GS08 - Chest Thoracostomy: Pigtail Complication with Intrathoracic Foreign Body Retention.

Introduction/Purpose: Small-caliber pigtail thoracostomy tubes are common and are regularly used to treat pneumothoraces and pleural fluid collections. While chest thoracostomy can be lifesaving for patients, the use of small caliber thoracostomy tubes is not without complications and risks such as retained foreign body, pulmonary injuries, bleeding, infection, occluded catheters, among many others. It is essential for surgeons and physicians on trauma teams, working in the emergency department, ICU (intensive care unit), or hospitals to understand the potential complications of the various pigtail catheters and how to respond to and prevent complications.

Methods or Case Description: We present a case of a pigtail catheter placed emergently to treat a pneumothorax with intrathoracic retention of the catheter sheath. The catheter sheath used to straighten and guide the pigtail catheter, was not removed as intended–it was advanced with the pigtail catheter into the thoracic cavity. Upon initial chest tube placement the patient's lung re expanded, breath sounds equalized and the chest radiograph confirmed adequate tube placement. The patient was then admitted to the ICU for further critical care management. After admission the patient began showing symptoms and a CT was performed.When the patient was weaned off sedation, he exhibited pain out of proportion to normal catheter placement/positioning. CT imaging revealed the retained foreign body catheter sheath. The cardiothoracic surgeon was consulted and thoracoscopically removed the sheath en bloc from the pleural space.

Outcomes: This complication of pigtail thoracostomy tube placement is primarily due to physician error. Other contributing factors include poor catheter kit design and lack of familiarity. There may also be a gap in continuing medical education or residency procedural training. Pigtail catheters are radio opaque by design however, the pigtail sheath does not contain radio opaque material which prevents it from showing up on routine imaging following chest tube placement. This is important to note as both the attending physician and radiologist failed to see the retained sheath on a standard post-thoracostomy X-ray. Physicians who regularly perform chest thoracostomy with pigtail catheters must be aware of the untethered sheath and the lack of radio opacity on pigtail catheter sheaths to prevent intrathoracic retention of the catheter sheath and its associated complications.

Conclusion: This case illustrates the need for surgeons to be knowledgeable and able to effectively work with a variety of tools at their disposal. More importantly it presents a case to change the design of pigtail catheters and/or improve the residency training for all physicians who will use them in a clinical setting. Understanding the failure points of procedural implements and how to avoid them will prevent retained foreign bodies during thoracostomy and improve patient outcomes.