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Case Report:
D. J. Williams, S. I. Jaggar, and C. J. Morgan
Upper airway obstruction as a result of massive subcutaneous emphysema following accidental removal of an intercostal drain
Br. J. Anaesth. 2004; 0: aei039v1 [Abstract] [PDF]
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[Read E-letter] Prevention of pneumothorax
Andrew R Bodenham   (11 April 2005)

Prevention of pneumothorax 11 April 2005
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Andrew R Bodenham

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Re: Prevention of pneumothorax

I congratulate the authors on the management of this difficult case of massive air leak after subclavian vein catheterisation for permanent pacemaker insertion. This route of access is favoured by Cardiologists for placement of pacing wires as it is thought to provide a more stabie site with less chance of pacing wire migration.

I would like to raise another facet of the case, which was not raised in the report, namely prevention of the pneumothorax in the first place. Pneumothorax and other procedural complications related to needle insertions for central venous access can be almost completely eliminated by the routine use of ultrasound. This site can be accessed using ultrasound, particularly if screening is available to correct any catheter tip malposition [1]. Despite the recommendations of NICE [2] based on a number of clinical publications, there remains a reluctance by many centres to invest in appropriate ultrasound devices for this purpose, and it is the continued belief of many clinicians that they do not need the aid of such devices. A somewhat semantic debate continues in the correspondence columns about the cost effectiveness of ultrasound guided central venous catheterisation [3].

There is an ongoing attitude that such complications are minor (not to the patient) and an inherent risk of the procedure. The patient in this report must have suffered considerable stress, discomfort, and probable long term disability during convalescense, despite the reported eventual successful outcome. Analysis of this case suggests that the cost of the complication would be in the order of 15 days unnecessary stay on the ward at £300, plus 27 days on ITU at £1,500 a day, for a procedure that otherwise would be done as a day case or perhaps an overnight stay. Such costs total approximately £46,000 and would obviously cause further disruption in terms of blocked beds for other cases. The high costs and excess length of stay following iatrogenic pneumothorax have been highlighted previously in a large survey of multiple acute hospitals in the USA [4]. Ultrasound machines can be purchased for around £10 – £15,000 apiece and running costs are low. When viewed in this context their routine use make very good financial, legal and medical sense.

1. Sharma A, Bodenham AR, Mallick A.Ultrasound-guided infraclavicular axillary vein cannulation for central venous access. Brit J Anaesth 2004: 93: 188-92

2. National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for central venous catheters (NICE technology appraisal, No. 49.) London: NICE, 2002

3. Scott DHT. Ultrasound for central venous catheterisation. An economic evaluation of cost effectiveness. Anaesthesia 2005; 60: 407

4. Zhan C, Miller MR Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization. JAMA. 2003; 290: 1868-1874

Conflict of Interest:

None declared