52 in 52 – #6: The P-CAT Trial

Welcome back to the “52 in 52” series. This collection of posts features recently published must-know articles. Our sixth post looks at the P-CAT trial.

Authors: Sarah Mongold, MD (Chief Resident, Emergency Medicine Physician, San Antonio, TX); Brannon Inman (Chief Resident, Emergency Medicine Physician, San Antonio, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

AKA: THE “P-CAT” TRIAL

Clinical question:

Are 14 Fr percutaneous catheters (aka ‘pigtail’ chest tubes) noninferior to 32 Fr surgical chest tubes in management of traumatic hemothorax?

• Multicentre prospective randomized control trial

PICO:

Population:

• Adults ≥18 years old with a traumatic hemothorax or hemopneumothorax.
• Excluded if
  • predominately pneumothorax
  • hemodynamically unstable
  • thoracic tube placed in the OR
  • consent unable to be obtained
• Decision to place chest tube was at the discretion of the attending surgeon
  • Generally computed tomography volumetric quantified hemothoraces ≥ 300 mL were drained

Intervention:

• Small (14 Fr) percutaneous catheter (pigtail catheter)

Comparison:

• Large (28-32 Fr) open chest tube

Outcome:

• Small (14 Fr) percutaneous catheters were noninferior to large (28-32 Fr) open chest tube
  • Similar rates of failure
  • Similar rates of surgical drainage
  • Statistically more initial output and output at 24hr in pigtail group
  • Statistically more favorable insertion perception experience (IPE) scores in pigtail group

Take away:

• Pigtails are noninferior to large diameter thoracostomy tubes in patients with hemothorax.
• The study did not meet enrollment target (needed 95 patients in each arm, but reached 56 and 63 in pigtail and large Fr tubes, respectively).
  • Cited chronological issues coupled with COVID-19 pandemic.
  • Early termination could potentially create a falsely noninferior result.
• Trend towards more blunt trauma in pigtail group.
• Overall greater patient satisfaction in pigtail group.

Author Conclusion:

• Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.

My take:

Pigtail catheters are a likely more humane and better tolerated option for the management of a traumatic hemothorax in hemodynamically stable patients. The routine practice of inserting, what is essentially, a sterile garden hose in a patient’s thorax for a hemothorax is likely not necessary. I would preferentially place pigtail chest tubes for the management of these patients, assuming my hospital policy and admitting surgeon are on board with this practice.

For more on chest thoracostomy, including pigtail and chest tube placement, see this post by Anthony DeVivo.

Reference:

1. Kulvatunyou N, Bauman ZM, Zein Edine SB, 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. 2021;91(5):809-813. doi:10.1097/TA.0000000000003180