Ball Chad G, Lord Jason, Laupland Kevin B, Gmora Scott, Mulloy Robert H, Ng Alex K, Schieman Colin, Kirkpatrick Andrew W
Department of Surgery, Foothills Medical Centre, Calgary, AB, Canada.
Can J Surg. 2007 Dec;50(6):450-8.
Thoracic trauma is commonly treated with tube thoracostomy. The overall complication rate associated with this procedure is up to 30% among all operators. The primary purpose of this study was to define the incidence and risk factors for complications in chest tubes placed exclusively by resident physicians. The secondary objective was to outline the rate of complications occult to postinsertional supine anteroposterior (AP) chest radiographs (CXRs).
Over a 12-month period at a regional trauma centre, we retrospectively reviewed all severely injured trauma patients (injury severity score >or= 12) who underwent tube thoracostomy (338/761 patients). Insertional, positional and infective complications were identified. Patients were assessed for complications on the basis of resident operator characteristics, patient demographics, associated injuries and outcomes. Thoracoabdominal CT scans and corresponding CXRs were also used to determine the rate of complications occult to postinsertional supine AP CXR.
Of the patients, 338 (44%) had CXR and CT imaging. Out of 76 (22%) chest tubes placed by residents in 61 (18%) patients (99% of whom had blunt trauma injuries), there were 17 complications; 6 (35%) were insertional; 9 (53%) were positional and 2 (12%) were infective. Tube placement outside the trauma bay (p = 0.04) and nonsurgical resident operators (p = 0.03) were independently predictive of complications. The rates of complications according to training discipline were as follows: 7% general surgery, 13% internal and family medicine, 25% other surgical disciplines and 40% emergency medicine. Resident seniority, time of day and other factors were not predictive. Six of 11 (55%) positional and intraparenchymal lung tube placements were occult to postinsertional supine AP CXR.
Chest tubes placed by resident physicians are commonly associated with complications that are not identified by postinsertional AP CXR. Thoracic CT is the only way to reliably identify this morbidity. The differential rate of complications according to resident specialty suggests that residents in non-general surgical training programs may benefit from more structured instruction and closer supervision in tube thoracostomy.
胸外伤通常采用胸腔闭式引流术治疗。在所有实施该手术的医生中，与此手术相关的总体并发症发生率高达30%。本研究的主要目的是确定仅由住院医师放置胸管时并发症的发生率及危险因素。次要目标是概述插入后仰卧前后位胸部X线片（CXR）未显示的并发症发生率。
在一家地区创伤中心为期12个月的时间里，我们回顾性分析了所有接受胸腔闭式引流术的严重创伤患者（损伤严重度评分≥12）（338/761例患者）。确定了插入、位置和感染性并发症。根据住院医师操作者特征、患者人口统计学、相关损伤和结局对患者进行并发症评估。还使用胸腹CT扫描和相应的CXR来确定插入后仰卧前后位CXR未显示的并发症发生率。
338例（44%）患者进行了CXR和CT成像。在61例（18%）患者（其中99%为钝性创伤）中，住院医师放置了76根（22%）胸管，发生了17例并发症；6例（35%）为插入性并发症；9例（53%）为位置性并发症，2例（12%）为感染性并发症。在创伤室外放置胸管（p = 0.04）和非外科住院医师操作者（p = 0.03）是并发症的独立预测因素。根据培训专业，并发症发生率如下：普通外科7%，内科和家庭医学13%，其他外科学科25%，急诊医学40%。住院医师年资、一天中的时间和其他因素无预测作用。11例位置性和实质内肺胸管放置中有6例（55%）插入后仰卧前后位CXR未显示。
住院医师放置的胸管通常会出现插入后前后位CXR未发现的并发症。胸部CT是可靠识别这种发病率的唯一方法。根据住院医师专业不同的并发症发生率差异表明，非普通外科培训项目的住院医师可能会从胸腔闭式引流术更结构化的指导和更密切的监督中受益。
