C. W. Jones1, R. L. Griffin2, G. McGwin2, J. Jansen1, J. D. Kerby1, P. L. Bosarge1 1University Of Alabama at Birmingham,Department Of Surgery, Division Of Acute Care Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Epidemiology,Birmingham, Alabama, USA
INTRODUCTION Thoracic injury accounts for 25% of all trauma deaths. While tube thoracostomy can be lifesaving it is also a source of preventable morbidity. Malpositioned chest tubes, the most commonly reported complication, lead to retained hemothorax or pneumothorax, and can result in the need for subsequent procedures including placement of a second chest tube or more invasive surgical procedures to access the pleural space. The goal of this study was to compare complications of chest tube placement among trauma patients whose chest tubes were placed at outside institutions prior to patient transfer with those placed at the trauma center.
METHODS Trauma patients directly admitted to an academic, Level-I trauma center between 2004 and 2013 who underwent chest tube placement prior to arrival at the trauma center were matched to patients admitted to the same trauma center who had a chest tube first placed at that center. Patients were matched on year of admission, age±5 years, injury mechanism, and Injury Severity Score ± 5. Medical record review was conducted to collect data on complications including empyema, residual hemothorax, residual pneumothorax, malposition, placement of a second chest tube, and use of VATS. The trauma registry was used to collect information on clinical outcomes (i.e., thoracotomy, pneumonia, death after 24 hours, hospital length of stay, days in the ICU, days on ventilator support). A paired t-test compared continuous outcomes, and a conditional logistic regression compared the likelihood of complications and death between groups.
RESULTS From 2004-2013, a total of 4216 patients had a chest tube first placed in trauma center, and 364 patients had a chest tube placed outside of the trauma center. At the time of this abstract, chart abstraction was completed on 151 of these 364 patients, all of whom matched to a patient with a chest tube placed at the trauma center. Patients with a chest tube placed outside of the trauma center had shorter hospital length of stay (17.3 vs 22.1 days, p=0.0339) and days on ventilator support (13.1 vs 17.6, p=0.0406). These patients, though, had increased likelihood of malposition (OR 5.26, 95% CI 2.86-10.00), residual hemothorax (OR 5.88, 95% CI 3.03-11.11), residual pneumothorax (OR 6.67, 95% CI 3.57-12.50), as well as having a second chest tube placed (OR 3.45, 95% CI 2.08-5.56). However, patients with a chest tube placed outside of the trauma center were 67% less likely to get pneumonia (OR 0.33, 95% CI 0.13-0.84). There was no difference in empyema, need for VATS, thoracotomy, or death.
CONCLUSIONS These early data suggest an increased complication rate for patients transferred from another facility; however, the reason for this increase is not yet definitive. Future research is needed to examine the reason for the observed increase, whether it be related to training of the personnel at non-trauma institutions or characteristics related to the patient or their injury.