and 1 patient developed recurrent pneumothorax [10]. Some studies have shown the benefits of negative suction recruited patients after lung resection surgeries or lobectomies to evaluate the impact of negative suction primarily over the air leak [6, 8, 14, 22]. Only a few studies on trauma patients have shown the benefit of low-pressure negative pleural suction in reducing the duration of ICD [19, 20]. However, the outcome of our study was following the study conducted by Morales et al. They studied 110 trauma patients and did not show any advantage with negative suction [10].

We did not observe any beneficial effect with the application of low-pressure negative suction with ICD on the duration of ICD as well as hospital stay. There was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema in both groups. A multi-center trial with a large sample size is required in trauma patients to reach a consensus regarding the use of negative suction.

This was a randomized controlled trial and included a homogenous cohort of trauma patients. However, this study had a small sample size and was a single-center study. A multicentre study with a larger sample size is advocated.

Author Contribution

All authors contributed to the study's conception and design. Material preparation, data collection, and analysis were performed by [Dr. Amit Priyadarshi] and [Dr Sahil Gupta]. The first draft of the manuscript was written by [Dr. Amit Priyadarshi] and verified by [Dr. Subodh Kumar]Statistical analysis was done by Dr Shivam PandeyAll authors read and approved the final manuscript.

WHO Road safety data/Newsroom/Factsheet. WHO Newsroom [Internet]. 2023 [cited 2023 Feb 12]; Available from: https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries.
Boserup B, Sutherland M, Paloka R, McKenney M, Elkbuli A. The Impact of Seatbelt Use on Trauma Outcomes in Adult Motor Vehicle Collision Patients With Rib Fractures: A National ACS-TQP-PUF Database Analysis. J Surg Res. 2022;270:376–85.
Feliciano DV. The diagnostic and therapeutic approach to chest trauma. Semin Thorac Cardiovasc Surg [Internet]. 1992 Jul 1 [cited 2023 Jan 22];4(3):156–62. Available from: http://www.semthorcardiovascsurg.com/article/104306799290039N/fulltext.
Narayanan R, Kumar S, Gupta A, Bansal VK, Sagar S, Singhal M et al. An Analysis of Presentation, Pattern and Outcome of Chest Trauma Patients at an Urban Level 1 Trauma Center. Indian Journal of Surgery [Internet]. 2018 Feb 1 [cited 2023 Dec 19];80(1):36–41. Available from: https://link.springer.com/article/10.1007/s12262-016-1554-2.
Kulvatunyou N, Bauman ZM, Zein Edine SB, de Moya M, Krause C, Mukherjee K et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma Acute Care Surg [Internet]. 2021 Nov 1 [cited 2023 Dec 19];91(5):809–13. Available from: https://journals.lww.com/jtrauma/fulltext/2021/11000/the_small__14_fr__percutaneous_catheter__p_cat_.6.aspx.
Brunelli A, Monteverde M, Borri A. Comparison of water seal and suction after pulmonary lobectomy: a prospective, randomized trial. Annals of thoracic surgery [Internet]. 2004 [cited 2023 Dec 19];77(6):1932–7. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0003497504000682.
Rocco G, Brunelli A, Rocco R. Suction or no suction- how to manage a chest tube after pulmonary resection. 2017 [cited 2023 Dec 19]; Available from: https://www.thoracic.theclinics.com/article/S1547-4127(16)30054-8/fulltext.
Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg [Internet]. 2001 [cited 2023 Dec 19];71(5):1613–7. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0003497501024742.
Marshall MB, Maher D, Joshua B. Suction vs Water Seal After Pulmonary Resection: A Randomized Prospective Study. Chest [Internet]. 2002 [cited 2023 Dec 19];121(3):831–5. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0012369216447197.
Morales CH, Mejía C, Roldan LA, Saldarriaga MF, Duque AF. Negative pleural suction in thoracic trauma patients: A randomized controlled trial. Journal of Trauma and Acute Care Surgery [Internet]. 2014 [cited 2023 Dec 19];77(2):251–5. Available from: https://journals.lww.com/jtrauma/fulltext/2014/08000/Negative_pleural_suction_in_thoracic_trauma.11.aspx.
Zhou J, Chen N, Hai Y, Lyu M, Wang Z, Gao Y et al. External suction versus simple water-seal on chest drainage following pulmonary surgery: An updated meta-analysis. Interact Cardiovasc Thorac Surg [Internet]. 2019 Jan 1 [cited 2023 Dec 19];28(1):29–36. Available from: https://academic.oup.com/icvts/article/28/1/29/5056123.
Lang P, Manickavasagar M, Burdett C, Treasure T, Fiorentino F, Barua A et al. Suction on chest drains following lung resection: Evidence and practice are not aligned. European Journal of Cardio-thoracic Surgery [Internet]. 2016 Feb 1 [cited 2023 Dec 19];49(2):611–6. Available from: https://academic.oup.com/ejcts/article/49/2/611/2465265.
Qiu T, Shen Y, Wang M, zhao, Wang Y, peng, Wang D, Wang Z, zong et al. External Suction versus Water Seal after Selective Pulmonary Resection for Lung Neoplasm: A Systematic Review. PLoS One [Internet]. 2013 Jul 9 [cited 2023 Dec 19];8(7). Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0068087.
Prokakis C, Koletsis EN, Apostolakis E, Panagopoulos N, Kouki HS, Sakellaropoulos GC et al. Routine suction of intercostal drains is not necessary after lobectomy: A prospective randomized trial. World J Surg [Internet]. 2008 Nov [cited 2023 Dec 19];32(11):2336–42. Available from: https://link.springer.com/article/10.1007/s00268-008-9741-3.
Deng B, Tan QY, Zhao YP, Wang RW, Jiang YG. Suction or non-suction to the underwater seal drains following pulmonary operation: Meta-analysis of randomised controlled trials. Eur J Cardiothorac Surg. 2010;38(2):210–5.
Ayed AK. Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomized study. Ann Thorac Surg [Internet]. 2003 [cited 2023 Dec 19];75(5):1593–6. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0003497502048944.
Li X, Wang S, Yin M, Li X, Qi Y, Ma Y et al. Treatment of peripheral bronchopleural fistula with interventional negative pressure drainage. Ther Adv Respir Dis [Internet]. 2022 [cited 2023 Dec 19];16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9297443/.
Feenstra TM, Dickhof C, Jaap Deunk. Systemic review and meta analysis of tube thoracostomy following traumatic chest injury- suction versus water seal. Springer link [Internet]. 2018 [cited 2023 Dec 19]; Available from: https://link.springer.com/article/10.1007/s00068-018-0942-7.
Majumdar MN, Razzaque AK, Rahman MS, Kibria AA, Rahman R, Hossain SS. Role of Continuous low pressure suction in management of traumatic haemothorax and/or haemopneumothorax: experiences at NIDCH and CMH Dhaka. Journal of Armed Forces Medical College, Bangladesh [Internet]. 2014 [cited 2024 Feb 3];10(2):21 – 6. Available from: https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Majumdar+et+al.+Role+of+Continuous+Low+Pressure+Suction+in+Management+of+Traumatic+Haemothorax+and%2For+Haemopneumothorax.+Dhaka%3B+2014&btnG=.
Muslim M, Bilal A, Salim M, Khan MA, Baseer A, Ahmed M, TUBE THOROCOSTOMY:, MANAGEMENT AND OUTCOME IN PATIENTS WITH PENETRATING CHEST TRAUMA [Internet]. Vol. 20, J Ayub Med Coll Abbottabad. 2008. Available from: http://www.ayubmed.edu.pk/JAMC/PAST/20-4/Muslim.pdf.
Villegas MI, Hennessey RA, Morales CH, Londoño E. Risk factors associated with the development of post-traumatic retained hemothorax. Eur J Trauma Emerg Surg. 2011;37(6):583–9.
Alphonso N, Tan C, Utley M, Cameron R, Dussek J, Lang-Lazdunski L et al. A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection. In: European Journal of Cardio-thoracic Surgery [Internet]. 2005 [cited 2023 Dec 19]. p. 391–4. Available from: https://academic.oup.com/ejcts/article/27/3/391/447815.

No competing interests reported.

CONSORTChecklist.docx

Download PDF

Journal Publication

published 14 Jun, 2024

Read the published version in European Journal of Trauma and Emergency Surgery →

Editorial decision: Revision requested
28 Apr, 2024
Reviews received at journal
23 Apr, 2024
Reviewers agreed at journal
23 Apr, 2024
Reviews received at journal
27 Feb, 2024
Reviewers agreed at journal
23 Feb, 2024
Reviewers invited by journal
22 Feb, 2024
Editor assigned by journal
22 Feb, 2024
Submission checks completed at journal
09 Feb, 2024
First submitted to journal
09 Feb, 2024

You are reading this latest preprint version

Role of Low-pressure Negative Pleural Suction in Patients With Thoracic Trauma - a Randomized Controlled Trial.

Status:

Journal Publication

Version 1

Abstract

Figures

INTRODUCTION

PATIENTS & METHODS

Statistical analysis:

RESULTS

DISCUSSION

CONCLUSION

STRENGTHS AND LIMITATIONS OF THE STUDY

Declarations

Author Contribution

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1