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Drumheller BC, Basel A, Adnan S, Rabin J, Pasley JD, Brocker J, Galvagno SM. Comparison of a novel, endoscopic chest tube insertion technique versus the standard, open technique performed by novice users in a human cadaver model: a randomized, crossover, assessor-blinded study. Scand J Trauma Resusc Emerg Med 2018; 26:110. [PMID: 30587216 PMCID: PMC6307118 DOI: 10.1186/s13049-018-0574-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background The technique of tube thoracostomy has been standardized for years without significant updates. Alternative procedural methods may be beneficial in certain prehospital and inpatient environments with limited resources. We sought to compare the efficacy of chest tube insertion using a novel, endoscopic device (The Reactor™) to standard, open tube thoracostomy. Methods Novice users were randomly assigned to pre-specified sequences of six chest tube insertions performed on a human cadaver model in a crossover design, alternating between the Reactor™ and standard technique. All subjects received standardized training in both procedures prior to randomization. Insertion site, which was randomly assigned within each cadaver’s hemithorax, was marked by the investigators; study techniques began with skin incision and ended with tube insertion. Adequacy of tube placement (intrapleural, unkinked, not in fissure) and incision length were recorded by investigators blinded to procedural technique. Insertion time and user-rated difficulty were documented in an unblinded fashion. After completing the study, participants rated various aspects of use of the Reactor™ compared to the standard technique in a survey evaluation. Results Sixteen subjects were enrolled (7 medical students, 9 paramedics) and performed 92 chest tube insertions (n = 46 Reactor™, n = 46 standard). The Reactor™ was associated with less frequent appropriate tube positioning (41.3% vs. 73.9%, P = 0.0029), a faster median insertion time (47.3 s, interquartile range 38–63.1 vs. 76.9 s, interquartile range 55.3–106.9, P < 0.0001) and shorter median incision length (28 mm, interquartile range 23–30 vs. 32 mm, interquartile range 26–40, P = 0.0034) compared to the standard technique. Using a 10-point Likert scale (1-easiest, 10-hardest) participants rated the ease of use of the Reactor™ no different from the standard method (3.8 ± 1.9 vs. 4.7 ± 1.9, P = 0.024). The Reactor™ received generally favorable scores for all parameters on the post-participation survey. Conclusions In this randomized, assessor-blinded, crossover human cadaver study, chest tube insertion using the Reactor™ device resulted in faster insertion time and shorter incision length, but less frequent appropriate tube placement compared with the standard technique. Additional studies are needed to evaluate the efficacy, safety and potential advantages of this novel device.
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Affiliation(s)
- Byron C Drumheller
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA.
| | - Anthony Basel
- Division of Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA
| | - Sakib Adnan
- School of Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA
| | - Joseph Rabin
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA
| | - Jason D Pasley
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA.,United States Air Force Center for Trauma and Readiness Sustainment (CSTARS)-Baltimore, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA
| | - Jason Brocker
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA.,United States Air Force Center for Trauma and Readiness Sustainment (CSTARS)-Baltimore, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA
| | - Samuel M Galvagno
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA.,Division of Critical Care Medicine, Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, 21201, USA
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Abstract
BACKGROUND Tube thoracostomy (TT) is a commonly performed procedure which is associated with significant complication rates. Currently, there is no validated taxonomy to classify and compare TT complications across different populations. This study aims to validate such TT complication taxonomy in a cohort of South African trauma patients. METHODS Post hoc analysis of a prospectively collected trauma database from Pietermaritzburg Metropolitan Trauma Service (PMTS) in South Africa was performed for the period January 2010 to December 2013. Baseline demographics, mechanism of injury and complications were collected and categorized according to published classification protocols. All patients requiring bedside TT were included in the study. Patients who necessitated operatively placed or image-guided TT insertion were excluded. Summary and univariate analyses were performed. RESULTS A total of 1010 patients underwent TT. The mean age was (±SD) of 26 ± 8 years. Unilateral TTs were inserted in n = 966 (96%) and bilateral in n = 44 (4%). Complications developed in 162 (16%) patients. Penetrating injury was associated with lower complication rate (11%) than blunt injury (26%), p = 0.0001. Higher complication rate was seen in TT placed by interns (17%) compared to TT placed by residents (7%), p = 0.0001. Complications were classified as: insertional (38%), positional (44%), removal (9%), infective/immunologic (9%), and instructional, educational or equipment related (0%). CONCLUSIONS Despite being developed in the USA, this classification system is robust and was able to comprehensively assign and categorize all the complications of TT in this South African trauma cohort. A universal standardized definition and classification system permits equitable comparisons of complication rates. The use of this classification taxonomy may help develop strategies to improve TT placement techniques and reduce the complications associated with the procedure. LEVEL OF EVIDENCE V. STUDY TYPE Single Institution Retrospective review.
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Hernandez MC, Zielinski MD, Aho JM. Tube Thoracostomy Complications: More to Learn: Reply. World J Surg 2018; 42:311-312. [PMID: 28884351 DOI: 10.1007/s00268-017-4219-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew C Hernandez
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Martin D Zielinski
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Johnathon M Aho
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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