It is Journal Club presentation on Chest Tube drainage

2. Journal Club
Chest tube complications:
How well are we training
our residents?
Dr Shakil Ahmad, MO
05.01.2016

3. 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

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

5. 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.

6. 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’ .

7. Background…..
 Thoracic trauma is commonly treated with
tube thoracostomy.
 The overall complication rate associated with
this procedure is up to 30% among all
operators.

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

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

10. Research methodology
 Methodology: Single centred retrospective
cohorts study.
 Sampling procedure:
Inclusion criteria: Severely injured trauma
patients (injury severity score ≥ 12) who
underwent tube thoracostomy.

11. Research methodology
continued...
 Exclusion criteria:
– patients with pre-existing thoracic drainage.
– patients with chest tubes placed by attending
staff physicians or surgeons.

12. Variables analysed
 Complications:
 Insertional,
 positional and
 Infective
on the basis of basis of
- resident operator characteristics,
- patient demographics,
- associated injuries and
- outcomes

13. 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)

14. Findings/Results contd...
 there were 17 complications;
-insertional: 6 (35%);
-positional:9 (53%) and
-infective: 2 (12%)

15. 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

16. 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.

17. Limitations
 Retrospective
 Small sample size for subgroup analysis
 Supervision of residents were not always
available

18. 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.

19. 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.

20. 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.

21. 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.)

22. 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.

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

24. Group discussion & Question
answer