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Eur J Cardiothorac Surg 2002;22:673-678
© 2002 Elsevier Science NL

Morbidity of percutaneous tube thoracostomy in trauma patients

Division of Thoracic and Vascular Surgery, University Hospital, F-97139 Pointe-à-Pitre Cedex, Guadeloupe

Received 4 July 2001; received in revised form 1 July 2002; accepted 11 July 2002.

* Tel.: +590-89-14-42; fax: +590-89-10-29
e-mail: m.deneuville{at}chu-guadeloupe.fr

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion References

 
Objectives: This prospective study was designed to evaluate the complications of percutaneous tube thoracostomy (PTT) performed for chest trauma in our institution and to determine predictive factors. Methods: One hundred and thirty-four primary PTTs were performed in 128 patients for blunt (83) and penetrating (45) chest traumas. Failure was defined as undrained hemothorax or pneumothorax, post-tube removal complications and empyema. Univariate and multivariate hazard analyses were used to assess the association between potential risk factors and complications. Results: The overall complication rate was 25% including 30 (23%) failures and nine (7%) improper placement with iatrogenic injuries to the lung (n=4) or subclavian vein (n=1). Complications were managed with 18 repeat PTTs and ten early thoracotomies for clotted hemothorax (two), persistent air leak (two), fluid collection (three) or a combination (three) at a mean delay of 6.5±2.4 days. Failure of additional PTT required late decortication for empyema (three) or decortication (three) at a mean delay of 23±7 days. One patient died postoperatively, the only death directly related to PTT failure among the four (3.1%) deaths that occurred in this study. Hospital length of stay was significantly increased in patients with PTT failure (24±19 vs. 15±8 days in uncomplicated PTT, P=0.004). By univariate analysis, polytraumatism (relative risk (RR) 2.7, P<0.05), the need for assisted ventilation (RR 2.7, P=0.003) and tube insertion by emergency physicians (RR 8.7, P<0.0001) were significantly associated with increased incidence of complications in blunt trauma. Multivariate analysis identified the performance of the procedure by operators other than thoracic surgeons and residents trained in thoracic surgery as the only independent risk factor in both blunt and penetrating trauma (RR 58 and 71, respectively, P<0.00001). Conclusions: PTT is associated with significant morbidity and extended hospitalizations, partly related to inappropriate training of all individuals dealing with trauma care. Additional training should be recommended and some conventional indications for PTT should be revised. A prospective study is currently in progress to evaluate the benefit of early videothoracoscopy in trauma and failure of primary PTT.

Key Words: Thoracic injuries • Thoracostomy • Hemothorax • Chest tube • Complications

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion References

 
Percutaneous tube thoracostomy (PTT) remains the most widely performed procedure to manage blunt and penetrating chest traumatisms. Although generally considered a simple procedure, placing of a chest tube is associated with numerous complications which are only too apparent to all thoracic surgeons who deal with large numbers of such injuries on a regular basis [1–9]. Recurrent air leak [4,5] and failure to evacuate blood from the pleural space [2,10,11] often result in complications including clotted hemothorax, empyema and fibrothorax leading to extended hospitalizations.

In Guadeloupe, a French West Indian island with 422,200 inhabitants, the incidence of traffic accidents is almost twice that observed in any other French community. Penetrating wounds to the chest from personal violence mostly related to drug addiction and alcoholism are also frequently seen [9].

In our institution, an annual case load of almost 200 blunt and penetrating chest traumas results in repeated encounters with problems in the management of PTT despite co-operative efforts made in both the emergency department and the thoracic surgery unit. In an effort of quality improvement, a prospective study was designed to define the complications of PTT in trauma patients and to determine predictive factors that may be prevented or reduced.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion References

 
Over 2 years, all consecutive patients admitted to the University Hospital, Guadeloupe for either blunt or penetrating chest trauma requiring a PTT were included in a prospective study. Indications for PTT included all more than minor pneumothoraces/hemothoraces diagnosed initially or within the first 3 days from admission.

The site (mid-axillary or mid clavicular line) and technique (trocar or blunt dissection) of tube placement was left to the discretion of each operator, provided the tube had a minimal diameter of 28 French and was connected to the same underwater-seal drainage system (Pleurevac A-7000, Genzyme SA, Cergy-Pontoise, France). Direct supervision by the attending thoracic surgeon or the ICU senior physician was not the rule but technical assistance could be obtained anytime on request if required.

After placement, all PTTs were checked daily by either a senior thoracic surgeon or an ICU physician. Chest tubes were removed at the discretion of the trauma team provided minimal drainage (less than 80 ml/8 h) and no air leak were present. The removals were performed with the patient at maximal inspiratory effort by, or under close direct supervision of, a senior thoracic surgeon or an ICU physician.

All patients with large chest collections and/or productive drainage at day 8 had a chest CT scan before tube removal. No prophylactic antibiotherapy was used in this study.

The following patients were excluded from the study: (1) patients under 15 years of age; (2) patients requiring thoracotomy after PTT for initial hemothorax >1500 ml, continued bleeding or massive air leak; (3) patients in whom pleural catheters were used as definitive treatment; and (4) those who died within the first day.

The following data were recorded: age, sex, mechanism of injury, associated lesions, indications for PTT, setting and operator, site and technique of insertion, duration of drainage, in-hospital outcome as well as need and duration of assisted ventilation. For the purpose of the study, all patient data and details of diagnosis, management and outcome were recorded on a coded form separate from the patient's hospital records and transferred on a computerized data base at the Department of Biostatistics.

Complications were defined as (1) improper placement with or without iatrogenic injuries, (2) undrained hemo/pneumothorax despite PTT, (3) recurrent pneumothorax following tube removal, (4) intrapleural collections following tube removal and (5) other post-removal complications.

The group of operators referred to as ‘thoracic’ includes attending thoracic surgeons and senior residents training at the unit of thoracic surgery. ‘Non-thoracic’ operators comprised all other individuals performing PTT, namely residents in general surgery, emergency or ICU physicians and general/digestive surgeons.

2.1. Statistical analysis
All values are expressed as the mean±SD or median (25th–75th percentile) for skewed data. Differences in the distribution of specified variables were assessed by one-way analysis of variance for continuous variables of Gaussian distribution, Wilcoxon's test for skewed variables and the ² statistic or Fisher's exact test for categorical variables.

To assess the association between potential risk factors and complications, relative risks (RR) (confidence intervals, 95%) were calculated using univariate and multivariate hazard analyses. Differences were considered significant at the P<0.05 level.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion References

 
One hundred and thirty-four primary PTTs were performed in 128 consecutive patients for 83 blunt and 45 penetrating chest traumas (39 stab and six gunshot wounds). Clinical data of patients, mechanism of injury and indications for PTT are detailed in Tables 1 and 2. In the group of 83 patients with blunt trauma, 26 were polytrauma and 24 required assisted ventilation mainly for brain lesion with coma (n=10), pulmonary contusion (n=9) or recovery following abdominal surgery (n=5). The duration of drainage was not significantly different in blunt trauma (5.1±2.4 days) compared to penetrating trauma (4.6±1.4 days). PTT was performed by thoracic operators in 88 out of 128 patients (65%), without significant difference between blunt and penetrating trauma.

Thirty-two patients (25%) suffered one or more complications including nine (7%) improper placement, four undrained hemo/pneumothoraces, 12 recurrent pneumothoraces after tube removal, seven incomplete lung expansion with retained fluid collection, four combined complications and three empyema (Table 3). The overall adjusted complication rate per procedure was 29% (39/134) without significant difference between PTTs performed for blunt trauma compared to penetrating wounds. Overall, four (3.1%) improper placements resulted in iatrogenic injuries to the lung (n=2), lung and diaphragm (n=1) and subclavian vein (n=1), all associated with the use of rigid trocar with a sharp-tip meta rod by non-thoracic operators.

Five tubes were improperly inserted without iatrogenic injuries outside the pleural cavity or too apically to drain fluid collections. All were replaced but all five patients subsequently had additional complications, i.e. undrained hemothorax (three), retained fluid collection (one) and empyema (one).

Overall, 30 (23%) failures, unrelated to improper placement, were observed (Tables 3 and 4) without a statistical difference in blunt (24%) compared to penetrating trauma (22%). Six were minimal recurrent pneumothoraces or pleural effusion that resolved with non-operative treatment.

The remaining complications were managed with additional PTT which failed in five patients who subsequently required secondary thoracotomy for empyema (n=2) or decortication at a mean delay of 23±7 days. One patient died postoperatively from septic shock, the only death directly related to complications of PTT.

The median hospital length of stay was significantly increased two-fold in complicated PTTs (15 days (25th–75th percentile 10–34)) compared to uncomplicated PTTs (7 days (5–12), P<0.0001). Although not significant, the duration of drainage as well as the delay in secondary treatment, including additional PTT and surgery, tend to be increased in patients with polytraumatism. In this subgroup of patients, the hospital length of stay was significantly increased compared to the group of patients with complications but suffering less severe injuries (41±18 vs. 18±11 days, P=0.007). In contrast, hospital lengths of stay were comparable in patients with complications managed by an early surgical approach and in those treated conservatively or with effective additional PTT.

The indications for drainage (hemothorax vs. pneumothorax), the technique of insertion, the presence of a pulmonary contusion, abdominal injuries and performance of abdominal surgery were not significantly associated with an increased RR for complications. In contrast, by univariate analysis, polytraumatism (RR 2.7, P<0.05), the need for assisted ventilation (RR 2.7, P=0.003) and tube insertion by emergency physicians (RR 8.7, P<0.0001) were all significantly associated with an increased incidence of complications in blunt trauma.

Multivariate analysis identified the performance of the procedure by operators other than thoracic surgeons and residents trained in thoracic surgery as the only independent risk factor in both blunt and penetrating trauma (RR 58 and 71, respectively, P<0.00001) (Table 5).

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion References

However, this study further emphasizes the high rates of complications and failure for a commonplace procedure in trauma care. In part, the complications observed in our study may have been due to the occasional use of the trocar method of tube placement, a technique generally [1,6,7,12–14] recognized as carrying an increased risk of iatrogenic injuries. However, the relatively small numbers (11%) prevented the demonstration of formal statistical significance. Nevertheless, all five trocar associated complications involved non-thoracic operators.

The most important conclusion of the present study is the significant operator-dependent variability in the rate of complications with an almost ten-fold increased risk in procedures performed by individuals other than thoracic surgeons and residents training in thoracic surgery. A similar difference between surgeons and physicians has been reported by Etoch et al. [8].

The operator-dependent complications comprise two distinct entities, iatrogenic injuries and other complications. The rate of improper placement was clearly in excess of other studies (rates lower than 1%) [1–3,8,11] but with retrospective data collection, so that the true incidence of iatrogenic lesions may have been underestimated. In a prospective study, Hirshberg et al. [7] reported a 6% rate of iatrogenic injuries, which is very similar to our own findings.

There can be little doubt about the relationships between iatrogenic complications and insufficient training of the operator. The relationships between non-iatrogenic complications and the operator's level of formation are less clear. There are at least two potential explanations for these findings: (1) the need for urgent PTT by individuals other than thoracic surgeons may be more prone to complications in the most severely injured patients; or (2) the operator performing PTT might have been less skilled. Indeed, many factors may be confounding in the most severely injured patients admitted in intensive care units.

The presence of a pulmonary contusion [10] and initial shock as well as the need for admission to the ICU or for mechanical ventilation [8] have been shown to increase the incidence of complications. In the present study, multivariate analysis was unable to detect any impact of these factors but this may be due to the small number of procedures included. However, a trend towards longer duration of drainage, increased rate of repeated PTTs for failure and delayed surgery was observed in patients admitted to the ICU compared to less severe cases of isolated blunt trauma (data not shown). Cumulated effects of these factors resulted in a significant two-fold increase in the hospital length of stay in these patients compared to the group of patients with complications treated at the surgical ward.

Therefore, although attenuated by the pre-established protocol, unapparent bias related to different approaches in management, assessment and removal of PTT between thoracic surgeons alone and ICU physicians may play a role in increased morbidity. However, those possible biases are not operating in most penetrating traumas for which multivariate analysis also identified the performance of PTT by a non-thoracic operator as the only independent predictor for complications.

Taken together, these data suggest that improper training of all physicians dealing with trauma care is likely to participate in the high morbidity rates of PTT. Indeed, it would be inappropriate and dangerous to confine PTT handling only to thoracic surgeons. It has been demonstrated by others that non-specialist physicians involved in trauma care may become competent enough in technical performance to reach less than minimal rates of complications [12]. As assumed by Waksman et al. [15], alternative atraumatic techniques of insertion, such as the use of an endoscopic trocar-cannula, which do not require special surgical skills could be used by untrained personnel.

Toward an effective, real-world quality improvement, surgery residents, emergency and ICU physicians as well as general surgeons should be more involved in true additional training [14] including understanding the indications for PTT and the appropriate technique of placement, and knowledge of potential complications and general principles of post-placement management and care [4]. In addition, co-operative efforts should be made between all individuals dealing with trauma care and thoracic surgeons should be involved earlier in the management of the most severe blunt traumas admitted to the ICU.

However, beyond operator variability, there is repeated and convincing evidence in the literature that the procedure of PTT itself is subject to almost a 25% failure rate unrelated to technical errors. Those failures comprise mainly post-removal air leaks [2,4,5], residual fluid collection [2,10] and empyema [1–3,9–11,16]. As complications are not generally observed at such high rates for chest tubes inserted intraoperatively [9], it is reasonable to assume that technical limitations which comprise difficult postero-basal positioning of the tube and an inability to evacuate large clots are inherent in the percutaneous ‘blind’ method. In addition, recurrent air leaks and bleeding may result from an absence of spontaneous healing of pulmonary damages [5,9,17] as well as from injuries of chest wall vessels [17,18].

It has been shown that persistent fluid collection and multiple chest tube placement were predictive factors of development of empyema [10] that may be prevented by early thoracotomy [2,11]. In the presence of post-removal collection, our data indicate, as do previous studies [2,19], that additional tube placement is ineffective in almost half of all cases. This problem is specifically relevant in patients with polytraumatism and/or in patients requiring mechanical ventilation who cannot be weaned from the respirator until surgical re-expansion of the afflicted lung has been achieved.

Taken together, these data suggest that both indications for non-operative management of traumatic hemothoraces [20] and post-tube removal complications should be revised.

Several studies have advocated the use of video-assisted thoracoscopy (VATS) as a safe, effective and less aggressive approach in the trauma setting [16–19,21–23]. Previous reports have stressed the paramount importance of performing VATS within 8 days of injury in the management of failed primary PTT [16,17].

	5. Conclusion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion References

 
This study clearly shows that a significant morbidity from PTT is operator-dependent and suggests that failures may partly result from inherent limitations of the blind method of insertion. An effective, real-world quality improvement should involve both additional training of all trauma physicians and revision of some well established indications for PTT in chest trauma. A prospective study is currently in progress at our institution to evaluate the benefit of videothoracoscopy in the primary management of chest trauma and failure of primary PTT.

	Acknowledgments

 
The author thanks John Clayton, MD, PhD for his contribution to the statistic management of the data and for his help in the redaction of the manuscript.

	Footnotes

 
Presented at the 8th European Conference on General Thoracic Surgery of the European Society of Thoracic Surgeons, London, UK, November 1–4, 2000.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusion References

 

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