Pediatric Normokinetic Biliary Dyskinesia: Pain with Cholecystokinin on Hepatobiliary Iminodiacetic Acid Scan Predictive of Symptom Resolution After Cholecystectomy.

Introduction: Biliary dyskinesia is typically defined as a gallbladder ejection fraction (EF) <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA) testing. Cholecystectomy often leads to resolution of associated biliary colic symptoms. Alternatively, there is a subset of symptomatic patients with normal gallbladder EF on CCK-HIDA. It has been proposed that pain with CCK injection is more predictive of symptom resolution after cholecystectomy than low gallbladder EF. We reviewed our experience with pediatric patients with positive CCK provocation testing and a normal gallbladder EF in the absence of gallstones. Materials and Methods: We retrospectively reviewed the records of all pediatric patients with normal hepatobiliary iminodiacetic acid EFs (35%-80%) and pain with CCK injection at a tertiary care center between 2016 and 2020. Age, gender, body mass index (BMI), CCK-HIDA results, and pathology analysis were noted. Short- and long-term resolution of symptoms was determined by patient self-reporting at a mean of 3 weeks and 46 months, respectively. Results: Seventeen patients met inclusion criteria. Average age was 15.1 years (range, 12-17 years) with median BMI 24.9 (± 4.9 kg/m2). Mean CCK-HIDA EF was 56.3% (± 11.4%). In total, 62.5% of patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology analysis. Of patients available for short-term and long-term postoperative follow-up, 80% and 83% reported complete or near complete resolution of symptoms, respectively. Conclusions: Normokinetic biliary dyskinesia is poorly understood but appears to be associated with chronic inflammation and cured by surgical intervention. Laparoscopic cholecystectomy results in resolution of symptoms for a majority of patients and should be considered in those with pain with CCK injection despite normal imaging studies. Clinical Trial Registration Number: 1657640-2.

Biliary hyperkinesia in adolescents-it isn't all hype!

BACKGROUND: Biliary dyskinesia generally refers to a hypofunctioning gallbladder with an ejection fraction (EF) of <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA testing). In adults, biliary hyperkinesia has a defined association with biliary colic symptoms and can be relieved with surgical intervention. This clinical entity has not been well described in children or adolescents. In fact, only recently have we seen biliary hyperkinesia on HIDA at our centers. To that end, we reviewed our recent experience with adolescents who have presented and been treated for this unusual clinical entity. METHODS: With IRB approval, we retrospectively reviewed the records of all patients with abnormally high HIDA EFs (>80%) cared for by the pediatric surgery services at two tertiary care centers over the span of a three-year period. Age, sex, BMI, CCK-HIDA results, and preoperative testing and post-operative pathology were noted. Resolution of symptoms was determined by subjective patient self-reporting at postoperative visit. RESULTS: Eighteen patients met inclusion criteria. Average age 15.7 (range, 10-17 years), median BMI 27.3 (±8.2). Fifteen patients were female and 3 were male. Average CCK-HIDA EF was 91.6% (±5.2), 82.4% of the patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology. Postoperatively, 82.4% of the patients available for follow up (n=17) reported complete or near complete resolution of symptoms. CONCLUSIONS: Biliary hyperkinesia is an emerging clinical entity in children and adolescents and has a similar presentation to biliary hypokinesia. While the pathophysiologic mechanism of pain is not fully elucidated, laparoscopic cholecystectomy appears to provide a surgical cure for these patients and should be considered in the differential for the patient with an unremarkable workup and history suggestive of biliary colic.

Potentially preventable prehospital deaths from motor vehicle collisions.

BACKGROUND: In 2011, about 30,000 people died in motor vehicle collisions (MVCs) in the United States. We sought to evaluate the causes of prehospital deaths related to MVCs and to assess whether these deaths were potentially preventable. METHODS: Miami-Dade Medical Examiner records for 2011 were reviewed for all prehospital deaths of occupants of 4-wheeled motor vehicle collisions. Injuries were categorized by affected organ and anatomic location of the body. Cases were reviewed by a panel of 2 trauma surgeons to determine cause of death and whether the death was potentially preventable. Time to death and hospital arrival times were determined using the Fatality Analysis Reporting System (FARS) data from 2002 to 2012, which allowed comparison of our local data to national prevalence estimates. RESULTS: Local data revealed that 39% of the 98 deaths reviewed were potentially preventable (PPD). Significantly more patients with PPD had neurotrauma as a cause of death compared to those with a nonpreventable death (NPD) (44.7% vs. 25.0%, P =.049). NPDs were significantly more likely to have combined neurotrauma and hemorrhage as cause of death compared to PPDs (45.0% vs. 10.5%, P <.001). NPDs were significantly more likely to have injuries to the chest, pelvis, or spine. NPDs also had significantly more injuries to the following organ systems: lung, cardiac, and vascular chest (all P <.05). In the nationally representative FARS data from 2002 to 2012, 30% of deaths occurred on scene and another 32% occurred within 1 h of injury. When comparing the 2011 FARS data for Miami-Dade to the remainder of the United States in that year, percentage of deaths when reported on scene (25 vs. 23%, respectively) and within 1 h of injury (35 vs. 32%, respectively) were similar. CONCLUSIONS: Nationally, FARS data demonstrated that two thirds of all MVC deaths occurred within 1 h of injury. Over a third of prehospital MVC deaths were potentially preventable in our local sample. By examining injury patterns in PPDs, targeted intervention may be initiated.

Heterotopic gastric mucosa mimicking a Meckel's diverticulum in a young girl.

Heterotopic gastric mucosa (HGM) is a rare, but acknowledged source of gastrointestinal pathology in pediatric patients. Sometimes clinically confused with a Meckel's diverticulum, HGM diagnosis is often made postoperatively by pathology. We present a case of jejunal HGM with a positive technetium pertechnetate scan in the right lower quadrant that resembled a Meckel's diverticulum.

Are burn patients really at risk for thrombotic events?

There continues to be debate about the routine use of deep vein thrombosis (DVT) prophylaxis in burn patients. The concern is that routine prophylaxis may lead to adverse events. The debate hinges on the incidence of DVT and its relation to the risk-benefit ratio. This study seeks to estimate the true rate of DVT in burn patients, and to evaluate possible risk factors to its development. The Nationwide Inpatient Sample was queried for all patients with age ≥18 years with ICD-9 codes for burn injuries. Demographic data, comorbidities, burn data, length of stay, total charges, procedures, presence of central venous catheter, and mortality were recorded. Patients were classified based on the presence of DVT. Student's t-test, χ test, and logistic regression were performed. 36,638 burn patients were identified. DVT rate was 0.8%. Patients with DVT were older, had longer hospitalizations, more procedures, and higher charges. On logistic regression, black race, TBSA ≥20%, history of previous venous thrombotic events, blood transfusion, and mechanical ventilation were the significant factors associated with DVT. Patients with DVT were almost twice as likely to die during the admission (P = .011). This is the largest series to date examining the risk factors for DVT in burn patients. DVT developed in approximately 0.8% of burn patients. Black race, TBSA ≥20%, blood transfusions, and mechanical ventilation were associated with approximately 2-fold odds of developing DVT. Identification of these additional risk factors may allow targeted patient prophylaxis. Additionally, patients with DVT incurred higher total charges and longer hospitalization.

Novel technique for avoidance of pressure competition between a negative pressure wound therapy device and chest drains in the management of deep sternal wound infections.

In recent years, the use of negative pressure wound therapy (NPWT) devices has changed the way sternal wound infections are being managed. It is not uncommon for deep sternal wound infections to occur together with mediastinal or even pleural collections requiring underwater seal drainage. In these patients in whom there is a communication between the pleural and mediastinal cavities, the concomitant use of an NPWT device negates the pressure gradient within the pleural and mediastinal drains, allowing suppurative fluid to stagnate. We present a novel technique to address this limitation of NPWT devices in patients with sternal wound infections that communicate with a pleural collection.

Mycobacterium abscessus infection in a burn intensive care unit patient.

BACKGROUND: Infection is the leading cause of death in burn patients. Historically, this was due to burn wound sepsis but pneumonia has now emerged as the most common source. In light of the increasing incidence of multi-drug-resistant organisms, the description of rare infections is paramount in continuing the fight against deadly pathogens. We aim to describe the second case of non-tuberculous mycobacterium (NTM) reported in a burn patient. Difficulties in diagnosis and management will also be highlighted. METHODS: A 70-y-old Caucasian female, with a past medical history for type 2 diabetes mellitus, was transferred to our facility after a house fire. She had sustained a 28% total body surface area (TBSA) flame burn to her neck, torso, and all four extremities. She underwent excision and grafting on hospital day five with multiple subsequent attempts at excision and grafting due to graft loss. On hospital day 14, a tracheostomy was performed. Her hospital course was complicated by ongoing respiratory failure, renal injury, and sepsis. RESULTS: Mycobacterium abscessus was found on blood cultures from central venous catheters and arterial line catheters as well as on tracheal aspirate and bronchoalveolar lavage (BAL) on hospital day 86. Imaging then revealed multiple pulmonary nodular densities with patchy ground-glass opacities. After multiple adjustments to the antibiotic regimen, tigecycline, clarithromycin, and cefoxitin therapy was started. She remained on this regimen for almost 4 wks. Her other infections included Acinetobacter baumanii treated with tobramycin and colistin, as well as Candida albicans for which she received fluconazole. Ultimately, her clinical state worsened leading to withdrawal of care. CONCLUSIONS: Sepsis NTM is rare in burn patients with only one other case described in the English-language literature. Both cases reflect differences in diagnosis and management. This highlights the need to discuss rare infections in an attempt to broaden the clinician's awareness of such pathogens, as well as to collaborate to form a consensus about their management.

An analysis of prehospital deaths: Who can we save?

BACKGROUND: Since their inception in the late 1970s, trauma networks have saved thousands of lives in the prehospital setting. However, few recent works have been done to evaluate the patients who die in the field. Understanding the epidemiology of these deaths is crucial for trauma system performance evaluation and improvement. We hypothesized that specific patterns of injury could be identified and targeted for intervention. METHODS: Medical examiner reports in a large, urban county were reviewed including all trauma deaths during 2011 that were not transported to a hospital (i.e., died at the scene) or dead on arrival. Age, sex, date of death, mechanism, and list of injuries were recorded. An expert panel reviewed each case to determine the primary cause of death, and if the patient's death was caused by potentially survivable injuries or nonsurvivable injuries. RESULTS: A total of 512 patients were included. Patients were 80% male, died mostly of blunt (53%) and penetrating (46%) causes, and included 21% documented suicides. The leading cause of death was neurotrauma (36%), followed by hemorrhage (34%), asphyxia (15%), and combined neurotrauma/hemorrhage (15%). The anatomic regions most frequently injured were the brain (59%), chest (54%), and abdomen (35%). Finally, 29% of the patient deaths were classified as a result of potentially survivable injuries given current treatment options, mostly from hemorrhage and chest injuries. CONCLUSION: More than one of every five trauma deaths in our study population had potentially survivable injuries. In this group, chest injuries and death via hemorrhage were predominant and suggest targets for future research and implementation of novel prehospital interventions. In addition, efforts targeting suicide prevention remain of great importance. LEVEL OF EVIDENCE: Epidemiologic study, level V.

Surgical and anesthetic considerations in histrelin capsule implantation for the treatment of precocious puberty.

BACKGROUND: Precocious puberty treatment traditionally meant anxiety-provoking monthly depot injections until the advent of the annually implanted histrelin capsule. This study is the first to evaluate the surgical and anesthetic aspects of histrelin implantation for precocious puberty. METHODS: All cases from one surgeon at a tertiary pediatric hospital were reviewed for patient age, anesthetic type, technical difficulties, and complications. RESULTS: From 12/2007 to 3/2013, 114 cases (49% implantations, 25% removals/re-implantations, 25% removals) were performed. Local anesthesia was employed in 100% of non-general anesthesia cases (n=109, 96%), augmented by inhaled N2O in 49%. Five patients (4%) underwent general anesthesia: three neurologically-impaired and two coordinated with scheduled MRIs. Procedural difficulties (n=18, 16%) included implant fracture during removal (n=16/58 removals, 28%). Fracture never occurred during implantation. Three children (3%) suffered complications. One infection was treated with antibiotics, and two implants were removed for systemic allergic reaction. Six children (5%) had unscheduled post-operative checks for pain (n=3, 3%), allergy to elastic dressing (n=2, 2%), or rash (n=1, 1%). Mean charges for general anesthesia were $10,188±1292 versus $528±147 for N2O or local alone (p<0.0001). CONCLUSION: While histrelin implantation is straightforward, removal presents technical challenges. Local anesthesia, with possible N2O supplementation, is well-tolerated and introduces substantial resource and cost savings.

Time to resuscitate a sacred cow...with normal saline.

Normal saline (NS) is not used for trauma resuscitation because of its potential for acidosis. Lactated Ringer's (LR) is preferred instead. However, the two crystalloids have never been compared in trauma patients. We hypothesized that NS would be an acceptable fluid for resuscitation in the trauma patient. In 2011, a Level I trauma center switched resuscitation fluid from LR to NS. Admissions before and after the change were retrospectively reviewed. Demographics, vitals, blood work, and fluid intake were recorded over 24 hours. Acidosis level, stratified by Injury Severity Score (ISS), was compared. Four hundred ten patients were included, 207 in the LR cohort and 203 in the NS. Chloride (LR 105.26 ± 4.75 vs NS 106.48 ± 4.19), base excess (-2.53 ± 3.77 vs -3.28 ± 4.15), pH (7.37 ± 0.08 vs 7.36 ± 0.07), and bicarbonate (22.83 ± 3.45 vs 21.65 ± 5.06) were statistically different but not clinically significant. This was also true when results were stratified by ISS. In addition, there was no difference in the number of blood gases drawn between the groups (584 vs 544, P = nonsignificant). NS resuscitation is a safe, viable alternative to LR in the trauma population studied. Its use carries a potentially substantial cost savings on a national level.

A review of 218 pediatric cases of hepatocellular carcinoma.

PURPOSE: This study evaluates the incidence trends and clinical outcomes of children with hepatocellular carcinoma (HCC) and assesses factors predictive of patient survival. METHODS: The Surveillance, Epidemiology, and End Results registry was queried from 1973 to 2009 for all patients between ages 0 and 19 with primary HCC. Demographics, tumor histology, surgical intervention, and patient survival were collected. RESULTS: Overall, 218 patients were identified. The annual age-adjusted incidence was 0.05 cases per 100,000 in 2009. Fibrolamellar subtype tumors were exclusive to children >5years old and exhibited greater survival compared to non-fibrolamellar subtype (57% vs. 28%, respectively, p=0.002). Tumor extirpation for patients with resectable disease significantly improved overall survival at 5years compared to no surgery (60% vs. 0%, respectively, p<0.0001). Overall 5-, 10- and 20-year survival for the entire cohort was 24%, 23%, and 8%, respectively. Independent prognostic factors of lower mortality according to multivariate analysis were surgical resection (hazard ratio (HR)=0.18), non-Hispanic ethnicity (HR=0.52), and local disease at presentation (HR=0.46). CONCLUSION: Over the past four decades, the incidence of HCC has remained relatively stable. Children of Hispanic ethnicity have high mortality rates. However, HCC resection for curative intent significantly improves outcomes.

The value of cholangiography through Jackson-Pratt drains in the management of postoperative biliary injuries.

Iatrogenic biliary injury is the most significant complication after laparoscopic cholecystectomy. We present our experience with an alternative diagnostic approach using transcatheter cholangiography (TCC) through a Jackson-Pratt (JP) drain and discuss potential benefits and limitations of the technique. From March 2002 to February 2012, 40 patients with major postoperative biliary injury underwent biliary reconstruction at our institution. Mean age was 51.7 ± 18.1 years (range, 19 to 86 years) with 30 (75%) females. Seventeen (42.5%) injuries were detected intraoperatively and in 13 (32.5%) cases, JP drains were placed for biliary drainage. Lesions were classified according to Bismuth grade: I (10 patients [25%]), II (10 patients [25%]), III (six patients [15%]), IV (10 patients [25%]), and V (four patients [10%]). TCC was performed in seven patients with JP drains (53.8%). It fully defined the injury site in three cases of limited magnetic resonance cholangiopancreatography (MRCP) such as common hepatic duct and common bile duct leaks and in four cases (57.1%) that endoscopic retrograde cholangiopancreatography (ERCP) was limited as a result of clipping of the distal common bile duct. TCC showed promising results in cases of limited MRCP and ERCP such as fistulous orifices or leakage. It may represent an alternative adjunct in the diagnostic armamentarium of complex biliary injuries.

The role of MR cholangiopancreatography in preoperative assessment for repair of major iatrogenic biliary injury: 10-year experience.

BACKGROUND/AIMS: Major iatrogenic biliary injury is a potentially life-threatening complication after laparoscopic cholecystectomy. Early diagnosis is essential to improve outcomes, however, to date, there is no consensus regarding the best imaging approach for preoperative assessment of these injuries. METHODOLOGY: From March 2002 to February 2012, 40 patients with postoperative major biliary injury underwent biliary reconstruction at our Institution. Mean age was 51.7 ± 18.1 years (19-86) with 30 (75%) females. Magnetic resonance cholangiopancreatography (MRCP) were compared with different diagnostic modalities and definitive intraoperative findings. RESULTS: Of 40 patients, 10 (25%) had Bismuth type I, 10 (25%) Bismuth type II, 6 (15%) Bismuth type III injury, 10 (25%) Bismuth type IV and, 4 (10%) Bismuth type V. MRCP has similar accuracy to define injury site, but is superior in delineating proximal ductal anatomy that was often not visualized with endoscopic retrograde cholangiopancreatography (ERCP). CONCLUSION: MRCP is a reliable, accurate and readily available diagnostic tool to assess complex biliary injuries. It provides adequate visualization of the proximal and distal biliary trees and may be considered as first-line test in the management of major iatrogenic biliary injuries. Revision of current guidelines for diagnostic approach of this condition is warranted.

Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient's cervical spine?

BACKGROUND: Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient. METHODS: Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed. RESULTS: A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries. CONCLUSIONS: In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date.

Role of magnetic resonance cholangiopancreatography in diagnosing choledochal cysts: Case series and review.

AIM: To determine the merits of magnetic resonance cholangiopancreatography (MRCP) as the primary diagnostic test for choledochal cysts (CC's). METHODS: Between 2009 and 2012, patients who underwent MRCP for perioperative diagnosis were identified. Demographic information, clinical characteristics, and radiographic findings were recorded. MRCP results were compared with intraoperative findings. A PubMed search identified studies published between 1996-2012, employing MRCP as the primary preoperative imaging and comparing results with either endoscopic retrograde cholangiopancreatography (ERCP) or operative findings. Detection rates for CC's and abnormal pancreaticobiliary junction (APBJ) were calculated. In addition detection rates for clinically related biliary pathology like choledocholithiasis and cholangiocarcinomas in patients diagnosed with CC's were also evaluated. RESULTS: Eight patients were identified with CC's. Six patients out of them had type IV CC's, 1 had type I and 1 had a new variant of choledochal cyst with confluent dilatation of the common bile duct (CBD) and cystic duct. Seven patients had an APBJ and 3 of those had a long common-channel. Gallstones were found in 2 patients, 1 had a CBD stone, and 1 pancreatic-duct stone was also detected. In all cases, MRCP successfully identified the type of CC's, as well as APBJ with ductal stones. From analyzing the literature, we found that MRCP has 96%-100% detection rate for CC's. Additionally, we found that the range for sensitivity, specificity, and diagnostic accuracy was 53%-100%, 90%-100% and 56%-100% in diagnosing APBJ. MRCP's detection rate was 100% for choledocholithiasis and 87% for cholangiocarcinomas with concurrent CC's. CONCLUSION: After initial ultrasound and computed tomography scan, MRCP should be the next diagnostic test in both adult and pediatric patients. ERCP should be reserved for patients where therapeutic intervention is needed.

Biliary-colonic fistula caused by cholecystectomy bile duct injury.

Biliary-colonic fistula is a rare complication after laparoscopic cholecystectomy. We present a case of post-cholecystectomy iatrogenic biliary injury that resulted in a fistula between the common hepatic duct and large bowel. Magnetic resonance cholangiopancreatography provided good visualization of injury even with concurrent normal level of alkaline phosphatase. Radiologic findings and surgical management of this condition are discussed in detail.

Examining triage patterns of inhalation injury and toxic epidermal necrolysis-Stevens Johnson syndrome.

The American Burn Association recommends that patients with toxic epidermal necrolysis-Stevens Johnson syndrome (TEN-SJS) or burn inhalation injuries would benefit from admission or transfer to a burn center (BC). This study examines to what extent those criteria are observed within a regional burn network. Hospital discharge data from 2000 to 2010 was obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Disease-9th revision discharge diagnoses for TEN-SJS or burn inhalation injury and their triage destination were compared using burn triage referral criteria to determine whether the patients were triaged differently from American Burn Association recommendations. Two hundred ninety-nine TEN-SJS and 131 inhalation injuries were admitted to all South Florida hospitals. Only 25 (8.4%) of TEN-SJS and 27 (21%) of inhalation injuries were admitted to the BC. BC patients had greater length of stay (TEN-SJS 22 vs 10 days; inhalation 13 vs 7) and were more likely to be funded by charity or be self-paid (TEN-SJS 24 vs 9.5%, P = .025; inhalation 44 vs 14%, P < .001), but less likely to hold some form of private or government insurance (TEN-SJS 72 vs 88%, P = .02; inhalation 48 vs 81%, P = .006). TEN-SJS BC patients were more frequently discharged home for self-care (76 vs 50%, P = .006). Non-BC patients were more often discharged to other healthcare facilities (28 vs 0% TEN-SJS, 20 vs 7.4% inhalation). Inappropriate triage may occur in more than 3 out of 4 of the TEN-SJS and inhalation injury patients within our burn network. Unfamiliarity with triage criteria, patient insurance status, and overcoding may play a role. Further studies should fully characterize the problem and implement education or incentives to encourage more appropriate triage.

An analysis of 73 cases of pediatric malignant tumors of the thymus.

BACKGROUND: Tumors of the thymus are very rare in the pediatric population. This study examines the current trends and outcomes of children with thymus tumors. METHODS: The Surveillance, Epidemiology and End Results (SEER) registry was queried for all patients <20 y of age with primary thymic malignancies from 1973 to 2008. RESULTS: A total of 73 pediatric patients were identified with malignant thymic tumors. The median age at diagnosis was 13 y old. Among the 20 patients that presented with distant disease, 70% died. Conversely, among the 23 patients that presented with locoregional disease, 70% survived. Although the overall mean survival time was 89 ± 116 mo, 45% of patients died over the study period. Patients with Hodgkin lymphomas and germ cell tumors exhibited the highest survival (76% and 60% at 10 y, respectively). Multivariate analysis was used to identify local or regional tumor stage (odds ratio = 4.5, 95% confidence interval = 1.4-14.5) and surgical resection (OR = 3.8, 95% confidence interval = 1.4-10.8) as independent predictors of survival. CONCLUSIONS: Malignant thymomas and lymphomas are the most common histological variants of pediatric thymus tumors, and patients with Hodgkin lymphomas exhibit the highest survival. Surgery is more commonly performed on malignant thymomas and is an independent prognostic indicator of survival.

Identifying pitfalls in chest tube insertion: improving teaching and performance.

OBJECTIVE: Chest tube thoracostomies are common surgical procedures, but little is known about how practitioners learn the skill. This study evaluates the frequency with which correctly performed tasks are executed by subjects during chest tube thoracostomies. DESIGN: In this prospective study, we developed a mobile-learning module, containing stepwise multimedia guidance on chest tube insertion. Next, we developed and tested a 14-item checklist, modeled after key skills in the module. Participants, defined as "novice" (fewer than 10 chest tubes placed) or "expert" (10 or more placed), were assigned to either the video or control group. A trained clinician used the checklist to rate participants while they inserted a chest tube on a TraumaMan simulator. SETTING: University of Miami, Miller School of Medicine, a tertiary care academic institution. PARTICIPANTS: Current medical students, residents, and the United States Army Forward Surgical Team members rotating through the institution. One hundred twenty-eight subjects entered and finished the study. RESULTS: One hundred twenty-eight subjects enrolled in the study; 86 (67%) were residents or US Army Forward Surgical Team members, 66 (77%) were novices, and 20 (23%) were experts. Novices most frequently connected the tube to suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). They least frequently completed full finger sweeps (33%), avoided the neurovascular bundle (35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to correctly perform a finger sweep (42%, p<0.001) and clamp the distal end of the chest tube (42%, p<0.001). Of all the steps, experts least frequently completed full finger sweeps (70%) and avoided the neurovascular bundle (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p = not significant). CONCLUSIONS: Avoiding the neurovascular bundle, controlled pleural entry, and finger sweeps are most often performed incorrectly among novices. This information can help instructors to emphasize key didactic steps, possibly easing trainees' learning curve.