Intercostal catheter insertion: are we really doing well?

Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.
ANZ Journal of Surgery (Impact Factor: 1.12). 05/2012; 82(6):392-4. DOI: 10.1111/j.1445-2197.2012.06093.x
Source: PubMed

ABSTRACT   Intercostal catheters (ICC) are the standard management of chest trauma, but are associated with complications in up to 30%. The aim of this study was to evaluate errors in technique during ICC insertion to characterize the potential benefit of improved training programmes.
  Prospective audit of all ICC in trauma patients at a level 1 trauma centre for over 12 months. Exclusions were pigtail catheters and ICC inserted during thoracic surgery. Errors were identified from patient examination and chest imaging; they were defined as insertional, positional, incorrect size (<28 French) and lack of antibiotic prophylaxis. Ongoing complications unrelated to an error in technique, for example blocked tube, were not analysed.
  Fifty-seven patients received a total of 94 ICC during the study period. Patients were predominantly male (77%), mean age of 40 ± 20 years, mean injury severity score 27 ± 13, mean abbreviated injury scale chest 3.8 ± 0.72. 86% were blunt trauma and 14% penetrating chest injuries. Thirty-six errors in technique occurred in 33 ICC insertions (38%). The most common errors were absence of prophylactic antibiotics (13%), ICC too far out (9%), kinked (6%) and wrong-sized ICC (5%). Emergency had a significantly greater frequency of errors than other specialties (67%, relative risk 2.11, P= 0.002). The majority of ICC were inserted by registrars, and registrars made a greater number of errors than fellows or consultants (relative risk 2.00, P= 0.02).
  This study identified a large number of preventable errors for ICC insertion in trauma patients. Standardized institutional credentialing systems may be required to ensure adequate proficiency of trainees performing this procedure.

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    ABSTRACT: Objective To determine whether ED doctors, comprising both consultants and registrars, can accurately identify the 4th or 5th intercostal space (ICS), commonly used for intercostal catheter insertion.Methods An observational study was designed using a sample of ED doctors applying their clinical skills to a convenience sample of patients reflecting a heterogeneous mix of ED patients. Patients already receiving a CXR in our ED were examined by a registrar or consultant who placed a radiopaque marker on the patients' chest wall over the site they determined to be the 4th or 5th ICS. Consultant radiologists reported the marker's position from postero-anterior projection CXRs, and results were analysed comparing consultants with registrars, right to left hemithoraces and male to female patients.ResultsED doctors participating in the present study placed the marker over the 4th or 5th ICS 36.2% of the time, with no significant difference between consultant and registrar groups, nor right or left hemithoraces. Accuracy was improved in female patients compared with male patients.Conclusion Emergency registrars and consultants sampled from a regional ED appeared unable to reliably identify the 4th or 5th ICS, as evidenced by marker position, in a heterogeneous patient population.
    Emergency medicine Australasia: EMA 10/2014; 26(5). DOI:10.1111/1742-6723.12276 · 1.22 Impact Factor
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    ABSTRACT: Introduction: Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. Methods: This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. Results: A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20‐29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54).Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the ‘triangle of safety’ but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation.
    Annals of The Royal College of Surgeons of England 11/2014; 96(8). DOI:10.1308/003588414X14055925058599 · 1.22 Impact Factor
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    ABSTRACT: Introduction: Routine chest radiography (CXR) following tube thoracostomy (TT) is a standard practice in most trauma centres worldwide. Evidence supporting this routine practice is lacking and the actual yield is unknown. Materials and methods: We performed a retrospective review of 1042 patients over a 4-year period who had a routine post-insertion CXR performed in accordance with current ATLS1 recommendations. Results: A total 1042 TTs were performed on 1004 patients. Ninety-one per cent of patients (913/1004) were males, and the median age for all patients was 24 years. Seventy-five per cent of all injuries (756/ 1004) were from penetrating trauma, and the remaining 25% (248/1004) were from blunt. The initial pathologies requiring TT were: haemopneumothorax: 34% (339/1042), haemothroax: 31% (314/1042), simple pneumothorax: 25% (256/1042), tension pneumothorax: 8% (77/1042) and open pneumothorax: 5% (54/1042). One hundred and three patients had TTs performed on clinical grounds alone without a pre-insertion CXR [Group A]. One hundred and ninety-one patients had a pre-insertion CXR but had persistent clinical concerns following insertion [Group B]. Seven hundred and ten patients had pre- insertion CXR but no clinical concerns following insertion [Group C]. Overall, 15% (152/1004) [9 from Group A, 111 from Group B and 32 from Group C] of all patients had their clinical management influenced as a direct result of the post-insertion CXR. Conclusions: Despite the widely accepted practice of routine CXR following tube thoracostomy, the yield is relatively low. In many cases, good clinical examination post tube insertion will provide warnings as to whether problems are likely to result. However, in the more rural setting, and in resource challenged environments, there is a relatively high yield from the CXR, which alters management. Further prospective studies are needed to establish or refute the role of the existing ATLS1 guidelines in these specific environments.
    Injury 01/2014; DOI:10.1016/j.injury.2014.06.01 · 2.46 Impact Factor


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May 29, 2014