Iatrogenic risk of tube thoracostomy: A retrospective trauma database analysis

Traumatic hemothorax, pneumothorax, and hemopneumothorax are life-threatening conditions which are often treated with thoracostomy. Prior research has identified thoracostomy as an independent risk factor for both mortality and increased hospital length of stay (LOS). Given the coexistence of increased mortality and LOS, the objective of this study was to examine whether this mortality risk is driven by iatrogenic factors such as in-hospital complications.

This retrospective cohort study used data from the 2019 American College of Surgeons-Trauma Quality Program database. This study included all adult patients in the database with traumatic hemothorax, pneumothorax, or hemopneumothorax. Patients with missing data or no signs of life upon arrival were excluded. Patients were propensity score matched. Rates of mortality, LOS, and rates of complications were compared between groups. Mediation analysis was performed to link thoracostomy, complications, and mortality.

Our post-match sample consisted of 36,550 patients, 18,275 who underwent thoracostomy and 18,275 who did not. Thoracostomy was associated with increased mortality and LOS (p < 0.001). After correcting for multiple comparisons, thoracostomy was also associated with increased incidence of 17 of the 21 in-hospital complications that the database tracks (p < 0.05). Mediation analysis showed the association between thoracostomy and mortality is mediated by complications, with cardiac arrest accounting for 35% of mortality risk.

This study suggests that in-hospital complications may partially drive the increased mortality associated with thoracostomy in patients with traumatic hemothorax, pneumothorax, or hemopneumothorax. We recommend a reexamination of clinical guidelines regarding the threshold for thoracostomy as well as increased caution post-procedure to minimize downstream complications.