Journal ClubChest tube complications: How well are we training our residents?Dr Shakil Ahmad, MO05.01.2016

Article Name: Chest tube complications: How well are we

training our residents?

Author: Andrew W. Kirkpatrick et. Al. Foothills Medical Centre, Calgary, Alberta, Canada.

Canadian Journal of Surgery, Vol. 50, December 2007

Topic

This study was about incidence and risk factors for complications in chest tubes placed exclusively by residents.

Topic continued....

As we frequently get chest injury patients who need immediate chest insertion, our residents should be able perform this life saving procedure and they will face certain complications after the procedure . That’s why this study is selected.

Search strategy

This topic was recommended by our supervisor Dr Enamul Haque Sir and found in “Pubmed” as an indexed article, searching by the key words ‘Chest tube and original’ .

Background…..

Thoracic trauma is commonly treated with tube thoracostomy.

The overall complication rate associated with this procedure is up to 30% among all operators.

Objective of the study

Primary purpose- to find the incidence and risk factors for complications in chest tubes placed exclusively by residents.

Objective of the study

Secondary purpose- to outline the rate of complications not found in postinsertional supine anteroposterior (AP) chest radiographs.

Research methodology

Methodology: Single centred retrospective cohorts study.

Sampling procedure: Inclusion criteria: Severely injured trauma patients (injury severity score ≥ 12) who underwent tube thoracostomy.

Research methodology continued...

Exclusion criteria: – patients with pre-existing thoracic drainage.– patients with chest tubes placed by attending

staff physicians or surgeons.

Variables analysed

Complications: Insertional, positional and Infective on the basis of basis of- resident operator characteristics, - patient demographics, - associated injuries and- outcomes

Findings/Results

Total severely injured ptient-761 Patients underwent chest drain insertion-

338(44%) Chest tubes placed by residents- 76 (22%) in

61 (18%) patients (99% of whom had blunt trauma injuries)

Findings/Results contd...

there were 17 complications; -insertional: 6 (35%); -positional:9 (53%) and -infective: 2 (12%)

Findings/Results contd...

Rates of complications according to training discipline among residents were as follows: 7% -general surgery, 13%-internal and family medicine, 25%-other surgical disciplines and 40%-emergency medicine

Findings/Results contd...

Six(6) of 11 (55%) positional and intraparenchymal lung tube placement complications were not found in postinsertional supine AP CXR but found in CT chest.

Limitations

Retrospective Small sample size for subgroup analysis Supervision of residents were not always

available

Conclusion of author

Chest tubes placed by residents are commonly associated with complications that are not always identified by postinsertional AP CXR.

Thoracic CT is the only way to reliably identify this morbidity.

Conclusion of author continued....

The differential rate of complications according to resident specialty suggests that residents in non–general surgical training programs may benefit from more structured instruction and closer supervision in tube thoracostomy.

Critical appraisal

Although the study is almost 10 years old it corresponds to the clinical scenario of our hospital because residents of RMCH orthopaedics frequently get polytrauma patients with chest injury but chest drain insertion is not practised by them.

Recommendation:

Chest tube insertion has been classified as a mandatory skill for all physicians involved in the care of injured patients, including emergency medicine specialists. (Emergency medicine condition/skills list. JACEP 1976;5:599-604.)

Recommendation continued…

Chest tube thoracostomy should not be reserved solely for those with surgical training.

“Given number” of procedures should be observed for minimal competence;

Skill performance component along with didactic teaching may the effective way to train the residents.

Conclusion

Chest Tube insertion should be practiced by orthopaedics residents of RMCH under supervision keeping mind to avoid the complications.

Group discussion & Question answer