Complications of small bore chest drains

We read with interest the article by Davies et al on the complications of small bore ‘Seldinger’ chest drains. We share the authors’ concerns about adequately securing chest drains especially as it appears that drain displacement/falling out is the most common complication of small bore drains inserted by the Seldinger technique ranging from 7.6% (4/52) in Horsley’s prospective study to 21% (21/100) in the present retrospective one. It was also worrying to note that suture use was documented in < 10% of cases. Purely from a medico-legal aspect, we feel it is incorrect for the authors to assume that a suture was placed ‘in the majority of patients’ as, if it is not documented, it is not been done. The displacement or falling out of chest drains is obviously a cause of excess patient morbidity, often merits drain re-insertion and potentially delays discharge. In our own experience through audits at two large district general hospitals in Lancaster and Huddersfield, 14.3% (7/49) and 7.5 % (3/40) small bore drains fell out respectively (data presented at local audit meetings). Six of the seven drains at Lancaster and all three that fell out in Huddersfield were not secured by a suture though in both hospitals it was routine practice to apply the special Drain–Fix dressing mentioned by Davies et al. Surprisingly, the British Thoracic Society (BTS) guideline on insertion of chest drains states that a suture is not usually required to secure small gauge chest tubes while large and medium bore chest drain incisions should be closed by a suture appropriate for a linear incision. In contrast, Richard Light in his textbook on Pleural Diseases clearly advocates the placement of an anchoring suture for guide-wire tube thoracostomy. As practising clinicians we believe it is logical that small bore drains are more likely to fall out rather than larger ones as the former are shorter in length (the length of a standard 12F drain is 22 cm while that of a 20F drain is 41 cm), more flexible and therefore more susceptible to be inadvertently pulled out. Although wide bore chest drains inserted through blunt dissection have their own complications (malposition, penetration of lung and other organs, infection, haemorrhage), falling out is not mentioned in most large studies as a common complication. Perhaps this is because wide bore drains are always sutured in place. Until a prospective randomized controlled trial addresses the issue of suturing small bore ‘Seldinger’ drains, we believe it should be good medical practice to secure these with an anchoring suture and hope that the long-awaited updated BTS guideline on chest drains due to be published in 2009 incorporates this common-sense measure. This is especially relevant in the context of the National Patient Safety Agency’s recent rapid response report on the risks of chest drain insertion.