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Kuan S, Lynch R, Dea AO. Critical tasks and errors associated with intercostal chest drain insertion. Postgrad Med J 2024:qgae113. [PMID: 39239973 DOI: 10.1093/postmj/qgae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 07/13/2024] [Accepted: 08/19/2024] [Indexed: 09/07/2024]
Abstract
INTRODUCTION To describe critical tasks and errors associated with intercostal chest drain insertion, in order to develop enhanced procedural guidelines for task performance and training. METHODS Expert emergency medicine physicians participated in a three-phased study. First, hierarchical task analyses was used to identify tasks, sub-tasks, and the sequence of tasks. Second, systematic human error reduction and prediction approach was used to identify and classify the errors associated with each sub-task culminating in a probability, criticality, and detectability rating for each error. Third, failure modes, effects and criticality analysis technique was used to convert probability and criticality estimates to occurrence and severity scores. Criticality index score, a measure of the propensity for the error to cause harm or procedural failure for each error, was calculated and the top 20 errors most likely to cause harm were ranked. RESULTS Thirteen tasks and 61 sub-tasks were identified and yielded 86 potential errors. Error classification included errors of action, checking, and selection. The error with the highest criticality score was 'identifying a point of entry lower than the fifth intercostal space'. The top four ranked errors all relate to the identification and correct marking of the location site for the intercostal drain within the safe triangle. CONCLUSIONS Tasks and sub-tasks associated with intercostal chest drain insertion was described and evaluated for criticality. The most critical task was the correct identification of a safe insertion point. Applications include development of procedural guidelines with tasks vulnerable to error highlighted and training interventions that promotes safe task performance.
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Affiliation(s)
- Samuel Kuan
- Emergency Medicine Consultant, Emergency Department Regional Hospital, Longford Road, Mullingar, County Westmeath N91 NA43, Ireland
| | - Richard Lynch
- Emergency Medicine Consultant, Emergency Department Regional Hospital, Longford Road, Mullingar, County Westmeath N91 NA43, Ireland
| | - Angela O Dea
- Patient Safety and Simulation, University of Galway, University Road, Galway, County Galway H91 TK33, Ireland
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Tarantino B, Wood M, Hancock D, Shah K. Does pre-injury anticoagulation make chest tubes any less safe? A nationwide retrospective analysis. Am J Emerg Med 2024; 82:47-51. [PMID: 38788529 DOI: 10.1016/j.ajem.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/26/2024] [Accepted: 05/04/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Oral anticoagulation is becoming more common with the aging population, which raises concern for the risk of invasive procedures that can cause bleeding, such as chest tube placement (thoracostomy). With the increase in CT imaging, more pneumothoraces and hemothoraces are being identified. The relative risk of thoracostomy in the presence of anticoagulation is not well-established. The objective of this study was to determine whether pre-injury anticoagulation affects the relative risk of tube thoracostomy following significant chest trauma. METHODS This retrospective cohort study used data from the 2019 American College of Surgeons-Trauma Quality Program (ACS-TQP) database using R version 4.2.2. Data from the database was filtered based on inclusion and exclusion criteria. Outcomes were then assessed with the population of interest. Demographics, vitals, comorbidities, and injury parameters were also collected for each patient. This study included all adult patients (≥18 years) presenting with traumatic hemothorax, pneumothorax, or hemopneumothorax. Patients with missing data in demographics, vitals, comorbidities, injury parameters, or outcomes, as well as those with no signs of life upon arrival, were excluded from the study. Patients were stratified into groups based on whether they had pre-injury anticoagulation and whether they had a chest tube placed in the hospital. The primary outcome was mortality, and the secondary outcome was hospital length of stay (LOS). Logistic and standard regressions were used by a statistician to control for age, sex, and Injury Severity Score (ISS). RESULTS Our study population included 72,385 patients (4250 with pre-injury anticoagulation and 68,135 without pre-injury anticoagulation). Pre-injury anticoagulation and thoracostomy were each independently associated with increased mortality and LOS. However, there was a non-significant interaction term between pre-injury anticoagulation and thoracostomy for both outcomes, indicating that their combined effects on mortality and LOS did not differ significantly from the sum of their individual effects. CONCLUSION This study suggests that both pre-injury anticoagulation and thoracostomy are risk factors for mortality and increased LOS in adult patients presenting with hemothorax, pneumothorax, or hemopneumothorax, but they do not interact with each other. We recommend further study of this phenomenon to potentially improve clinical guidelines. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
| | - Myles Wood
- Weill Cornell Medicine, United States of America
| | | | - Kaushal Shah
- Weill Cornell Medicine, United States of America
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LoMonaco J, Klemisch RJ, Ilgen JS, Sobba B, Badulak J, Varghese TK, Morris AE. A Multidisciplinary Curriculum to Standardize Chest Procedures Training for Trainees in General Surgery, Emergency Medicine, and Critical Care. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2024; 20:11421. [PMID: 38984064 PMCID: PMC11231065 DOI: 10.15766/mep_2374-8265.11421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 03/19/2024] [Indexed: 07/11/2024]
Abstract
Introduction Critical care, emergency medicine, and surgical trainees frequently perform surgical and Seldinger-technique tube thoracostomy, thoracentesis, and thoracic ultrasound. However, approaches to teaching these skills are highly heterogeneous. Over 10 years, we have developed a standardized, multidisciplinary curriculum to teach these procedures. Methods Emergency medicine residents, surgical residents, and critical care fellows, all in the first year of their respective programs, underwent training in surgical and Seldinger chest tube placement and securement, thoracentesis, and thoracic ultrasound. The curriculum included preworkshop instructional videos and 45-minute in-person practice stations (3.5 hours total). Sessions were co-led by faculty from emergency medicine, thoracic surgery, and pulmonary/critical care who performed real-time formative assessment with standardized procedural steps. Postcourse surveys assessed learners' confidence before versus after the workshop in each procedure, learners' evaluations of faculty by station and specialty, and the workshop overall. Results One hundred twenty-three trainees completed course evaluations, demonstrating stable and positive responses from learners of different backgrounds taught by a multidisciplinary group of instructors, as well as statistically significant improvement in learner confidence in each procedure. Over time, we have made incremental changes to our curriculum based on feedback from instructors and learners. Discussion We have developed a unique curriculum designed, revised, and taught by a multidisciplinary faculty over many years to teach a unified approach to the performance of common chest procedures to surgical, emergency medicine, and critical care trainees. Our curriculum can be readily adapted to the needs of institutions that desire a standardized, multidisciplinary approach to thoracic procedural education.
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Affiliation(s)
- Jacob LoMonaco
- Third-Year Resident, Department of Emergency Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas
| | - Robert J Klemisch
- Acting Instructor, Department of Emergency Medicine, University of Washington School of Medicine
| | - Jonathan S Ilgen
- Professor, Department of Emergency Medicine, University of Washington School of Medicine
| | - Beth Sobba
- Third-Year Resident, Department of Obstetrics and Gynecology, Ochsner Clinic Foundation
| | - Jenelle Badulak
- Assistant Professor, Department of Emergency Medicine, University of Washington School of Medicine
| | - Thomas K Varghese
- Professor, Department of Surgery, University of Utah School of Medicine
| | - Amy E Morris
- Associate Professor, Department of Medicine, University of Washington School of Medicine
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De Mol L, Lievens A, De Pauw N, Vanommeslaeghe H, Van Herzeele I, Van de Voorde P, Konge L, Desender L, Willaert W. Assessing Chest Tube Insertion Skills Using a Porcine Rib Model-A Validity Study. Simul Healthc 2023:01266021-990000000-00087. [PMID: 37782127 DOI: 10.1097/sih.0000000000000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Assessments require sufficient validity evidence before their use. The Assessment for Competence in Chest Tube Insertion (ACTION) tool evaluates proficiency in chest tube insertion (CTI), combining a rating scale and an error checklist. The aim of this study was to collect validity evidence for the ACTION tool on a porcine rib model according to the Messick framework. METHODS A rib model, consisting of a porcine hemithorax that was placed in a wooden frame, was used as simulator. Participants were recruited from the departments of surgery, pulmonology, and emergency medicine. After familiarization with the rib model and the equipment, standardized instructions and clinical context were provided. They performed 2 CTIs while being scored with the ACTION tool. All performances were assessed live by 1 rater and by 3 blinded raters using video recordings. Generalizability-analysis was performed and mean scores and errors of both groups on the first performance were compared. A pass/fail score was established using the contrasting groups' method. RESULTS Nine novice and 8 experienced participants completed the study. Generalizability coefficients where high for the rating scale (0.92) and the error checklist (0.87). In the first CTI, novices scored lower than the experienced group (38.1/68 vs. 47.1/68, P = 0.042), but no difference was observed on the error checklist. A pass/fail score of 44/68 was established. CONCLUSION A solid validity argument for the ACTION tool's rating scale on a porcine rib model is presented, allowing formative and summative assessment of procedural skills during training before patient contact.
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Affiliation(s)
- Leander De Mol
- From the Department of Human Structure and Repair (L.D.M., A.L., N.D.P., I.V.H., L.D., W.W.), Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Gastrointestinal Surgery (H.V., W.W.), Ghent University Hospital, Ghent, Belgium; Department of Thoracic and Vascular Surgery (I.V.H., L.D.), Ghent University Hospital, Ghent, Belgium; Department of Basic and Applied Medical Sciences (P.V.d.V.), Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Emergency Medicine (P.V.d.V.), Ghent University Hospital, Ghent, Belgium; Faculty of Health and Medical Sciences, (L.K.) University of Copenhagen, Copenhagen, Denmark; and Copenhagen Academy for Medical Education and Simulation (CAMES) (L.K.), Copenhagen, Denmark
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Kouyoumjian S, Velilla MA, Paxton JH. A novel simulation model for tube thoracostomy. SAGE Open Med 2023; 11:20503121231178336. [PMID: 37324122 PMCID: PMC10262666 DOI: 10.1177/20503121231178336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
Objective Tube thoracostomy is a life-saving procedure that must be performed competently and expeditiously by emergency care providers. The primary objective of this project was to develop a simple, easily-reproducible, and realistic simulation model for tube thoracostomy placement by learners of emergency medicine. Methods This chest tube simulator utilizes two slabs of pork ribs with associated intercostal muscle and fascial planes to aid learners in identifying anatomic landmarks, palpating intercostal spaces, and performing blunt dissection in a manner that approximates human anatomy. Holes are cut on both sides of a 1.8-bushel capacity rectangular plastic clothing hamper, and rib slabs are secured to the hamper with zip ties or metal wire. A bed pillow with plastic cover is then placed inside of the plastic hamper to simulate lung tissue. The rib-hamper complex is then wrapped with cellophane or elastic compression bandages to further anchor the rib slabs and simulate skin and subcutaneous tissues. Results The initial cost of our thoracostomy model is approximately $50, much less than the $1,000-$3,000 cost for a commercial model. Although the hamper and pillow can be reused an indefinite number of times, the other components of our model must be replaced occasionally. Assuming a lifespan of 1,000 uses, our model costs approximately $1.78 per attempt, compared to $4.00 per attempt with the cheapest commercial mannequin system. In fact, assuming a longer useful lifespan for the mannequin does not substantially improve this comparison (e.g. $3.10 versus $1.77 per attempt for a 10,000 attempt lifespan for the commercial mannequin), largely due to the higher cost of commercial replacement skin pads when compared to the components consumed in our model with each attempt. Conclusions We describe a porcine thoracostomy model that simulates the look and feel of human ribs for purposes of tube thoracostomy training, although it could also be used for thoracentesis and thoracotomy simulation. This model is relatively cheap (costing around $50) and easy to produce within a few minutes utilizing commonly-available materials. Further study is needed to determine whether an inexpensive model like ours provides the same educational value as more expensive commercial mannequin models.
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Affiliation(s)
| | | | - James H. Paxton
- James H. Paxton, Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine St, Detroit, MI 48201-1928, USA.
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Marinica AL, Nagaraj MB, Elson M, Vella MA, Holena DN, Dumas RP. Evaluating emergency department tube thoracostomy: A single-center use of trauma video review to assess efficiency and technique. Surgery 2023; 173:1086-1092. [PMID: 36740501 DOI: 10.1016/j.surg.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/01/2022] [Accepted: 12/22/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Emergency department tube thoracostomy is a common procedure; however, assessing procedural skills is difficult. We sought to describe procedural variability and technical complications of emergency department tube thoracostomy using trauma video review. We hypothesized that factors such as hemodynamic abnormality lead to increased technical difficulty and malpositioning. METHODS Using trauma video review, we reviewed all emergency department tube thoracostomy from 2020 to 2022. Patients were stratified into hemodynamically abnormal (systolic blood pressure <90 or heart rate >120) and hemodynamically normal (systolic blood pressure ≥90 or heart rate ≤120). Emergency department tube thoracostomies outside of video-capable rooms, with incomplete visualization, or in patients undergoing cardiopulmonary resuscitation or resuscitative thoracotomy were excluded. The primary outcome was a procedure score modified from the validated tool ranging from 0 to 11 (higher score indicating better performance). Also measured were procedural times to (1) decision to place, (2) pleural entry, and (3) procedure completion. Postprocedure x-ray and chart review were used to determine accuracy. RESULTS In total, 51 videos met the inclusion criteria. The median age was 34 [interquartile range 24-40] years, body mass index 25.8 [interquartile range 21.8-30.7], predominately male (75%), blunt injury (57%), with Injury Severity Score of 22 [14.5-41]. The median procedure score was 9 [7-10]. Emergency department tube thoracostomies in patients with abnormal hemodynamics had significantly lower procedure scores (8 vs 10, P < .05). Hemodynamically abnormal patients had significantly shorter times from decision to proceed to pleural entry (4.05 vs 8.25 minutes, P < .001), and to completion (6.31 vs 14.23 minutes, P < .001). The most common complication was malpositioning (35.1%), with no significant difference noted when comparing hemodynamically normal and abnormal patients (P = .41). CONCLUSION Using trauma video review we identified significant procedural variability in emergency department tube thoracostomy, mainly that hemodynamic abnormality led to lower proficiency scores and increased malpositioning. Efforts are needed to define procedural benchmarks and evaluation in the context of patient outcomes. Using this technology and methodology can help establish procedural norms.
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Affiliation(s)
| | - Madhuri B Nagaraj
- University of Texas Southwestern Medical Center, Division of Burn, Trauma, Acute, and Critical Care Surgery, Dallas, TX. https://twitter.com/nagaraj_madhuri
| | - Matthew Elson
- University of Texas Southwestern Medical Center, Division of Burn, Trauma, Acute, and Critical Care Surgery, Dallas, TX. https://twitter.com/mElsonMD
| | - Michael A Vella
- University of Rochester Medical Center, Division of Acute Care Surgery and Trauma, NY. https://twitter.com/MichaelVella32
| | - Daniel N Holena
- Medical College of Wisconsin, Division of Acute Care Surgery, Milwaukee, WI. https://twitter.com/Daniel_Holena
| | - Ryan P Dumas
- University of Texas Southwestern Medical Center, Division of Burn, Trauma, Acute, and Critical Care Surgery, Dallas, TX. https://twitter.com/RPDUmasMD
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Yee J, San Miguel C, Khandelwal S, Way D, Panchal A. Procedural Curriculum to Verify Intern Competence Prior to Patient Care. West J Emerg Med 2023; 24:8-14. [PMID: 36602482 PMCID: PMC9897246 DOI: 10.5811/westjem.2022.11.58057] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/28/2022] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Emergency medicine (EM) programs train residents to perform clinical procedures with known iatrogenic risks. Currently, there is no established framework for graduating medical students to demonstrate procedural competency prior to matriculating into residency. Mastery-based learning has demonstrated improved patient-safety outcomes. Incorporation of this framework allows learners to demonstrate procedural competency to a predetermined standard in the simulation laboratory prior to performing invasive procedures on patients in the clinical setting. This study describes the creation and implementation of a competency-based procedural curriculum for first-year EM residents using simulation to prepare learners for supervised participation in procedures during patient care. METHODS Checklists were developed internally for five high-risk procedures (central venous line placement, endotracheal intubation, lumbar puncture, paracentesis, chest tube placement). Performance standards were developed using Mastery-Angoff methods. Minimum passing scores were determined for each procedure. Over a two-year period, 38 residents underwent baseline assessment, deliberate practice, and post-testing against the passing standard score to demonstrate procedural competency in the simulation laboratory during intern orientation. RESULTS We found that 37% of residents required more than one attempt to achieve the minimum passing score on some procedures, however, all residents ultimately met the competency standard on all five high-risk procedures in simulation. One critical incident of central venous catheter guideline retention was identified in the simulation laboratory during the second year of implementation. CONCLUSION All incoming first-year EM residents demonstrated procedural competence on five different procedures using a mastery-based educational framework. A competency-based EM curriculum allowed for demonstration of procedural competence prior to resident participation in supervised clinical patient care.
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Affiliation(s)
- Jennifer Yee
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - Christopher San Miguel
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - Sorabh Khandelwal
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - David Way
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - Ashish Panchal
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
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Sweet AAR, Beks RB, de Jong MB, van Baal MCPM, IJpma FFA, Hietbrink F, Beeres FJP, Leenen LPH, Groenwold RHH, Houwert RM. Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review. J Trauma Acute Care Surg 2021; 91:427-434. [PMID: 33605708 DOI: 10.1097/ta.0000000000003118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients. METHODS A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal. RESULTS Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention. CONCLUSION In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed. LEVEL OF EVIDENCE Systematic review study, level IV.
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Affiliation(s)
- Arthur A R Sweet
- From the Department of Surgery (A.A.R.S., M.B.d.J., M.C.P.v.B., F.H., L.P.H.L., R.M.H.), University Medical Center Utrecht, Utrecht; Department of Surgery (R.B.B.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Surgery (F.F.A.I.), University Medical Center Groningen, Groningen, the Netherlands; Department of Orthopedics and Trauma Surgery (F.J.P.B.), Luzerner Kantonsspital, Luzern, Switzerland; Department of Clinical Epidemiology (R.H.H.G.), Leiden University Medical Center, Leiden, the Netherlands
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Villanueva C, Doyle M, Parikh R, Manganas C. Patient Safety During Chest Drain Insertion-A Survey of Current Practice. J Patient Saf 2021; 17:e115-e120. [PMID: 27653495 DOI: 10.1097/pts.0000000000000304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The aim of this study was to identify the degree of awareness of the current guidelines and common practices for pleural drain insertion. METHODS A 10-item questionnaire was sent electronically to junior physicians from 4 different hospitals in the South Eastern Sydney and Illawarra Shoalhaven Local Health District. Participants were asked to give their level of experience and management practices for chest drain insertion. RESULTS A total of 94 junior medical officers from 4 hospitals in the district completed the survey. More than 20% had never inserted a chest drain at the time; 72% had primarily learned from bedside teaching and peer learning, but 11% had no training at all. More than 50% of physicians felt that the biggest threat to the procedure was their own lack of confidence for drain insertion. Despite current guidelines, 25% insert chest drains routinely without the aid of ultrasound. A third of interviewees were aware of local guidelines but had not read them. Most physicians (86%) believe that formal standardized training should be available for junior physicians. CONCLUSIONS Our findings demonstrate the ongoing need for improved procedural training in chest drain insertion, with emphasis on mandatory thoracic ultrasound. We consider it important to continue to raise concern and awareness that chest drain insertion is not a harmless procedure, and further physician procedural competence is required.
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Affiliation(s)
| | - Mathew Doyle
- From the Cardiothoracic Surgical Unit, St George Hospital, Kogarah
| | - Roneil Parikh
- From the Cardiothoracic Surgical Unit, St George Hospital, Kogarah
| | - Con Manganas
- From the Cardiothoracic Surgical Unit, St George Hospital, Kogarah
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Zante B, Schefold JC. Simulation training for emergency skills: effects on ICU fellows' performance and supervision levels. BMC MEDICAL EDUCATION 2020; 20:498. [PMID: 33298042 PMCID: PMC7726897 DOI: 10.1186/s12909-020-02419-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 12/02/2020] [Indexed: 05/16/2023]
Abstract
BACKGROUND The application of manual emergency skills is essential in intensive care medicine. Simulation training on cadavers may be beneficial. The aim of this study was to analyze a skill-training aiming to enhance ICU-fellows´ performance. METHODS A skill-training was prepared for chest tube insertion, pericardiocentesis, and cricothyroidotomy. Supervision levels (SL) for entrustable professional activities (EPA) were applied to evaluate skill performance. Pre- and post-training, SL and fellows´ self- versus consultants´ external assessment was compared. Time on skill training was compared to conventional training in the ICU-setting. RESULTS Comparison of pre/post external assessment showed reduced required SL for chest tube insertion, pericardiocentesis, and cricothyroidotomy. Self- and external assessed SL did not significantly correlate for pre-training/post-training pericardiocentesis and post-training cricothyroidotomy. Correlations were observed for self- and external assessment SL for chest tube insertion and pre-assessment for cricothyroidotomy. Compared to conventional training in the ICU-setting, chest tube insertion training may further be time-saving. CONCLUSIONS Emergency skill training separated from a daily clinical ICU-setting appeared feasible and useful to enhance skill performance in ICU fellows and may reduce respective SL. We observed that in dedicated skill-training sessions, required time resources would be somewhat reduced compared to conventional training methods.
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Affiliation(s)
- Bjoern Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Joerg C. Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
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Khallouf J, Mantziari S, Uldry E. Shock after thoracic drainage. Surgery 2020. [DOI: 10.1016/j.surg.2020.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Tang MB, Li JL, Tian SY, Gao XL, Liu W. Predictive factors for pleural drainage volume after uniportal video-assisted thoracic surgery lobectomy for non-small cell lung cancer: a single-institution retrospective study. World J Surg Oncol 2020; 18:162. [PMID: 32641064 PMCID: PMC7346611 DOI: 10.1186/s12957-020-01941-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/01/2020] [Indexed: 12/25/2022] Open
Abstract
Objective To identify the predictive factors associated with pleural drainage volume (PDV) after uniportal video-assisted thoracic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC). Methods A total of 440 consecutive NSCLC patients who underwent uniportal VATS lobectomy were enrolled in this study between November 2016 and July 2019. Thirty-four parameters, including patients’ clinicopathological characteristics and other potential predictors were collected. Daily drainage volume was summed up as PDV. Univariate analysis and multivariate regression models were fitted to identify independent predictive factors for PDV. Results The median PDV was 840 ml during the median drainage duration of 4 days. A strong correlation was observed between PDV and drainage duration (correlation coefficient = 0.936). On univariate analysis, age, forced expiratory volume in 1 s % predicted (FEV1%), left ventricular ejection fraction (LVEF), operation time, serum total protein (TP), and body mass index (BMI) showed a significant correlation with PDV (P value, < 0.001, < 0.001, 0.003, 0.008, 0.028, and 0.045, respectively). Patients with smoking history (P = 0.030) or who underwent lower lobectomy (P = 0.015) showed significantly increased PDV than never smokers or those who underwent upper or middle lobectomy, respectively. On multivariate regression analysis, older age (P< 0.001), lower FEV1% (P< 0.001), lower LVEF (P = 0.011), lower TP (P = 0.013), and lower lobectomy (P = 0.016) were independent predictors of increased PDV. Conclusions Predictive factors of PDV can be identified. Based on these predictors, patients can be treated with tailored individualized safe chest tube management.
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Affiliation(s)
- Ming-Bo Tang
- Department of Thoracic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, Jilin, 130021, China
| | - Jia-Lin Li
- Department of Thoracic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, Jilin, 130021, China
| | - Su-Yan Tian
- Department of Division of Clinical Research, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Xin-Liang Gao
- Department of Thoracic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, Jilin, 130021, China
| | - Wei Liu
- Department of Thoracic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, Jilin, 130021, China.
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Jewer J, Parsons MH, Dunne C, Smith A, Dubrowski A. Evaluation of a Mobile Telesimulation Unit to Train Rural and Remote Practitioners on High-Acuity Low-Occurrence Procedures: Pilot Randomized Controlled Trial. J Med Internet Res 2019; 21:e14587. [PMID: 31389340 PMCID: PMC6701160 DOI: 10.2196/14587] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 11/18/2022] Open
Abstract
Background The provision of acute medical care in rural and remote areas presents unique challenges for practitioners. Therefore, a tailored approach to training providers would prove beneficial. Although simulation-based medical education (SBME) has been shown to be effective, access to such training can be difficult and costly in rural and remote areas. Objective The aim of this study was to evaluate the educational efficacy of simulation-based training of an acute care procedure delivered remotely, using a portable, self-contained unit outfitted with off-the-shelf and low-cost telecommunications equipment (mobile telesimulation unit, MTU), versus the traditional face-to-face approach. A conceptual framework based on a combination of Kirkpatrick’s Learning Evaluation Model and Miller’s Clinical Assessment Framework was used. Methods A written procedural skills test was used to assess Miller’s learning level— knows —at 3 points in time: preinstruction, immediately postinstruction, and 1 week later. To assess procedural performance (shows how), participants were video recorded performing chest tube insertion before and after hands-on supervised training. A modified Objective Structured Assessment of Technical Skills (OSATS) checklist and a Global Rating Scale (GRS) of operative performance were used by a blinded rater to assess participants’ performance. Kirkpatrick’s reaction was measured through subject completion of a survey on satisfaction with the learning experiences and an evaluation of training. Results A total of 69 medical students participated in the study. Students were randomly assigned to 1 of the following 3 groups: comparison (25/69, 36%), intervention (23/69, 33%), or control (21/69, 31%). For knows, as expected, no significant differences were found between the groups on written knowledge (posttest, P=.13). For shows how, no significant differences were found between the comparison and intervention groups on the procedural skills learning outcomes immediately after the training (OSATS checklist and GRS, P=1.00). However, significant differences were found for the control versus comparison groups (OSATS checklist, P<.001; GRS, P=.02) and the control versus intervention groups (OSATS checklist, P<.001; GRS, P=.01) on the pre- and postprocedural performance. For reaction, there were no statistically significant differences between the intervention and comparison groups on the satisfaction with learning items (P=.65 and P=.79) or the evaluation of the training (P=.79, P=.45, and P=.31). Conclusions Our results demonstrate that simulation-based training delivered remotely, applying our MTU concept, can be an effective way to teach procedural skills. Participants trained remotely in the MTU had comparable learning outcomes (shows how) to those trained face-to-face. Both groups received statistically significant higher procedural performance scores than those in the control group. Participants in both instruction groups were equally satisfied with their learning and training (reaction). We believe that mobile telesimulation could be an effective way of providing expert mentorship and overcoming a number of barriers to delivering SBME in rural and remote locations.
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Affiliation(s)
- Jennifer Jewer
- Faculty of Business, Memorial University, St John's, NL, Canada
| | | | - Cody Dunne
- Faculty of Medicine, Memorial University, St John's, NL, Canada
| | - Andrew Smith
- Faculty of Medicine, Memorial University, St John's, NL, Canada
| | - Adam Dubrowski
- Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
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Hertz P, Jensen K, Abudaff SN, Strøm M, Subhi Y, Lababidi H, Konge L. Ensuring basic competency in chest tube insertion using a simulated scenario: an international validation study. BMJ Open Respir Res 2019; 5:e000362. [PMID: 30622719 PMCID: PMC6307557 DOI: 10.1136/bmjresp-2018-000362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/07/2018] [Accepted: 11/09/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction Chest tube insertion can be associated with serious complications. A structured training programme is needed to minimise complications and enhance patient safety. Novices should pass a reliable test with solid evidence of validity before performing the procedure supervised on patients. The aim of this study was to establish a credible pass/fail standard. Methods We used an established assessment tool the Chest Tube Insertion Competency Test (TUBE-iCOMPT). Validity evidence was explored according to Messick’s five sources of validity. Two methods were used to establish a credible pass/fail standard. Contrasting groups’ method: 34 doctors (23 novices and 11 experienced surgeons) performed the procedure twice and all procedures were video recorded, edited, blinded and rated by two independent, international raters. Modified Angoff method: seven thoracic surgeons individually determined the scores that defined the pass/fail criteria. The data was gathered in Copenhagen, Denmark and Riyadh, Saudi Arabia. Results Internal consistency reliability was calculated as Cronbach’s alpha to 0.94. The generalisability coefficient with two raters and two procedures was 0.91. Mean scores were 50.7 (SD±13.2) and 74.7 (SD±4.8) for novices and experienced surgeons, respectively (p<0.001). The pass/fail score of 62 points resulted in zero false negatives and only three false positives. Discussion We have gathered valuable additional validity evidence for the assessment tool TUBE-iCOMPT including establishment of a credible pass/fail score. The TUBE-iCOMPT can now be integrated in mastery learning programmes to ensure competency before independent practice.
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Affiliation(s)
- Peter Hertz
- Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen and the Capital Region of Denmark, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiothoracic Surgery, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Katrine Jensen
- Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen and the Capital Region of Denmark, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiothoracic Surgery, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | | | - Michael Strøm
- Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen and the Capital Region of Denmark, Rigshospitalet, Copenhagen, Denmark.,Department of Vascular Surgery, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Yousif Subhi
- Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen and the Capital Region of Denmark, Rigshospitalet, Copenhagen, Denmark
| | | | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen and the Capital Region of Denmark, Rigshospitalet, Copenhagen, Denmark
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Tension hydrothorax: Emergency decompression of a pleural cause of cardiac tamponade. Am J Emerg Med 2018; 36:1524.e1-1524.e4. [DOI: 10.1016/j.ajem.2018.04.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 11/21/2022] Open
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Teaching Residents Chest Tubes: Simulation Task Trainer or Cadaver Model? Emerg Med Int 2018; 2018:9179042. [PMID: 30140461 PMCID: PMC6081584 DOI: 10.1155/2018/9179042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/12/2018] [Accepted: 05/30/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To compare simulation task trainers (sim) with cadaver for teaching chest tube insertion to junior residents. Methods Prospective study involving postgraduate year (PGY) one and two emergency medicine (EM) and PGY-1 surgery residents. Residents were randomized into sim or cadaver groups based on prior experience and trained using deliberate practice. Primary outcomes were confidence in placing a chest tube and ability to place a chest tube in a clinical setting during a seven-month follow-up period. Secondary outcomes include skill retention, using an objective assessment checklist of 15 critical steps in chest tube placement, and confidence after seven months. Results Sixteen residents were randomized to cadaver (n=8) and simulation (n=8) groups. Both groups posttraining had statistically significant increase in confidence. No significant difference existed between groups for median posttraining assessment scores (13.5 sim v 15 cadaver). There was no statistically significant difference between groups for confidence at any point measured. There was moderate correlation (0.58) between number of clinical attempts reported in a seven-month follow-up period and final assessment score. Conclusion Both sim and cadaver models are effective modalities for teaching chest tube placement. Medical education programs can use either modalities to train learners without notable differences in confidence.
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MANEJO DE LAS PLEUROSTOMÍAS. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2017.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Pavlović M, Ilić B, Nastasijević - Borovac D, Pavlović S, Ilić D, Stanković M, Milojković M. DRAINAGE OF PLEURAL SPACE BY APICAL APPROACH AS A STEP BEFORE DEFINITIVE SURGICAL RESOLUTION OF SPONTANEOUS PNEUMOTHORAX RECURRENCE: A CASE REPORT. ACTA MEDICA MEDIANAE 2018. [DOI: 10.5633/amm.2018.0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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20
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Brogi E, Gargani L, Bignami E, Barbariol F, Marra A, Forfori F, Vetrugno L. Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:325. [PMID: 29282107 PMCID: PMC5745967 DOI: 10.1186/s13054-017-1897-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022]
Abstract
Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.
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Affiliation(s)
- E Brogi
- Department of Anaesthesia and Intensive Care, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - L Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - E Bignami
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - F Barbariol
- Department of Medicine, University of Udine, Udine, Italy
| | - A Marra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - F Forfori
- Department of Anaesthesia and Intensive Care, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - L Vetrugno
- Department of Medicine, University of Udine, Udine, Italy
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21
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Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis. J Trauma Acute Care Surg 2017; 83:1136-1141. [PMID: 28930941 DOI: 10.1097/ta.0000000000001700] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Thoracic trauma resulting in hemothorax (HTx) is typically managed with thoracostomy tube (TT) placement; however, up to 20% of patients develop retained HTx which may necessitate further intervention for definitive management. Although optimal management of retained HTx has been extensively researched, little is known about prevention of this complication. We hypothesized that thoracic irrigation at the time of TT placement would significantly decrease the rate of retained HTx necessitating secondary intervention. METHODS A prospective, comparative study of patients with traumatic HTx who underwent bedside TT placement was conducted. The control group consisted of patients who underwent standard TT placement, whereas the irrigation group underwent standard TT placement with immediate irrigation using 1 L of warmed sterile 0.9% saline. Patients who underwent emergency thoracotomy, those with TTs removed within 24 hours, or those who died within 30 days of discharge were excluded. The primary end point was secondary intervention defined by additional TT placement or operative management for retained HTx. A propensity-matched analysis was performed with scores estimated using a logistic regression model based on age, sex, mechanism of injury, Abbreviated Injury Scale chest score, and TT size. RESULTS In over a 30-month period, a total of 296 patients underwent TT placement for the management of traumatic HTx. Patients were predominantly male (79.6%) at a median age of 40 years and were evenly split between blunt (48.8%) and penetrating (51.2%) mechanisms. Sixty (20%) patients underwent thoracic irrigation at time of initial TT placement. The secondary intervention rate was significantly lower within the study group (5.6% vs. 21.8%; OR, 0.16; p < 0.001). No significant differences in TT duration, ventilator days, or length of stay were noted between the irrigation and control cohort. CONCLUSION Thoracic irrigation at the time of initial TT placement for traumatic HTx significantly reduced the need for secondary intervention for retained HTx. LEVEL OF EVIDENCE Therapeutic Study, Level III.
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Saun TJ, Odorizzi S, Yeung C, Johnson M, Bandiera G, Dev SP. A Peer-Reviewed Instructional Video is as Effective as a Standard Recorded Didactic Lecture in Medical Trainees Performing Chest Tube Insertion: A Randomized Control Trial. JOURNAL OF SURGICAL EDUCATION 2017; 74:437-442. [PMID: 27979724 DOI: 10.1016/j.jsurg.2016.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/10/2016] [Accepted: 10/31/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Online medical education resources are becoming an increasingly used modality and many studies have demonstrated their efficacy in procedural instruction. This study sought to determine whether a standardized online procedural video is as effective as a standard recorded didactic teaching session for chest tube insertion. DESIGN A randomized control trial was conducted. Participants were taught how to insert a chest tube with either a recorded didactic teaching session, or a New England Journal of Medicine (NEJM) video. Participants filled out a questionnaire before and after performing the procedure on a cadaver, which was filmed and assessed by 2 blinded evaluators using a standardized tool. SETTING Western University, London, Ontario. Level of clinical care: institutional. PARTICIPANTS A total of 30 fourth-year medical students from 2 graduating classes at the Schulich School of Medicine & Dentistry were screened for eligibility. Two students did not complete the study and were excluded. There were 13 students in the NEJM group, and 15 students in the didactic group. RESULTS The NEJM group׳s average score was 45.2% (±9.56) on the prequestionnaire, 67.7% (±12.9) for the procedure, and 60.1% (±7.65) on the postquestionnaire. The didactic group׳s average score was 42.8% (±10.9) on the prequestionnaire, 73.7% (±9.90) for the procedure, and 46.5% (±7.46) on the postquestionnaire. There was no difference between the groups on the prequestionnaire (Δ + 2.4%; 95% CI: -5.16 to 9.99), or the procedure (Δ -6.0%; 95% CI: -14.6 to 2.65). The NEJM group had better scores on the postquestionnaire (Δ + 11.15%; 95% CI: 3.74-18.6). CONCLUSIONS The NEJM video was as effective as video-recorded didactic training for teaching the knowledge and technical skills essential for chest tube insertion. Participants expressed high satisfaction with this modality. It may prove to be a helpful adjunct to standard instruction on the topic.
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Affiliation(s)
- Tomas J Saun
- University of Toronto, Toronto, Ontario, Canada.
| | | | | | - Marjorie Johnson
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Ruparel RK, Laack TA, Brahmbhatt RD, Rowse PG, Aho JM, AlJamal YN, Kim BD, Morris DS, Farley DR, Campbell RL. Securing a Chest Tube Properly: A Simple Framework for Teaching Emergency Medicine Residents and Assessing Their Technical Abilities. J Emerg Med 2017; 53:110-115. [PMID: 28408233 DOI: 10.1016/j.jemermed.2017.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 02/22/2017] [Accepted: 02/25/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Quality-improvement efforts at our institution have identified chest tube dislodgement as a preventable complication of tube thoracostomy. Because proper fixation techniques are not well described in the literature and are seldom formally taught, techniques vary among residents. OBJECTIVE Our aim was to develop and test a framework for teaching and assessing chest tube securement. METHODS A repeated-measures study design was used. At baseline, 19 emergency medicine residents (program years 1-3) placed and secured a chest tube in a cadaver. After a 45-min proficiency-based teaching session using a low-cost chest tube simulator (approximate cost, $5), each resident again placed and secured a chest tube in a cadaver, followed by 3-month retention testing. All securements were evaluated by two raters using a four-point checklist and a five-point global assessment scale (GAS). The checklist addressed suture selection, tying knots down to the tube, wound approximation, and tube displacement relative to skin. RESULTS After the initial educational intervention, median scores for the group improved significantly over baseline for the GAS (p < 0.001), checklist (p < 0.001), and amount of displacement (p = 0.01). At 3 months, GAS, checklist, and displacement scores did not differ significantly from the immediate post-test scores. Inter-rater reliability was substantial, with weighted κ values of .77 for the GAS and .70 for the checklist. CONCLUSIONS Quality of chest tube securement by emergency medicine residents can be significantly improved with an inexpensive chest tube simulator and a brief workshop. The four-point checklist served as a reliable and effective means for teaching and assessing chest tube securement.
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Affiliation(s)
- Raaj K Ruparel
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Torrey A Laack
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Brian D Kim
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - David S Morris
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - David R Farley
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
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Drinhaus H, Annecke T, Hinkelbein J. [Chest decompression in emergency medicine and intensive care]. Anaesthesist 2017; 65:768-775. [PMID: 27629501 DOI: 10.1007/s00101-016-0219-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Decompression of the chest is a life-saving invasive procedure for tension pneumothorax, trauma-associated cardiopulmonary resuscitation or massive haematopneumothorax that every emergency physician or intensivist must master. Particularly in the preclinical setting, indication must be restricted to urgent cases, but in these cases chest decompression must be executed without delay, even in subpar circumstances. The methods available are needle decompression or thoracentesis via mini-thoracotomy with or without insertion of a chest tube in the midclavicular line of the 2nd/3rd intercostal space (Monaldi-position) or in the anterior to mid-axillary line of the 4th/5th intercostal space (Bülau-position). Needle decompression is quick and does not require much material, but should be regarded as a temporary measure. Due to insufficient length of the usual 14-gauge intravenous catheters, the pleural cavity cannot be reached in a considerable percentage of patients. In the case of mini-thoracotomy, one must be cautious not to penetrate the chest inferior of the mammillary level, to employ blunt dissection techniques, to clearly identify the pleural space with a finger and not to use a trocar. In extremely urgent cases opening the pleural membrane by thoracostomy without inserting a chest tube is sufficient in mechanically ventilated patients. Complications are common and mainly include ectopic positions, which can jeopardise effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as haemorrhage or infections. By respecting the basic rules for safe chest decompression many of these complications should be avoidable.
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Affiliation(s)
- H Drinhaus
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland.
| | - T Annecke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland
| | - J Hinkelbein
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland
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Kugler NW, Carver TW, Knechtges P, Milia D, Goodman L, Paul JS. Thoracostomy tube function not trajectory dictates reintervention. J Surg Res 2016; 206:380-385. [PMID: 27884332 DOI: 10.1016/j.jss.2016.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 07/19/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hemothorax and/or pneumothorax can be managed successfully managed with tube thoracostomy (TT) in the majority of cases. Improperly placed tubes are common with rates near 30%. This study aimed to determine whether TT trajectory affects the rate of secondary intervention. METHODS A retrospective review of all adult trauma patients undergoing TT placement over a 4-y period was performed. TT trajectory was classified as ideal, nonideal, or kinked-based on anterior-posterior chest x-ray. TTs with sentinel port outside the thoracic cavity were excluded. The primary outcome was any secondary intervention. RESULTS Four-hundred eighty-six patients and a total of 547 hemithoraces underwent placement and met inclusion criteria. The majority of patients were male (76%), with a median age of 41 y, and majority suffered blunt trauma ideal trajectory was identified in 429 (78.4%). Kinked TTs were noted in 33 (6%) hemothoraces with a 45.5% replacement rate. Review with staff demonstrates inherent bias to replace kinked TTs. The overall secondary intervention rate was 27.8%. Kinked TTs were removed from final analysis due to treatment bias. Subsequent analysis demonstrated no significant difference between ideal and nonideal trajectories (25.1% versus 34.1%, P = 0.09). CONCLUSIONS Intrathoracic trajectory of nonkinked TTs with the sentinel port within the thoracic cavity does not affect secondary intervention rates, including the rate of surgical intervention.
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Affiliation(s)
- Nathan W Kugler
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Thomas W Carver
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul Knechtges
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Milia
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lawrence Goodman
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jasmeet S Paul
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Kugler NW, Carver TW, Paul JS. Thoracic irrigation prevents retained hemothorax: a pilot study. J Surg Res 2016; 202:443-8. [PMID: 27038661 DOI: 10.1016/j.jss.2016.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/19/2016] [Accepted: 02/26/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Upward of 20% of patients undergoing thoracostomy tube (TT) placement develop retained hemothorax (HTx) requiring secondary intervention. The aim of this study was to define the rate of secondary intervention in patients undergoing prophylactic thoracic irrigation. METHODS A prospective observational trial of 20 patients who underwent thoracic irrigation at the time of TT placement was conducted. Patients with HTx identified on chest x-ray were included. After standard placement of a 36-French TT, the HTx was evacuated using a sterile suction catheter advanced within the TT. Warmed sterile saline was instilled into the chest through the TT followed by suction catheter evacuation. The TT was connected to the sterile drainage atrium and suction applied. TTs were managed in accordance with our standard division protocol. RESULTS The population was predominantly (70%) male at median age 35 years, median ISS 13, with 55% suffering penetrating trauma. Thirteen (65%) patients underwent TT placement within 6 h of trauma with the remainder within 24 h. Nineteen patients received the full 1000-mL irrigation. The majority demonstrated significant improvement on postprocedure chest x-ray. The secondary intervention rate was 5%. A single patient required VATS on post-trauma day zero for retained HTx. Median TT duration was 5 d with median length of stay of 7 d. No adverse events related to the pleural lavage were noted. CONCLUSIONS Thoracic irrigation at the time of TT placement for traumatic HTx may decrease the rate of retained HTx.
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Affiliation(s)
- Nathan W Kugler
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Thomas W Carver
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jasmeet S Paul
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Katballe N, Moeller LB, Olesen WH, Litzer MM, Andersen G, Nekrasas V, Licht PB, Bach P, Pilegaard HK. A Novel Device for Accurate Chest Tube Insertion: A Randomized Controlled Trial. Ann Thorac Surg 2015; 101:527-32. [PMID: 26409714 DOI: 10.1016/j.athoracsur.2015.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/03/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Optimal positioning of a large-bore chest tube is in the part of the pleural cavity that needs drainage. It is recommended that the chest tube be positioned apically in pneumothorax and basally for fluids. However, targeted chest tube positioning to a specific part of the pleural cavity can be a challenge. METHODS A new medical device, the KatGuide, was developed for accurate guiding of a chest tube (28F) to an intended part of the pleural cavity. The primary end point of this randomized, controlled trial was optimal position of the chest tube. The optimal position in pneumothorax was apical (above the aortic arch), and the optimal position in hemothorax, hydrothorax, chylothorax, or empyema was basal (2 cm above the diaphragm or lower). The patients were randomized for the KatGuide method or the conventional forceps method, and rates of optimal position were compared. RESULTS A total of 109 patients were enrolled (KatGuide: n = 49; conventional: n = 60). Chest tubes were optimally position in 41 (84%) in the KatGuide group vs 32 (53%) in the conventional group (p = 0.001). Experienced operators (>50 previous chest tube insertions) inserted 39 of the chest tubes, of which, 15 of 17 (88%) were optimally positioned in the KatGuide group vs 11 of 22 (50%) in the conventional group (p = 0.02). Two chest tubes (4%) were misplaced in the KatGuide group vs 11 (18%) in the conventional group (p = 0.04). No adverse device effects were observed. CONCLUSIONS The KatGuide significantly improves the probability of optimal chest tube position and reduces the risk of misplacement compared with the conventional method. ClinicalTrial.gov Trial Registration Number: NCT01522885.
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Affiliation(s)
- Niels Katballe
- Department of Cardiothoracic and Vascular Surgery and Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Lars B Moeller
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Winnie H Olesen
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Marina M Litzer
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Gratien Andersen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Vytautas Nekrasas
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Peter B Licht
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Peter Bach
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Hans K Pilegaard
- Department of Cardiothoracic and Vascular Surgery and Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Yıldırım B, Basaran O, Alatas OD, Yeniceri EN, Alatas OD, Yeniceri EN, Altun I, Tanriverdi O, Dogan V, Acar E, Biteker M. Chest tube insertion techniques on YouTube: is social media a reliable source of learning medical skills? Am J Emerg Med 2015; 33:1709-10. [PMID: 26386736 DOI: 10.1016/j.ajem.2015.08.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/21/2015] [Accepted: 08/24/2015] [Indexed: 02/08/2023] Open
Affiliation(s)
- Birdal Yıldırım
- Department of Emergency Medicine, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey.
| | - Ozcan Basaran
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Omer Dogan Alatas
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Emine Nese Yeniceri
- Department of Family Medicine, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Omer Dogan Alatas
- Department of Emergency Medicine, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Emine Nese Yeniceri
- Department of Family Medicine, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Ibrahim Altun
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Ozgur Tanriverdi
- Department of Medical Oncology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Volkan Dogan
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Ethem Acar
- Department of Emergency Medicine, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Murat Biteker
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
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Developing risk factors for post traumatic empyema in patients with chest trauma. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/s2221-6189(14)60082-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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The role of early postmortem CT in the evaluation of support-line misplacement in patients with severe trauma. AJR Am J Roentgenol 2015; 204:3-7. [PMID: 25539229 DOI: 10.2214/ajr.14.12796] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to retrospectively assess the role of early postmortem CT in evaluating support-line misplacement to improve future treatment in the trauma setting. MATERIALS AND METHODS We included all postmortem CT examinations that were performed for trauma patients within the 1st hour after declaration of death in our tertiary medical center between August 1, 2008, and August 31, 2013. Correct placement of the following support lines was evaluated: endotracheal tubes (ETTs), chest drains, central venous catheters (CVCs), and nasogastric tubes (NGTs). Prehospital resuscitation efforts were started in all cases. RESULTS Early postmortem CT was performed on average 22 minutes after declaration of death in 25 consecutive patients with severe trauma. Overall, 14 subjects (56%) had suboptimal or misplaced support lines. Of ETTs inserted into 18 trauma victims; three (17%) were mislaid in the right main bronchus and five (28%) were near or at the level of the carina. Of chest drains inserted into 13 subjects, 10 were suboptimally positioned (77%). Of CVCs inserted into eight subjects (seven femoral and one brachiocephalic), one femoral CVC (13%) was malpositioned in the soft tissues of the pelvis. Of NGTs inserted in five trauma victims, one was folded within the pharynx. CONCLUSION Early postmortem CT for patients who have experienced severe poly-trauma can be of important educational value to radiologists and the trauma teams, providing immediate feedback regarding the location of the support lines and possibly contributing to improved training and command of the learning curve by medical staff.
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Kuhajda I, Zarogoulidis K, Kougioumtzi I, Huang H, Li Q, Dryllis G, Kioumis I, Pitsiou G, Machairiotis N, Katsikogiannis N, Papaiwannou A, Lampaki S, Papaiwannou A, Zaric B, Branislav P, Porpodis K, Zarogoulidis P. Tube thoracostomy; chest tube implantation and follow up. J Thorac Dis 2014; 6:S470-9. [PMID: 25337405 DOI: 10.3978/j.issn.2072-1439.2014.09.23] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 09/01/2014] [Indexed: 01/12/2023]
Abstract
Pneumothorax is an urgent medical situation that requires urgent treatment. We can divide this entity based on the etiology to primary and secondary. Chest tube implantation can be performed either in the upper chest wall or lower. Both thoracic surgeons and pulmonary physicians can place a chest tube with minimal invasive techniques. In our current work, we will demonstrate chest tube implantation to locations, methodology and tools.
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Affiliation(s)
- Ivan Kuhajda
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Konstantinos Zarogoulidis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Ioanna Kougioumtzi
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Haidong Huang
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Qiang Li
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Georgios Dryllis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Ioannis Kioumis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Georgia Pitsiou
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Nikolaos Machairiotis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Nikolaos Katsikogiannis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Antonis Papaiwannou
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Sofia Lampaki
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Antonis Papaiwannou
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Bojan Zaric
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Perin Branislav
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Konstantinos Porpodis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Paul Zarogoulidis
- 1 Thoracic Surgery Department, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 3 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200433, China ; 5 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 6 Obstetric - Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 7 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
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Kwiatt M, Tarbox A, Seamon MJ, Swaroop M, Cipolla J, Allen C, Hallenbeck S, Davido HT, Lindsey DE, Doraiswamy VA, Galwankar S, Tulman D, Latchana N, Papadimos TJ, Cook CH, Stawicki SP. Thoracostomy tubes: A comprehensive review of complications and related topics. Int J Crit Illn Inj Sci 2014; 4:143-55. [PMID: 25024942 PMCID: PMC4093965 DOI: 10.4103/2229-5151.134182] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Tube thoracostomy (TT) placement belongs among the most commonly performed procedures. Despite many benefits of TT drainage, potential for significant morbidity and mortality exists. Abdominal or thoracic injury, fistula formation and vascular trauma are among the most serious, but more common complications such as recurrent pneumothorax, insertion site infection and nonfunctioning or malpositioned TT also represent a significant source of morbidity and treatment cost. Awareness of potential complications and familiarity with associated preventive, diagnostic and treatment strategies are fundamental to satisfactory patient outcomes. This review focuses on chest tube complications and related topics, with emphasis on prevention and problem-oriented approaches to diagnosis and treatment. The authors hope that this manuscript will serve as a valuable foundation for those who wish to become adept at the management of chest tubes.
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Affiliation(s)
- Michael Kwiatt
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Abigail Tarbox
- Department of Surgery, Northwestern University School of Medicine, Chicago, IL, USA
| | | | - Mamta Swaroop
- Department of Surgery, Northwestern University School of Medicine, Chicago, IL, USA ; OPUS 12 Foundation Global, Inc, USA
| | - James Cipolla
- Department of Surgery, Temple St Luke's Medical School, Bethlehem, PA, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Charles Allen
- Department of Surgery, Temple St Luke's Medical School, Bethlehem, PA, USA
| | | | - H Tracy Davido
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David E Lindsey
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Vijay A Doraiswamy
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Sagar Galwankar
- Department of Emergency Medicine, Winter Haven Hospital, University of Florida, Florida, USA ; OPUS 12 Foundation Global, Inc, USA
| | - David Tulman
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Nicholas Latchana
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Thomas J Papadimos
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Charles H Cook
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Stanislaw P Stawicki
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA ; OPUS 12 Foundation Global, Inc, USA
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Utter GH. The rate of pleural fluid drainage as a criterion for the timing of chest tube removal: theoretical and practical considerations. Ann Thorac Surg 2013; 96:2262-7. [PMID: 24209425 DOI: 10.1016/j.athoracsur.2013.07.055] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/11/2013] [Accepted: 07/16/2013] [Indexed: 11/20/2022]
Abstract
Clinicians place chest tubes approximately 1 million times each year in the United States, but little information is available to guide their management. Specifically, use of the rate of pleural fluid drainage as a criterion for tube removal is not standardized. Absent such tubes, pleural fluid drains primarily through parietal pleural lymphatics at rates approaching 500 mL of fluid per day or more for each hemithorax. Early removal of tubes does not appear to be harmful. A noninferiority randomized trial currently in progress comparing removal without considering the drainage rate to a conservative threshold (2 mL/kg body weight in 24 hours) may better inform tube management.
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Affiliation(s)
- Garth H Utter
- Department of Surgery, University of California, Davis, Medical Center, Sacramento, California.
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Rao PB, Natarajan P, Singh N, Trichur Ramaswamy R. Tube thoracostomy in prone position during spine surgery. ACTA ACUST UNITED AC 2013; 51:50. [PMID: 23711609 DOI: 10.1016/j.aat.2013.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hogg JR, Caccavale M, Gillen B, McKenzie G, Vlaminck J, Fleming CJ, Stockland A, Friese JL. Tube thoracostomy: a review for the interventional radiologist. Semin Intervent Radiol 2012; 28:39-47. [PMID: 22379275 DOI: 10.1055/s-0031-1273939] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Small-caliber tube thoracostomy is a valuable treatment for various pathologic conditions of the pleural space. Smaller caliber tubes placed under image guidance are becoming increasingly useful in numerous situations, are less painful than larger surgical tubes, and provide more accurate positioning when compared with tubes placed without image guidance. Basic anatomy and physiology of the pleural space, indications, and contraindications of small caliber tube thoracostomy, techniques for image-guided placement, complications and management of tube thoracostomy, and fundamental principles of pleurodesis are discussed in this review.
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Abstract
Pleural effusion is an accumulation of fluid in the pleural space that is classified as transudate or exudate according to its composition and underlying pathophysiology. Empyema is defined by purulent fluid collection in the pleural space, which is most commonly caused by pneumonia. A lung abscess, on the other hand, is a parenchymal necrosis with confined cavitation that results from a pulmonary infection. Pleural effusion, empyema, and lung abscess are commonly encountered clinical problems that increase mortality. These conditions have traditionally been managed by antibiotics or surgical placement of a large drainage tube. However, as the efficacy of minimally invasive interventional procedures has been well established, image-guided small percutaneous drainage tubes have been considered as the mainstay of treatment for patients with pleural fluid collections or a lung abscess. In this article, the technical aspects of image-guided interventions, indications, expected benefits, and complications are discussed and the published literature is reviewed.
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Affiliation(s)
- Hyeon Yu
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Chest radiography in the ICU: Part 1, Evaluation of airway, enteric, and pleural tubes. AJR Am J Roentgenol 2012; 198:563-71. [PMID: 22357994 DOI: 10.2214/ajr.10.7226] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE In this pictorial essay, we discuss and illustrate normal and aberrant positioning of nonvascular support and monitoring devices frequently used in critically ill patients, including endotracheal and tracheostomy tubes, chest tubes, and nasogastric and nasoenteric tubes, as well as their inherent complications. CONCLUSION The radiographic evaluation of the support and monitoring devices used in patients in the ICU is important because the potentially serious complications arising from their introduction and use are often not clinically apparent. Familiarity with normal and abnormal radiographic findings is critical for the detection of these complications.
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Allardet-Servent J, Papazian L. Investigation of pleural discharge/fluid. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00206-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Schley M, Rössler M, Konrad CJ, Schüpfer G. [Damage of the subclavian vein with a thorax drainage]. Anaesthesist 2009; 58:387-90. [PMID: 19189063 DOI: 10.1007/s00101-009-1507-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The necessity for insertion of a thorax drainage can lead to serious complications. Especially the use of a trocar instead of a mini-thoracotomy has a notable risk of misplacement or complications. Chest tubes per se can perforate the parietal pleura resulting in an extrathoracic position of the tube and contraindications for chest tubes should always be considered. Accidental lacerations of blood vessels should be avoided by a correct technique and a clear indication. A chest X-ray in one plane is not sufficient to prove correct positioning of a chest tube and suspected misplacement of a chest tube has to be assessed radiographically in at least two planes. A case of a fatal complication of a misplaced chest tube causing a laceration of the right subclavian vein is described.
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Affiliation(s)
- M Schley
- Institut für Anästhesie, Chirurgische Intensivmedizin, Rettungsmedizin und Schmerztherapie, Kantonsspital Luzern, 6000 Luzern 16, Schweiz
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Pearce AP. Chest drain insertion: Improving techniques and decreasing complications. Emerg Med Australas 2009; 21:91-3. [DOI: 10.1111/j.1742-6723.2009.01170.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fowler RA, Adhikari NKJ, Scales DC, Lee WL, Rubenfeld GD. Update in critical care 2007. Am J Respir Crit Care Med 2008; 177:808-19. [PMID: 18390962 DOI: 10.1164/rccm.200801-137up] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada .
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Pinheiro JMB. Chest-tube insertion. N Engl J Med 2008; 358:749; author reply 750. [PMID: 18272903 DOI: 10.1056/nejmc073146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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