Morbidity of percutaneous tube thoracostomy in trauma patients

Abstract

Objectives: This prospective study was designed to evaluate the complications of percutaneous tube thoracostomy (PTT) performed for chest trauma in our institution and to determine predictive factors.

Methods: One hundred and thirty-four primary PTTs were performed in 128 patients for blunt (83) and penetrating (45) chest traumas. Failure was defined as undrained hemothorax or pneumothorax, post-tube removal complications and empyema. Univariate and multivariate hazard analyses were used to assess the association between potential risk factors and complications.

Results: The overall complication rate was 25% including 30 (23%) failures and nine (7%) improper placement with iatrogenic injuries to the lung (n = 4) or subclavian vein (n = 1). Complications were managed with 18 repeat PTTs and ten early thoracotomies for clotted hemothorax (two), persistent air leak (two), fluid collection (three) or a combination (three) at a mean delay of 6.5 +/- 2.4 days. Failure of additional PTT required late decortication for empyema (three) or decortication (three) at a mean delay of 23 +/- 7 days. One patient died postoperatively, the only death directly related to PTT failure among the four (3.1%) deaths that occurred in this study. Hospital length of stay was significantly increased in patients with PTT failure (24 +/- 19 vs. 15 +/- 8 days in uncomplicated PTT, P = 0.004). By univariate analysis, polytraumatism (relative risk (RR) 2.7, P < 0.05), the need for assisted ventilation (RR 2.7, P = 0.003) and tube insertion by emergency physicians (RR 8.7, P < 0.0001) were significantly associated with increased incidence of complications in blunt trauma. Multivariate analysis identified the performance of the procedure by operators other than thoracic surgeons and residents trained in thoracic surgery as the only independent risk factor in both blunt and penetrating trauma (RR 58 and 71, respectively, P < 0.00001).

Conclusions: PTT is associated with significant morbidity and extended hospitalizations, partly related to inappropriate training of all individuals dealing with trauma care. Additional training should be recommended and some conventional indications for PTT should be revised. A prospective study is currently in progress to evaluate the benefit of early videothoracoscopy in trauma and failure of primary PTT.