title: An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa.
abstract: BACKGROUND
  Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity.
  
  
  METHODS
  This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013.
  
  
  RESULTS
  A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20-29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the 'triangle of safety' but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. </sec> Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation.
authors.affiliation: Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, South Africa.
authors.forename: V Y
authors.initials: VY
authors.lastname: Kong
authors.forename: G V
authors.initials: GV
authors.lastname: Oosthuizen
authors.forename: B
authors.initials: B
authors.lastname: Sartorius
authors.forename: C
authors.initials: C
authors.lastname: Keene
authors.forename: D L
authors.initials: DL
authors.lastname: Clarke
mesh_terms: D000328:Adult; D015505:Chest Tubes / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008485:Medical Audit; D011030:Pneumothorax / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D013019:South Africa / Q000453:epidemiology; D013907:Thoracostomy / Q000009:adverse effects* / Q000295:instrumentation*; D014193:Trauma Centers / Q000706:statistics & numerical data; D014950:Wounds, Penetrating / Q000453:epidemiology / Q000601:surgery; D055815:Young Adult