Episode #41: Patient Safety Issues: Tension Pneumothorax and Central Line Failure

April 20, 2021

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Today, we will be reviewing a couple of articles from the Articles Between Issues Section. This is so exciting because the APSF Newsletter is released 3 times a year and these articles between the issues are so important to keep the momentum going throughout the year.

Our first article was published online on December 7, 2020. It is “Tension Pneumothorax in the Operating Room: When Teamwork and Communication Save Patient Lives” by Ashley Wells and colleagues. You can find the article here. https://www.apsf.org/article/tension-pneumothorax-in-the-operating-room-when-teamwork-and-communication-save-patient-lives/

Table 1: Chest tube management safety checklist.

Chest Tube Apparatus
  • Position
    • Unit is upright and below the level of the chest to maximize gravitational drainage
  • Suction
    • Suction source connected and turned on
    • Bellows expanded, indicative of active suction
  • Water seal chamber
    • Water seal chamber filled properly with fluid (at least 2 cm H2O)
    • Intermittent tidaling present
      • Tidaling decreases as lung re-expands
      • Continuous bubbling may be indicative of an air leak
Chest Tube Tubing
  • Inspect connecting tubing
    • Ensure secure connection between thoracic catheter and drainage system
    • Check tubing for cracks or defects, especially if an air leak persists despite clamping near patient
    • Verify patent tubing by evaluating for blockages
      • External blockages: remove kinks, loops, clamps (clamp OFF if suction ON)
      • Internal blockages: flush tubing to remove potential debris or clot
  • Examine insertion site
    • Exposed distal tube eyelets indicate tubing may be outside of the pleural space
    • Seal air leak at insertion site with occlusive dressing, if present

The second article that we will be reviewing today is one of the newest releases from March 9, 2021 by Hong and colleagues. It is called “Failure of Central Line One-Way Valves upon Pulmonary Artery Catheter Removal.” You can find the article here. https://www.apsf.org/article/failure-of-central-line-one-way-valves-upon-pulmonary-artery-catheter-removal/

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© 2021, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. I am so excited to introduce a new type of show today. We have talked about APSF newsletter articles and we have discussed rapid responses to questions from our readers. But there is more great anesthesia patient safety content on our website…

Before we dive into today’s episode, we’d like to recognize GE Healthcare, a major corporate supporter of APSF. GE Healthcare has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, GE Healthcare – we wouldn’t be able to do all that we do without you!”

And now for the big reveal. Today, we will be reviewing a couple of articles from the Articles Between Issues Section. This is so exciting because as you probably know, the APSF Newsletter is released 3 times a year, and these articles between the episodes are so important to keep the momentum going throughout the year and they support the APSF mission statement which includes the following:

  • “Identifying safety initiatives and creating recommendations to implement directly and with partner organizations
  • Being a leading voice for anesthesia patient safety worldwide
  • Supporting and advancing anesthesia patient safety culture, knowledge, and learning”

So, with that, let’s discuss our first article today that was published online on December 7, 2020. It is “Tension Pneumothorax in the Operating Room: When Teamwork and Communication Save Patient Lives” by Ashley Wells and colleagues. To follow along with us, click on the Newsletter heading. Second one down is Articles between Issues. Then, scroll down to the 2nd page and the featured article is the 2nd one down.  I will include a link in the show notes as well.

The authors start us off with a summary of intraoperative tension pneumothorax and chest tube management. This is yet another area where teamwork and communication is vital for patient safety even though many anesthesia professionals would consider chest tube management to be the responsibility of the surgery team. Here, the authors argue that it really needs to be a shared responsibility which makes sense since anesthesia and surgery professionals must work together in order to keep patients safe in the operating room. Patients may require planned chest tube thoracostomy during the surgery for postoperative care and everyone needs to stay vigilant for confirming correct placement as well as appropriate function of the chest tube with adequate suction. The stakes are even higher with a critical ill patient who is decompensating and this is the time when communication and teamwork can save lives.

Before we get to the case presentation, I want to highlight the first 3 APSF priorities that are related to this article including: #1 Culture of safety, inclusion and diversity, #2 Teamwork, collegial communication and multidisciplinary collaboration, and #3 Preventing, detecting, determining pathogenesis, and mitigating clinical deterioration in the perioperative period.

Anesthesia and other healthcare professionals are trained to quickly recognize and treat tension pneumothorax, but this is not something we see every day. A tension pneumothorax involves air accumulation in the intrapleural space with the resultant lung collapse, pulmonary arterial shunting, hypoxemia, and cardiovascular collapse. The authors present the case of 60-year-old woman with a past medical history of smoking, hypertension, AIDS, and hepatitis C who presented with recurrent pneumonia and a loculated exudative pleural effusion. She was brought to the operating room for thoracentesis, pleural biopsy, chemical pleurodesis, and decortication with a left thoracoscopy approach. The surgery was complicated by parenchymal bleeding that required conversion to open left thoracotomy. At the end of the case, the patient was positioned from lateral to supine while still being mechanically ventilated when all of a sudden, the patient developed high peak airway pressures, hypoxemia, tachycardia, and significant hypotension. Physical exam findings included expanding subcutaneous emphysema and absent left-sided breath sounds. Management included hemodynamic support and a rapid survey of equipment which revealed that the suction was disconnected from the chest tube. The chest tube was flushed to remove an occlusive thrombi and suction was re-applied which led to improved hemodynamics and adequate oxygenation and ventilation. A chest X-Ray was performed that revealed correct positioning of the chest tube with the initial left pneumothorax which had resolved on the follow-up chest x-ray 2 hours later. I hope that you will check out the x-ray images that accompany this article after you finish listening to the show.

This case brings up some interesting points for discussion. Patient safety in the operating room has improved with increased huddle communications and time-outs before incision, but the end of the surgery is often less organized but no less critical. It is important to remain vigilant about correct placement and adequate function of chest tubes throughout any repositioning and emergence from anesthesia. The authors advocate for anesthesia professionals to be knowledgeable about chest tube management in order to troubleshoot any device malfunction and be able to perform closed-loop communication with the surgery team and other operating room team members. While tension pneumothorax does not occur frequently, chest tube thoracostomy is a common procedure to aid lung re-expansion by allowing fluid, blood, and air to drain from the pleural space. After the chest tube is placed, it is connected to a chest drainage system through a 3-way chamber. Negative pressure is restored with either gravity or suction acting as a one-way valve so that the lung can expand in the pleural space.  The 3-way chamber includes, you guessed it, 3 chambers: the collection chamber which collects fluid, the water seal chamber which is a column of water that inhibits air from returning to the pleural space during inhalation and finally, the suction chamber that can be connected to wall suction or placed on water seal. The tubing used to connect the chest tube to the chamber is also a source for malfunction since it needs to be free of any kinks, clamps, occlusive thrombi, or misplacements.

After the chest tube thoracostomy is placed, patients may still require mechanical ventilation prior to extubation. This is a time when the chest tube should be placed on suction to help the lung re-expand appropriately and to help prevent the development of a postoperative pneumothorax. Another important feature of the water seal chamber is the presence of fluid oscillations which is known as tidaling and this is a sign of lung re-expansion. Decreased fluid oscillations or decreased tidaling reflects lung re-expansion. At the time of emergence, verbal confirmation of adequate chest tube suction and visual confirmation with tidaling may help to improve patient safety.

Before we wrap up for today, the authors provide a chest tube management safety checklist that I will include in the show notes. Let’s review it now. First, check out the chest tube apparatus. Is it positioned upright and below the level of the chest in order to maximize drainage? Is the suction connected to the source and turned on? Have the bellows expanded to demonstrate that the suction is working? Is the water seal chamber filled with fluid of at least 2cm H2O? Can you see intermittent tidaling keeping in mind that this should decrease as the lung re-expands? If you see continuous bubbling, this may occur due to an air leak. Next, make sure that you evaluate the chest tube tubing. Is there a secure connection between the thoracic catheter and the drainage system? Are there any defects in the tubing? This may result in a persistent air leak even after clamping the tube near the patient. Are there any blockages in the tube? Blockages may include external blockages such as kinks, loops, and clamps or internal blockages from debris or blood clots. Finally, look at the chest tube insertion site. Can you see any exposed distal tube eyelets which may occur if the tubing is outside the pleural space? Plus, if there is an air leak at the insertion site, you may want to place an occlusive dressing. This chest tube management safety checklist is something that members of the surgery team or OR nurses may complete, but it is imperative the anesthesia professionals take part in this process as well to help establish and maintain a culture of safety.

The authors leave us with this final statement that I am going to read now: “Importantly, multidisciplinary communication, shared responsibility, and heightened vigilance is required by all members of the operating room to ensure proper chest tube management and prevent life-threatening complications.” Thank you to Wells and colleagues for sharing this case report and the important information about intraoperative chest tube management.

Before we wrap up for today, we have time for one more article between the issues. This time we are reviewing one of the newest releases from March 9, 2021 by Hong and colleagues. It is called “Failure of Central Line One-Way Valves upon Pulmonary Artery Catheter Removal”. To find the article, click on the Newsletter heading. Second one down is articles between issues and the article at the top is our next featured article. If you use pulmonary artery catheters or PACs at your institution and in your practice for critically ill patients and complex cardiothoracic cases, then this is an important article for you. The authors submitted this rapid response following failure of the Integral Hemostasis Valve after removal of the PAC leading to bleeding from the introducer port. This device failure required patients to undergo additional interventions and it is a big threat to patient safety.

Let’s get into the cases. The first case is of a 69 year-old man in the ICU following complicated coronary artery bypass grafting and Bentall procedure. Following a prolonged ICU stay, the patient was deemed stable for removal of his PA catheter from the introducer of his central line. The balloon was deflated prior to removal and immediately after removal there was bleeding from the white introducer port of the ARROWgard Blue Two-Lumen 9 French 10cm central venous catheter with Integral Hemostasis Valve. Troubleshooting included placement of the 8French light blue obturator cap on top of the hub. This didn’t work. Then, an Arrow Hands-Off Two-Lumen 7 French 30cm central venous catheter was placed through the defective one-way valve. This didn’t work either and bleeding continued. Due to the persistent bleeding, manual occlusion was performed until removal of the entire introducer sheath. Initial evaluation of the device revealed no evidence of damage to the white cap and rubber one-way valve. The patient had to undergo an additional procedure since a new central line needed to be replaced.

The second case involves a 63-year-old woman who was on veno-arterial extracorporeal membrane oxygenation with liver failure following re-do sternotomy and aortic and mitral valve replacements. The patient was appropriate for PAC removal, but after removal of the PAC, there was bleeding from the introducer port. The same central line was used in this case. The difference this time is that after removal of the PAC, the Integral Hemostasis Valve and the white plastic cap were completely dislodged with nothing prevent blood return from the introducer port. Since the team had seen this equipment failure before, they immediately removed the central line. The patient needed to have the central line replaced and needed blood product transfusions due to the excessive blood loss.

Thank you to the authors for sharing these cases. This is an important patient safety issue and when the introducer valve misfunctions, the patient is at risk for bleeding, infection, venous air embolism, and loss of necessary central access. Teleflex responded to this case report provided in this rapid response format. I am going to read their letter now.

“Dear Editor: On behalf of Teleflex, I would like to extend my thanks for giving us the opportunity to provide a response/feedback regarding the extraordinarily rare issue described in this article. We take patient safety and the quality of our medical devices very seriously. Unfortunately, in this case, the devices were not returned to Teleflex, so the proper testing and evaluation of the devices could not take place to determine the root cause. Therefore, in the interests of patient safety, I would strongly encourage clinicians, regardless of the device or manufacturer, to not only share the experience with their colleagues through an effective forum such as this publication, but also – more importantly – to return (if at all possible) any medical devices in which there are unanticipated issues encountered back to the manufacture as soon as possible, so that a thorough root cause investigation can take place to determine if there is indeed a product quality issue.”

Thank you to Teleflex for this response and important reminder about returning defective medical devices to the manufacturer for further testing. This is a vital step for improving patient safety.

I hope you enjoyed this articles between the issues segment and don’t worry, we’ll check back in to find out more about patient safety issues between the issues. If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. Have you joined the conversation on twitter? If so, we would love for you to tag us in a tweet using #ASPF podcast and tell us where you like to listen to the show. Thanks for listening and we can’t wait to hear from you soon!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2021, The Anesthesia Patient Safety Foundation