I posted a review a few weeks ago of an article I found in ANZ Journal of Surgery - here is another one! More critique of our Emergency department practice by our trauma colleagues.
Introduction: Intercostal catheters (ICC) are the standard management of chest trauma, but are associated with complications in up to 30%. The aim of this study was to evaluate errors in technique during ICC insertion to characterise the potential benefit of improved training programmes.
Methods: Prospective audit of all ICC in trauma patients at a level 1 trauma centre for over 12 months. Exclusions were pigtail catheters and ICC inserted during thoracic surgery. Errors were identified from patient examination and chest imaging; they were defined as insertional, positional, incorrect size (<28 French) and lack of antibiotic prophylaxis. Ongoing complications unrelated to an error in technique, for example blocked tube, were not analysed.
Results: Fifty-seven patients received a total of 94 ICC during the study period. Patients were predominantly male (77%), mean age of 40 ± 20 years, mean injury severity score 27 ± 13, mean abbreviated injury scale chest 3.8 ± 0.72. 86% were blunt trauma and 14% penetrating chest injuries. Thirty-six errors in technique occurred in 33 ICC insertions (38%). The most common errors were absence of prophylactic antibiotics (13%), ICC too far out (9%), kinked (6%) and wrong-sized ICC (5%). Emergency had a significantly greater frequency of errors than other specialties (67%, relative risk 2.11, P= 0.002). The majority of ICC were inserted by registrars, and registrars made a greater number of errors than fellows or consultants (relative risk 2.00, P= 0.02).
Discussion: This study identified a large number of preventable errors for ICC insertion in trauma patients. Standardised institutional credentialing systems may be required to ensure adequate proficiency of trainees performing this procedure.
Insertional errors were defined as ICC too far out, kinked, inadequate fixation, insertion through previous ICC hole.
Positional errors were defined as extrathoracic placement (obviously wrong) or in the wrong intercostal space. No mention of the safe triangle for ICC placement is made, which makes it hard to interpret if this is a useful statistic.
Incorrect size was stated to be size less than 28 Fr (noting pigtails were excluded).
Lack of antibiotic prophylaxis was the final error type.
There are many assumptions that this study bases it's conclusions on, and, to be honest I think they invalidate most of the findings. The nature of the assessment of ICC insertion is too simplistic- a more detailed analysis could have been made from a prospective study. For example - the most common error noted - antibiotic prophylaxis for ICC insertion in trauma has not been well elucidated in the literature, however meta analyses seem to show benefit. Correct sterile technique has not been noted as an error although evidence shows it reduces the infection rate.
Furthermore, evidence is becoming available to show that trauma dogma such as ICC size is becoming more untenable - particularly in stable small size traumatic pneumothorax which would normally score an ICC. I have not started doing it myself but an informed decision to use a small size tube (or pigtail) may not necessarily be 'wrong'. According to the British Thoracic Society - 28Fr + is indicated for hemothorax only.
There a number of demographic issues in this study - 24% of ICC done in theatre - possibly intraoperatively, which is a very different prospect from a procedure in ED.
My biggest problem with this study is there is no mention of actual complications- only 'errors' which were observed, with no clinical correlation (or relevance?). This may be me missing the point of the study, as the authors do state that they did not seek to note complications. I can't help but agree with their comment that direct observation would have been more likely to increase the pick up rate of error - breaches in sterile technique may have more relevance than antibiotic use! That said, the decreasing rate of error with increasing experience shows plausibility in the hypothesis.
Emergency doctors of all levels of experience had more errors - I think we could all benefit from some standardised training in the emergency training curriculum.......... Before another specialty forces it upon us!