It is not infrequent to see chest tubes lying in odd, albeit dangerous positions in critically ill patients when they are imaged (CT scans). What are the factors responsible for malpositioning of chest tubes and what effect this has on the patient course? What is the incidence of such occurrences?
Malpositioning of chest tubes are very frequent in emergency department especially when the procedure was performed by residents or PG students but they are rarely dangerous.
Dear Manoj, you are right but we have seen fairly large number of chest tubes in dangerous locations viz. paracardiac.
What should we do to decrease this occurrence
A prompt check X Ray .... If in doubt a lateral view as well and manipulate it as needed. Many times Check X rays are taken as routine but I f they are not checked and decisions are not taken on them then unnecessary complications can occur....
Using a trocar when Inserting chest tubes is probably one of the major factors when it comes to malpositioning chest tubes. My personal belief is that "old-fashioned" insertion of a gloved finger through the incision and into the pleural cavity following insertion of the tubu using a pean is the best guarantee against malpositioned chest tubes. However, a fast X-ray of the chest surely must follow the insertion - especially if the chest tube has been inserted prehospitally.
A colleague of mine, Dr Victor Kong audited 1054 chest drains inserted over a 4 year period at a high volume trauma centre. We are presenting the data at the AAST conference in August, but 22% of drains had insertional or positional complications, including 5 wrong side drain insertions. Increased supervision of junior doctors, better training and better communication are some of the most important correctable factors.
Allow me to share this trick I learned which has allowed me to consistently place well positioned chest tubes: after entering the pleura, hold the tip of the chest tube against your second finger and insert them together. If you are on the patient's left, use your right hand to insert the tube, and vice versa. Using your finger, keep the chest tube pressed against the postero-lateral wall of the chest while you advance the tube forward with your other hand. This will ensure it stays along the wall as it travels up to the apex, and prevents it from curling forward into the fissure or back down to the diaphragm.