PA PSRS Patient Saf Advis 2007 Sep;4(3):99.
Preventing Adverse Events Related to Chest Tube Insertion
Anesthesiology; Critical Care; Emergency Medicine; Surgery
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Introduction

A chest tube insertion tutorial program for physicians, particularly surgical and emergency department residents, is available from the U.S. Agency for Healthcare Research and Quality (AHRQ). The 11-minute DVD, “Problems and Prevention: Chest Tube Insertion,” discusses four major sources of adverse and fatal outcomes for patients and clinicians: breaks in sterile technique, inadequate anesthesia, incorrect insertion technique, and inadequate self-protection by clinicians. After using video clips of chest tube insertion procedures to illustrate these four problems, the program then discusses correct procedures and preventive measures; for example, remembering the mnemonic UWET (i.e., Universal precautions, Wider skin prep, Extensive draping, and Tray positioning) to help prevent breaks in sterile technique.1  

PA-PSRS Reports     

More than 1,100 reports have been submitted to PA-PSRS that mention chest tube insertion or placement. Most of these reports indicate chest tube insertion in response to a patient medical condition (e.g., pneumothorax). At least two reports of deaths were associated with problems or complications of chest tube placement, such as the following: 

Patient was undergoing a chest tube insertion by a CT surgeon. Difficulty was encountered, and a massive hemorrhage resulted. Patient experienced a cardiac arrest and transferred to intensive care unit, where she later died.  The patient went to the operating room for repair of a diaphragmatic tear following a motor vehicle accident. There was cardiac injury during insertion of the chest tube, and, ultimately, the patient died.

The patient’s thoracic internal organs were out of place due to the injury received in the accident. There was a pericardial tear and the heart was out of alignment, as was the stomach, which had pushed up into the lung area. The heart and stomach were injured during the placement of the chest tubes due to this misalignment, causing massive bleeding. The insults to the organs were repaired, but the heart ceased functioning, and numerous attempts to resuscitate were unsuccessful. 

Examples of the sources of adverse and fatal outcomes discussed in the DVD also can be found in reports submitted  to PA-PSRS, although most examples pertain to incorrect insertion technique. Some problems with technique that the DVD program focuses on include avoiding intercostal neurovascular damage, avoiding lacerations of the lung, and avoiding damage to other organs or structures.1 Examples in reports to PA-PSRS include those above and the following: 

Injured stomach from chest tube (perforation). 

Physician performed chest tube insertion. Approximately 15 minutes later, physician noted bright red blood draining into pleurovac. Patient taken to operating room for exploratory thoracotomy and wedge resection of right upper lobe. Upon closure, small arterial bleeder noted within layer of muscle. No further bleeding noted within chest. 

During its focus on insertion technique, the DVD program also discusses appropriate suturing to avoid leaks by closing the skin around the entry point and suturing the tube into position.1  Outcomes that may be related to suturing are apparent in multiple reports to PA-PSRS, such as the following examples: 

On admission assessment from operating room, bubbling observed in chest tube collection system. The original chest tube was inserted at another hospital. Upon further assessment, drain holes from chest tube exposed and sutures not intact. Chest tube discontinued and new chest tube inserted by trauma surgeon. 

Patient was pulled up in bed. Chest tube not secured properly. Chest tube was found on bed.

Obtaining the DVD

“Problems and Prevention: Chest Tube Insertion” was developed by the Charles “McC.” Mathius, Jr., National Study Center for Trauma and Emergency Medical Systems at the University of Maryland School of Medicine and funded by an AHRQ grant. More information is available from AHRQ at http://www.qualitytools.ahrq.gov/summary/summary.aspx?doc_id=9928.

Note

  1. Charles “McC.” Mathius, Jr., National Study Center for Trauma and Emergency Medical Systems, University of Maryland School of Medicine. Problems and prevention: chest tube insertion [DVD]. AHRQ Pub No. 06-0069-DVD. Rockville (MD): 2006 Sep.
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