J. A. Marks1, G. Telford1, J. McMaster1, N. D. Martin1, P. Kim1 1University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA
Introduction:
Recurrent pneumothorax after chest tube removal is a potential complication in trauma patients. One potential mitigating maneuver is placement of a U-stitch at the skin incision during initial tube placement that is tied down during tube removal. In this study, we evaluate this performance improvement initiative and its efficacy.
Methods:
At our urban, level one trauma center, we implemented a Clinical Management Guideline (CMG) mandating U-stitch placement with all chest tubes in January 2012. The CMG further dictates that the procedure is performed by two providers. One provider secures the skin suture, and the second provider maintains an occlusive dressing with Vaseline and dry gauze. The tube is removed at end inspiration, or while patient performs Valsalva maneuver. A chest x ray is performed 4-6 hours after tube thoracostomy is removed. Data was collected from our prospectively entered performance improvement database comparing pre and post CMG implementation.
Results:
During the year preceding CMG implementation there were 9 recurrent pneumothoraces requiring reinsertion of a chest tube out of a total of 172 chest tube placements (5.2% recurrence rate). In the two years after the CMG was instituted, recurrences were reduced to 1 out of 177 (0.6%) and 1 out of 139 (0.7%), respectively (p<0.002) (FIGURE).
Conclusion:
Recurrent pneumothorax after chest tube removal is a significant complication. Placement of a U-stitch as part of a CMG can significantly reduce this complication. This CMG should be considered broadly for all traumatic chest tube removals.
