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Iatrogenic Complications of Chest Tube Placement in Demented Patients
with a seven-day history of rhinorrhea and (.'Ou~h. On admission, the patient was febrile, productive of sputum, and tachypneic. A chest x-ray film revealed left lower lobe pneumonia. The white blood cell count was 1.9 x 10"/L, which included 10 percent blast forms. A rapid immuno~lohulin M (I~M) immunohlottin~ assay was positive. The patient responded to oral erythronlycin. The (.'omplement fixation (CF) titer on the sin~le serum specimen was subsequently determined to be 1/128. Case 2: An l1-year-old Wrl, who had completed chemotherapy for acute lymphocytic leukemia six months previously, was admitted to the hospital with fever and a (.'Ou~h of three weeks' duration. The respiratory disease did not respond to either amoxicillin or cefaclor. A chest x-ray film revealed left perihilar infiltrates. Her peripheral white blood cell count was 8.0 x 1
REFERENCES Perez CR, Lei~ M\\Z Myc01Jlasnul pneunwniae as the causative agent for pneumonia in the immunocompmmised host. Chest 1991; 100:860-61 2 Cimolai N, Mah D, Thomas E, Middleton ~ Rapid immunoblot diagnosis of acute MycoplasnUl pneurrwniae infection. Eur J Clin Microbiol Infect Dis 1990; 9:223-26 3 Cimolai N, Cheon~ ACH. IgM anti-PI immunoblotting: a standard for the rapid serolowcal dia~nosis of ltlycoplas,na pneunwniae infection in pediatric care. Chest 1992; 102:477-81
Iatrogenic Complications of Chest Tube Placement in Demented Patients
sion was therefore instituted. One night he opened the undernrater seal bottle and micturated into it instead of using the urine boUle provided. This necessitated a change of his chest tuhe. At the end of \\reek 2 his tube was removed, and he was discharged with a residual pneumothora.x to he followed up in the chest clinic. Our female patient was adlnitted with a large rnalignant left pleural effusion. She was hoarse and was virtually hedridden. There was no dyspnea at rest. The effusion was drained via a chest tube, after \\rhich chemical pleurodesis with hleoluycin was instituted. Her sleep was disturbed while she had the tuhe. and she he(.'ame a~ressive and abusive. She often pulled at the tuhe. As a result the pleurodesis failed, and she developed a pnt·unu)thonlx. Furthernlore, a subcutaneous staphylo(.'(K'cal ahscess fonned around the chest wound. The tube was therefore renlOVe(l, and the abscess was drained. Another chest tube was inserted at a ne\\' site. and a t"\\ o-week (.'()urse of Hucloxacillin, 500 lug every 6 h. was given. She kept manipulating the second tuhe as well. and pulled it out after five days, leavin~ a fistula draining pleural fluid. Repeated deep suturing of the fistula failed, and she was discharged with a supply of packs and banda~es for daily dressing. These cases highlight the difficulties asscK'iated with chest tubes in demented individuals. Chest tuhes, nasogastric tuhes, and sur~ical drains all require constant supervision in such patients. A 24-h vigil in a busy \\'ard, ho\\·ever. is often irnpossihle. lIence, all invasive nleasures should he employed prudently in patients with dementia after careful (.'()nsideration of henefits versus potential risks. In retrospect, we could have avoided clu'st-tuhe insertion in our patients. The male patient (.'(mld have heen treated \"ith draina~e of his pneumothorax via a cannula for syrnptolnatic relief and follo\\'ed up with serial radiographs. ()ur f('lnalt' patient was not dyspneic at rest and could have heen left alon(' considerin~ the nature of her illness and the presence of denlentia. 1
AI. Tariq. i\I.B .. R.eh., and 11lykkoottathyl r Joseph, AI.D., Sultan Qaboos (r"il;l'rsit~1 Hospital, .'Iuscat, Onul1) S~Jecl
Nonsurgical Management of Bleeding Secondary to Tube Thoracostomy A Case Report
To the Editor:
u) the Editor:
Iatrogenic complications from intravenous lines, chest tubes, urinary catheters, and pacemaker wires are more likely in patients with dementia because patient cooperation and understandin~may be lacking. We recently en(.'Ountered problems with chest tube drainage in two demented patients, a man aged 75 years and a woman aged BO. Both had recent memory loss, disorientation as to time and place, and altered diurnal sleep pattern, but no incontinence. Permission for chest tube insertion was obtained from their relatives. The male patient presented with sudden onset dyspnea and chest pain due to a spontaneous ri~ht pneumothorax. A chest tube was inserted and connected to an underwater seal. lie disliked the tube and complained that it restricted him. The \\rard staff therefi)re supplied him with a clamp to apply to the chest tube befi)re disconnectin~ it from the underwater seal whenever he ventured out. For a week there was no resolution of his pneumothorax, and it was discovered that he \\'as either not applying the clamp before disconnectin~ the chest tube from the undernrater seal or was wron~ly applying it to one of the tuhes (.'oming out of the undern'ater seal boule. Thus, he usually wandered about with his chest tube in free communication \~lith the atmosphere. Closer nursin~ supervi-
Bleedin~ secondary to tube thoracostolny frequpntly originates from an injured inter(.'()stal vessel. I -:1 A case of significant bleedin~ (> 1.4 Lover 2 h) after tube thorac.'()stonly was recently en(.'()untered in a 51-year-old woman with an exudative right pleural effusion, overwhelmin~ sepsis, disselninated intravascular coagulopathy. and multisystem organ failure. The tuhe was sterilely rt'placed with a 3O-ml balloon-tipped 24F Foley catheter connectt"d to 20 cm Il z() suction draina~e and placed on 1 Ib of tension. The wound site was tightly packed. Helnorrhage was inllnediately tarnponaded, and subsequently the catheter was renloved without recurrent hleeding. Henu)rrhage occurred although standard tt'chniques for tuhe thoracostonlY were employed. including (1) acquisition of a preprocedure chest radiograph; (2) high lateral insertion to prevent subdiaphragmatic placenlent; (3) dissection over the cephalad surface of the lower rih of the interspace to avoid injury to the inter<.'()stal vessels; (4) "hlunt techniqtlt·" insertion. rather than use of a trocar chest tube, which can Inore rt'adily injure chest wall and visceral structures; and (5) digital palpation of the pleural cavity to ensure nonadherence of the lung locally. In conclusion, hleeding seeondary to tuhe thoracostolny that is suspeeted to ori~inate froln the chest wall (it'. no air leak present)
1304
Communications to the Editor
REFERENCES Perez CR, Lei~ M\\Z Myc01Jlasnul pneunwniae as the causative agent for pneumonia in the immunocompmmised host. Chest 1991; 100:860-61 2 Cimolai N, Mah D, Thomas E, Middleton ~ Rapid immunoblot diagnosis of acute MycoplasnUl pneurrwniae infection. Eur J Clin Microbiol Infect Dis 1990; 9:223-26 3 Cimolai N, Cheon~ ACH. IgM anti-PI immunoblotting: a standard for the rapid serolowcal dia~nosis of ltlycoplas,na pneunwniae infection in pediatric care. Chest 1992; 102:477-81
Iatrogenic Complications of Chest Tube Placement in Demented Patients
sion was therefore instituted. One night he opened the undernrater seal bottle and micturated into it instead of using the urine boUle provided. This necessitated a change of his chest tuhe. At the end of \\reek 2 his tube was removed, and he was discharged with a residual pneumothora.x to he followed up in the chest clinic. Our female patient was adlnitted with a large rnalignant left pleural effusion. She was hoarse and was virtually hedridden. There was no dyspnea at rest. The effusion was drained via a chest tube, after \\rhich chemical pleurodesis with hleoluycin was instituted. Her sleep was disturbed while she had the tuhe. and she he(.'ame a~ressive and abusive. She often pulled at the tuhe. As a result the pleurodesis failed, and she developed a pnt·unu)thonlx. Furthernlore, a subcutaneous staphylo(.'(K'cal ahscess fonned around the chest wound. The tube was therefore renlOVe(l, and the abscess was drained. Another chest tube was inserted at a ne\\' site. and a t"\\ o-week (.'()urse of Hucloxacillin, 500 lug every 6 h. was given. She kept manipulating the second tuhe as well. and pulled it out after five days, leavin~ a fistula draining pleural fluid. Repeated deep suturing of the fistula failed, and she was discharged with a supply of packs and banda~es for daily dressing. These cases highlight the difficulties asscK'iated with chest tubes in demented individuals. Chest tuhes, nasogastric tuhes, and sur~ical drains all require constant supervision in such patients. A 24-h vigil in a busy \\'ard, ho\\·ever. is often irnpossihle. lIence, all invasive nleasures should he employed prudently in patients with dementia after careful (.'()nsideration of henefits versus potential risks. In retrospect, we could have avoided clu'st-tuhe insertion in our patients. The male patient (.'(mld have heen treated \"ith draina~e of his pneumothorax via a cannula for syrnptolnatic relief and follo\\'ed up with serial radiographs. ()ur f('lnalt' patient was not dyspneic at rest and could have heen left alon(' considerin~ the nature of her illness and the presence of denlentia. 1
AI. Tariq. i\I.B .. R.eh., and 11lykkoottathyl r Joseph, AI.D., Sultan Qaboos (r"il;l'rsit~1 Hospital, .'Iuscat, Onul1) S~Jecl
Nonsurgical Management of Bleeding Secondary to Tube Thoracostomy A Case Report
To the Editor:
u) the Editor:
Iatrogenic complications from intravenous lines, chest tubes, urinary catheters, and pacemaker wires are more likely in patients with dementia because patient cooperation and understandin~may be lacking. We recently en(.'Ountered problems with chest tube drainage in two demented patients, a man aged 75 years and a woman aged BO. Both had recent memory loss, disorientation as to time and place, and altered diurnal sleep pattern, but no incontinence. Permission for chest tube insertion was obtained from their relatives. The male patient presented with sudden onset dyspnea and chest pain due to a spontaneous ri~ht pneumothorax. A chest tube was inserted and connected to an underwater seal. lie disliked the tube and complained that it restricted him. The \\rard staff therefi)re supplied him with a clamp to apply to the chest tube befi)re disconnectin~ it from the underwater seal whenever he ventured out. For a week there was no resolution of his pneumothorax, and it was discovered that he \\'as either not applying the clamp before disconnectin~ the chest tube from the undernrater seal or was wron~ly applying it to one of the tuhes (.'oming out of the undern'ater seal boule. Thus, he usually wandered about with his chest tube in free communication \~lith the atmosphere. Closer nursin~ supervi-
Bleedin~ secondary to tube thoracostolny frequpntly originates from an injured inter(.'()stal vessel. I -:1 A case of significant bleedin~ (> 1.4 Lover 2 h) after tube thorac.'()stonly was recently en(.'()untered in a 51-year-old woman with an exudative right pleural effusion, overwhelmin~ sepsis, disselninated intravascular coagulopathy. and multisystem organ failure. The tuhe was sterilely rt'placed with a 3O-ml balloon-tipped 24F Foley catheter connectt"d to 20 cm Il z() suction draina~e and placed on 1 Ib of tension. The wound site was tightly packed. Helnorrhage was inllnediately tarnponaded, and subsequently the catheter was renloved without recurrent hleeding. Henu)rrhage occurred although standard tt'chniques for tuhe thoracostonlY were employed. including (1) acquisition of a preprocedure chest radiograph; (2) high lateral insertion to prevent subdiaphragmatic placenlent; (3) dissection over the cephalad surface of the lower rih of the interspace to avoid injury to the inter<.'()stal vessels; (4) "hlunt techniqtlt·" insertion. rather than use of a trocar chest tube, which can Inore rt'adily injure chest wall and visceral structures; and (5) digital palpation of the pleural cavity to ensure nonadherence of the lung locally. In conclusion, hleeding seeondary to tuhe thoracostolny that is suspeeted to ori~inate froln the chest wall (it'. no air leak present)
1304
Communications to the Editor