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Intercostal drainage tube or

intracardiac drainage tube?
N. Anitha, S. Ganesh Kamath1, Edison Khymdeit, Manjunath Prabhu
Departments of Anaesthesiology and 1Cardiovascular Thoracic Surgery, Kasturba Medical College, Manipal University,
Manipal, Karnataka, India

ABSTRACT Although insertion of chest drain tubes is a common medical practice, there are risks associated with this
procedure, especially when inexperienced physicians perform it. Wrong insertion of the tube has been known
to cause morbidity and occasional mortality. We report a case where the left ventricle was accidentally
punctured leading to near‑exsanguination. This report is to highlight the need for experienced physicians to
supervise the procedure and train the younger physician in the safe performance of the procedure.
Received: 28‑03‑16
Accepted: 30‑04‑16 Key words: Chest drain tube; Intercostal drainage tube; Intracardiac drainage tube

INTRODUCTION so he was referred to our hospital for further

management.
A chest drain tube is indicated for insertion
through the chest wall to allow for drainage On admission, his vitals were stable and ICD
of fluid, blood, air, or pus out of the chest. tube was found to be nonfunctional. A chest
Up to 20% of the complications have been X‑ray done on admission showed moderate
reported with the insertion of chest drains, pleural effusion. The ICD was in the direction
especially when performed by junior of the heart and not the apex of chest [Figure 1].
doctors. [1] The complications generally In two‑dimensional‑echocardiography, no
arise due to malposition of the catheter, tamponade was seen. On the 2nd day, the ICD
inadequate insertion, subcutaneous insertion, was adjusted, but there was no drainage and
or improper fixation of the tube. We report a hence the ICD was removed. On removal,
case where the intercostal tube penetrated the a gush of blood spurted out through the
left ventricle in a patient with no previous ICD insertion site, the wound was pressed
abnormality of either the heart or the chest tightly, and elastoplast was applied. His
wall. condition deteriorated and had an episode
of hypotension. The patient was resuscitated
CASE REPORT with crystalloids and shifted to Intensive Care

A male aged 35‑year‑old was admitted to a

Address for correspondence: Dr. Edison Khymdeit,
local hospital with alleged history of road Kasturba Medical College Faculty Room No: 08,
Access this article online
traffic accidents. The chief complaints were Kasturba Medical College Administrative Office, Tiger
Website: www.annals.in Circle, Manipal ‑ 576 104, Udupi, Karnataka, India.
chest pain and difficulty in breathing. It E‑mail: eddykhymdeit18@gmail.com
PMID:
*** was initially diagnosed as left hemothorax
DOI: with bilateral multiple rib fractures and left
10.4103/0971-9784.185561 This is an open access article distributed under the terms of the
clavicle fracture. A left intercostal drainage Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
Quick Response Code: License, which allows others to remix, tweak, and build upon the
tube (ICD) with trocar was inserted and a gush work non‑commercially, as long as the author is credited and the
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This was assumed to be from the hemothorax
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and when the bottle filled up, ICD was
clamped. Next day, the tube was unclamped Cite this article as: Anitha N, Kamath SG, Khymdeit E, Prabhu M.
with no drainage due to clotted blood. The Intercostal drainage tube or intracardiac drainage tube?. Ann Card
Anaesth 2016;19:545-8.
patient continued to have breathlessness and

© 2016 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow 545

 Anitha, et al.: Chest drainage tube: Intercostal or intracardiac?

Unit. One fresh frozen plasma and two packed red blood Surprisingly, there was no blood in the pericardial cavity
cells were also administered since his hemoglobin level as the pericardium was stuck to the left ventricle at that
prior to the bleed was 9.8 g/dl. He stabilized thereafter. area. The left lung was collapsed. The perforation was
sutured with 40 pledgeted prolene sutures. Postoperative
Emergency contrast‑enhanced computerized period was uneventful. He was on a small dose of
tomography scan was done. The scan showed an active inotrope and fiber‑optic bronchoscopy was done twice to
extravasation of contrast from the left ventricular wall clear the secretions. He was discharged on postoperative
to subcutaneous plane of the left lateral chest wall along day 12 with a settled chest X-ray [Figure 4].
the previous ICD tube tract which therefore suggested
ventriculo‑subcutaneous fistula due to the ICD tube DISCUSSION
[Figures 2 and 3].
Although insertion of the chest drain tube is a common
A surgical intervention was required as an emergency. medical practice, inaccurate insertion of the tube can
Intraoperatively, a 2 cm opening in the left pericardium have tragic consequences such as perforation of the
and a similar opening in the lateral side (4 cm from the left and right ventricles.[1] The National Patient Safety
atrioventricular groove) of the left ventricle were seen. Agency, UK, undertook a survey in 2008 to provide a
The pericardium had 250 ml of straw‑colored fluid database for the incidence of risk and harm relating
and the left pleural cavity had 500 ml of dark blood. to chest tube insertion. From a total number of 12,512

Figure 1: Chest X‑ray antero‑posterior view revealing the Figure 2: Computerized tomography with contrast, transverse
chest tube direction toward the heart shift of mediastinum and section showing the leak from the left ventricle to subcutaneous
haziness left chest tissue

Figure 3: Computerized tomography coronal section showing Figure 4: Chest X‑ray postero‑anterior view postoperative
the leak from the left ventricle before discharge

546 Annals of Cardiac Anaesthesia | Jul-Sep-2016 | Vol 19 | Issue 3

 Anitha, et al.: Chest drainage tube: Intercostal or intracardiac?

reported tube insertions, 15 (0.11%) insertions resulted

in severe harm (damage to vessels, trachea, and liver)
and a further 12 (0.09%) resulted in death (puncture of
lungs, heart, liver, and hemorrhage).[2]

Studies done prospectively as well as retrospectively

in different clinical settings found the rate of chest
tube malposition (CTM) to be over 20%.[3] Existing case
report literatures on CTMs include fatal complications
such as perforation of the lung, heart, and injury to
the pulmonary artery. There has also been a reported
case of phrenic nerve injury leading to paralysis of the
diaphragm.[4,5] Most of the complications happened
because of inexperienced doctors doing the procedure,
lack of fundamental knowledge and skill to insert Figure 5: Safe triangle area
a chest drain securely, wrong site of insertion, and
deficiency in diagnosis.[2] In addition, training of junior doctors in the art of safe
chest drain insertion should be a priority as highlighted
In one of such cases, opacification of the left side in the latest BTS guideline.[9] Individual hospitals
of the chest in an X‑ray was mistaken to be pleural can setup their own safety guidelines and protocols
effusion. The chest tube which had been inserted to minimize the risks to the patients. Insertion of
without ultrasound guidance had actually perforated smaller chest drains is better done with ultrasound
the left ventricle. Although removal of the drain under guidance followed by Seldinger’s technique. Larger
general anesthesia was uneventful and the patient was ICDs (24–32 F) are best inserted after blunt dissection
hemodynamically stable, the patient succumbed to and digital palpation.[9] The use of trocar is optional,
pneumonia after prolonged mechanical ventilation.[6] but the insertion should be controlled and the person
A similar case was reported by Goltz et al., wherein inserting it must be experienced. One can envisage
the chest tube was placed on the left side in the sixth the loss of control with the use of trocar, and a sudden
intercostal space without ultrasound guidance. The uncontrolled movement can easily cause injury to
chest tube perforated the hypertrophied left ventricle, different organs including the heart.
passed through the mitral valve into the left atrium,
exiting via a pulmonary vein. The tip was in the middle To conclude, we have highlighted a case of malpositioning
lobe of the opposite lung. The authors mentioned that of an ICD tube which had resulted in injury to the left
there was a resistance in passing the tube at a depth of ventricle. The malpositioning of the tube may be a
2–3 cm, but it was assumed to be adhesions and the case of gross negligence or simply the lack of skill and
tube was advanced.[7] expertise to perform the procedure. This definitely calls
for a stringent action from all institutes and hospitals
The British Thoracic Society (BTS) guidelines indicate to work on proper safe training and also develop safety
that the insertion should be done within the area known protocol in the line of the BTS guideline.
as the “safe triangle” [Figure 5]. This triangle is bound
by the lateral border of pectoralis major and the lateral Financial support and sponsorship
border of latissimus dorsi and a horizontal line passing Nil.
through the apex of the axilla.[8]
Conflicts of interest
To minimize the risk of complications, prior to the There are no conflicts of interest.
procedure, clinical signs, chest radiograph of the
patient, and the site for insertion should be reviewed. REFERENCES
The use of image guidance such as ultrasonography
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right ventricle: A complication of blind placement of a
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and especially for cases of empyema and effusions.[8] 1998;114:1213‑5.

Annals of Cardiac Anaesthesia | Jul-Sep-2016 | Vol 19 | Issue 3 547

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