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Re: Is the Andrews Introducer BEST

Dear Editor

Placement of chest drains can be associated with serious complications such as penetration of intra-thoracic and upper abdominal organs. This should be a less common occurrence nowadays as trochar use is no longer advocated.[1]

Chest tube malposition post insertion is also common[2] as it can be difficult to manoeuvre the drain with the standard equipment once it is in the chest cavity. Using standard technique Chan[3] found that placement of emergent thoracostomy tubes in the emergency department does not result in an increased complication rate as compared to placement on an inpatient ward. The instrumentation advised per the BTS guidelines for inserting chest drains is not particularly designed for the task.

A recent paper published by Andrews [4] may add further to the question posed in the BET. He has designed a forceps specifically for chest drain introduction and has shown that it rated easier to use than standard forceps by both experienced and inexperienced users. This may partly be due to the design of his ratchet mechanism allowing the user to take advantage of better motor control when flexing/gripping.

Standard forceps require the user to extend fingers in order to dissect down through the muscle layers. Difficulties may arise with the standard technique if the user withdraws the forceps and cannot subsequently find the track made necessitating further dissection and discomfort for the patient. With this new forceps the drain is placed in a conduit or circular channel created by vertical extensions on each arm of the forceps and also a 3rd limb proximally.

If Seldinger offers no advantage over traditional methods as shown in this BET[5] then the new forceps described by Andrews deserves closer inspection in relation to chest drain placement in emergency departments.

References

1. Haggie, J.A., Management of pneumothorax. Chest drain trocar unsafe and unnecessary. Bmj, 1993. 307(6901):443.

2. Baldt, M.M., et al. Complications after emergency tube thoracostomy: assessment with CT. Radiology, 1995. 195(2):539-43.

3. Chan, L., et al. Complication rates of tube thoracostomy. Am J Emerg Med, 1997. 15(4):368-70.

4. Andrews, E.,et al. A new specifically designed forceps for chest drain insertion. Injury, 2003. 34(12):957-9.

5. Argall, J. and J. Desmond, Seldinger technique chest drains and complication rate. Emerg Med J, 2003. 20(2):169-70.