An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa (original) (raw)
Related papers
Intercostal catheter insertion: are we really doing well?
ANZ Journal of Surgery, 2012
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. Methods: 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. Results: Fifty-seven patients received a total of 94 ICC during the study period. Patients were predominantly male (77%), mean age of 40 Ϯ 20 years, mean injury severity score 27 Ϯ 13, mean abbreviated injury scale chest 3.8 Ϯ 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). Discussion: 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.
Postgraduate medical journal, 2015
Intercostal chest drain (ICD) insertion is considered a core skill for the general physician. Recent guidelines have highlighted the risks of this procedure, while UK medical trainees have reported a concurrent decline in training opportunities and confidence in their procedural skills. We explored clinicians' attitudes, experience and knowledge relating to pleural interventions and ICD insertion in order to determine what changes might be needed to maintain patient safety and quality of training. Consultants and trainees delivering general medical services across five hospitals in England were invited to complete a questionnaire survey over a 5-week period in July and August 2014. 117 general physicians (32.4% of potential participants; comprising 31 consultants, 48 higher specialty trainees, 38 core trainees) responded. Respondents of all grades regarded ICD insertion as a core procedural skill. Respondents were asked to set a minimum requirement for achieving and maintaining ...
Chest drain insertion is not a harmless procedure--are we doing it safely?
2010
The incorrect insertion of a chest drain can cause serious harm or even death. All elective drains should be inserted in the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;triangle of safety&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; in line with the British Thoracic Society guidelines. The aim of this study was to test the awareness of junior doctors involved in inserting chest drains with these guidelines. Fifty junior doctors were questioned. Participants were asked to grade their experience of chest drain insertion and mark on a diagram where they felt was the optimum site for inserting a drain for a large pneumothorax in an elective situation. Only 44% (n=22) of doctors indicated they would insert a chest drain within the safe triangle. Level of experience, seniority and specialty all had an effect on knowledge of the correct site. Of those who had inserted drains unsupervised, 48% (n=16) would site the drain outside the safe triangle as would 75% (n=6) of those who had performed the procedure supervised. Only 25% of medics knew where to insert a drain, compared with 58% of doctors working in surgery. The majority of junior doctors do not have the basic knowledge to insert a chest drain safely. Further training in this procedure is needed for junior doctors.
Implantation of a Totally Subcutaneous ICD in Children
Heart, Lung and Circulation, 2011
Background: We examined all patients receiving a new ICD implant at Wellington Hospital between January 2001 and December 2005 to determine long-term outcomes in this patient population Methods: Follow up data were collected and Kaplan-Meier curves were constructed for survival and long-term outcomes. Results: In the study period 138 new ICDs were implanted, and the mean follow-up time was 85 months ± 17 months. Seventy-six percent of patients were male, 75% were European, 20% were Maori. Median age was 60 years (range 16-80 years). Fifty percent of patients had an ischaemic substrate. Seventy-four percent of ICDs were implanted for secondary prevention. The seven-year survival was 72.5%. No difference in mortality was observed between primary and secondary prevention groups. There was a trend towards increased mortality amongst males. The seven-year appropriate shock therapy rate was 57%. Appropriate shocks were more common in secondary prevention than in primary prevention patients (62% vs. 37%, hazard ratio 2.11, 95% CI 1.16-3.85). Twentyfour percent of patients received inappropriate shock therapy. This was more common in patients with prior atrial fibrillation (hazard ratio 3.32, 95% CI 1.66-6.67). The median lifespan of implanted devices was 81 months. The seven-year all cause hospitalisation was 85%, with sevenyear cardiac-cause hospitalisation being 76%. Conclusions: This is the first long-term follow-up study of ICD patients in New Zealand. Higher rates of implantation for secondary prevention and appropriate shock therapy were observed compared with other published registries. Rates of inappropriate shock therapy were similar to those in recently published reviews.
Journal of surgical education, 2015
To review the ability of junior doctors (JDs) in identifying the correct anatomical site for intercostal chest drain insertion and whether prior Advanced Trauma Life Support (ATLS) training influences this. We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact preferred site for intercostal chest drain insertion. This study was conducted in a large metropolitan university hospital in South Africa. A total of 152 JDs participated in the study. Among them, 63 (41%) were men, and the mean age was 24 years. There were 90 (59%) PGY1 doctors and 62 (41%) PGY2 doctors. Overall, 28% (42/152) of all JDs correctly identified the site that was located within the accepted safe triangle. A significantly higher proportion of PGY2 doctors selected the correct site when compared with PGY1 doctors (39% vs 20%, p = 0.026). Those who had prior ATLS provider training were 6.8...
A B S T R A C T Objective: To review the ability of junior doctors (JDs) in identifying the correct anatomical site for central venous catheterization (CVC) and whether prior Advanced Trauma Life Support (ATLS) training influences this. Design: We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact site for CVC insertion via the internal jugular (IJV) and the subclavian (SCV) approach. This study was conducted in a large metropolitan university hospital in South Africa. Results: A total of 139 JDs were included. Forty-four per cent (61/139) were males and the mean age was 25 years. There were 90 PGY1s (65%) and 49 PGY2s (35%). Overall, 32% (45/139) were able to identify the correct insertion site for the IJV approach and 60% (84/139) for the SCV approach. Of the 90 PGY1s, 34% (31/90) correctly identified the insertion site for the IJV approach and 59% (53/90) for the SCV approach. Of the 49 PGY2s, 29% (14/49) correctly identified the insertion site for the IJV approach and 63% (31/49) for the SCV approach. No significant difference between PGY1 and 2 were identified. Those with ATLS provider training were significantly more likely to identify the correct site for the IJV approaches [OR = 4.3, p = 0.001]. This was marginally statistically significant (i.e. p > 0.05 but <0.1) for the SCV approach. Conclusions: The majority of JDs do not have sufficient anatomical knowledge to identify the correct insertion site CVCs. Those who had undergone ATLS training were more likely to be able to identify the correct insertion site.
Trials
Background: Peripheral intravenous catheters (PVCs) are essential invasive devices, with 2 billion PVCs sold each year. The comparative efficacy of expert versus generalist inserter models for successful PVC insertion and subsequent reliable vascular access is unknown. Methods: A single-centre, parallel-group, pilot randomised controlled trial (RCT) of 138 medical/surgical patients was conducted in a large tertiary hospital in Australia to compare PVC insertion by (1) a vascular access specialist (VAS) or (2) any nursing or medical clinician (generalist model). The primary outcome was the feasibility of a larger RCT as established by predetermined criteria (eligibility, recruitment, retention, protocol adherence). Secondary outcomes were PVC failure: phlebitis, infiltration/extravasation, occlusion, accidental removal or partial dislodgement, local infection or catheter-related bloodstream infection; dwell time; insertion success, insertion attempts; patient satisfaction; and procedural cost-effectiveness. Results: Feasibility outcomes were achieved: 92% of screened patients were eligible; two patients refused participation; there was no attrition or missing outcome data. PVC failure was higher with generalists (27/50, 54%) than with VASs (33/69, 48%) (228 versus 217 per 1000 PVC days; incidence rate ratio 1.05, 95% confidence interval 0.61-1.80). There were no local or PVC-related infections in either group. All PVCs (n = 69) were successfully inserted in the VAS group. In the generalist group, 19 (28%) patients did not have a PVC inserted. There were inadequate data available for the costeffectiveness analysis, but the mean insertion procedure time was 2 min in the VAS group and 11 min in the generalist group. Overall satisfaction with the PVC was measured on an 11-point scale (0 = not satisfied and 10 = satisfied) and was higher in the VAS group (n = 43; median = 7) compared to the generalist group (n = 20; median = 4.5). The multivariable model identified medical diagnosis and bed-bound status as being significantly associated with higher PVC failure, and securement with additional non-sterile tape was significantly associated with lower PVC failure. Conclusion: This pilot trial confirmed the feasibility and need for a large, multicentre RCT to test these PVC insertion models.
Comparison of Two Different Central Venous Access Device Insertion Techniques: No Evil in Details
Medical Bulletin of Haseki, 2019
Santal venöz katater uzun süreli kemoterapi infüzyonu gereken ve damar yolu problemi olan hastalarda kullanılır. Bu çalışmada iki farklı teknik kullanılarak uygulanan santal venöz port işlemlerinin sonuçları ve komplikasyonları karşılaştırıldı. Yöntemler: Ocak 2015 ve Haziran 2017 tarihleri arasında subklavian vene iki farklı teknikle uygulanan santral venöz port işlemi uygulanan 118 olgu retrospektif olarak analiz edildi. Grup 1 floroskopi altında işlem yapılan olgulardan, grup 2 ise floroskopi kullanılmadan port takılan olgulardan oluşuyordu. Tüm işlemler sedasyon ve lokal anestezi altında uygulandı. Tüm portlar göğüs ön duvarında pectoral kasın fasyası üzerine yerleştirildi. Sonuçlar ve komplikasyonlar değerlendirildi. Bulgular: Toplam 118 port işlemi uygulandı. Bu olguların takiplerinde sekiz komplikasyon izlendi. Beş olguda pnömotoraks, iki olguda yara yerinde enfeksiyon, bir olguda ise katater kırılması görüldü. İstatistiksel olarak komplikasyon açısından her iki grup arasında anlamlı farlılık saptanmadı. Sonuç: Santral venöz portlar kemoterapi süresince onkolojik hastaların yaşam kalitelerini yükseltir. Santal venöz portların yaygın görülen komplikasyonlarının başında pnömotoraks, yara yeri enfeksiyonu ve katater tıkanmasıdır. Kritik hastalarda floroskopi kullanılması bu komplikasyonların azaltılmasında yardımcı olabilir. Bununla birlikte, bu tekniklerin floroskopi altında kullanımı her zaman mümkün olmayabilir, maliyetleri artırabilir ve deneyim gerektirir. Floroskopi kullanıldığında radyasyona maruz kalma riski de vardır. Bu çalışmanın sonuçlarına göre floroskopi kullanılması sonuçları değiştirmedi ve diğer gruba göre üstünlüğü gösterilemedi. Floroskopi altında santral venöz port takılması işleme kılavuzluk açısından avantajlı olmakla birlikte floroskopi kullanılmadan da deneyimli ellerde düşük komplikasyon oranlarıyla bu işlem uygulanabilir. Anahtar Sözcükler: Santral venöz port, komplikasyon, floroskopi Aim: Central venous access devices (CVADs) have been used for prolonged infusion chemotherapy and have facilitated the problem of vascular access. The aims of this study were to analyse the results and complications of two CVAD implantation techniques. Methods: We performed a retrospective study of 118 implantable venous access devices inserted via the subclavian vein using two different surgical techniques between January 2015 and June 2017 in İstanbul Haseki Training and Research Hospital, Clinic of General Surgery. While the devices were placed under fluoroscopic guidance in group 1, they were placed without fluoroscopy in group 2. All procedures were performed under sedation and local anesthesia. All devices were placed at the anterior chest wall over the pectoralis fascia. Outcome and complications were followed and recorded elaborately. Results: A total of 118 venous access devices were implanted. During follow-up, a total of eight complications were observed. Pneumothorax was observed in five, wound infection in two and catheter fracture was observed in one patient. There was no statistically significant difference in complications between the two groups. Conclusion: CVADs increase quality of life of patients with oncologic diseases during chemotherapy. Common periprocedural complications of CVADs are pneumothorax, wound infection and catheter occlusion. In critical patients, the use of fluoroscopy may be helpful in reducing complications. However, since fluoroscopy increases costs and requires experience, CVAD insertion under fluoroscopy guidance may not always be possible. There is also a risk of radiation exposure when using fluoroscopy. In regard to comparison of the two techniques, fluoroscopy guidance did not alter the results and its superiority over the other technique was not observed. Although image-guided insertion of subcutaneous chest ports has advantages over unguided insertion, the latter can be used in a selected group of patients in experienced hands.
Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP)
Journal of Emergency Medicine, Trauma and Acute Care
Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the 'safe zone' of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation.