# Inserting With Care: Classification of Complications Related to Chest Drain Insertion

## TL;DR

This study compares complication rates of chest drain insertions using two classification systems and finds that the Clavien-Dindo system provides a more accurate picture of clinical impact.

## Contribution

The study introduces the use of the Clavien-Dindo classification for chest drain complications in trauma care, offering a more clinically meaningful assessment.

## Key findings

- Conventional classification reported a 40.2% complication rate, while Clavien-Dindo reported 16.2%.
- Most positional complications did not require intervention, suggesting limited clinical significance.
- Pigtail catheters showed lower complication rates compared to intercostal catheters, though differences were not statistically significant.

## Abstract

Background

Intercostal catheters (ICCs) are standard management for traumatic pneumothorax (PTx), haemothorax (HTx), and haemo/pneumothorax (H/PTx). Pigtail catheters inserted using the Seldinger technique have emerged as a recognised alternative. Insertion steps are well described through the ‘triangle of safety’ using the sterile technique. Complication rates for chest drains have been reported as a variable rate, but complication reporting varies considerably, and some studies may overstate the clinical significance of minor events that do not require intervention. The Clavien-Dindo (CD) classification provides a standardised, intervention‑based method for grading complications and may offer a more clinically meaningful assessment than descriptive categories alone. This study examines chest drain complications at a regional trauma centre, comparing both conventional categories (positional, insertional, and infective) and a CD‑based definition.

Methods

A retrospective audit of all adult trauma-related ICC and pigtail drain insertions at Townsville University Hospital between February 2020 and February 2025 using data acquired from the Townsville Trauma Service Trauma Registry Information System (TRIS) was undertaken. Complications were recorded using (i) conventional definitions (insertional, positional, and infective) and (ii) CD-based complications (CDI, CDII, CDIIIa, CDIIIb, CDIVa, CDIVb, CDV). Comparative analysis was also performed to identify factors associated with adverse events.

Results

A total of 117 chest drains were inserted into 101 patients during the study period, with 71 of those being ICCs and 46 pigtail drains. The mean injury severity score (ISS) was 20.6; 90.5% percent of chest injuries were blunt and 9.5% were penetrating. Drain insertion was mostly performed for PTx and HPTx (43.6% and 41.9%, respectively), with a further 10.2% inserted for isolated HTx. One ICC was inserted for a chylothorax (CTx). The overall complication rate using the conventional definitions was 40.2% (2 insertional, 44 positional, and 1 infective). Most positional complications were due to post-drain removal (HTx (16) and PTx (20)); however, only 30% of these required drain reinsertions. The rate of complications using the CD classification was 16.2% (1 CDl, 14 CDIIIa, 3 CDIIIb, 1 CDIVa). There were no deaths related to chest drain insertion. In haemodynamically stable patients, ICCs demonstrated a higher proportion of both conventional complications (51% vs 37%) and CD‑classified complications (21.2% vs 5.3%); however, neither difference reached statistical significance. Clinician specialty and seniority had no effect on complication rates.

Conclusion

This study provides an important addition to the limited Australian literature on complications following chest drain insertion. Reported complication rates following chest drain insertion for chest trauma are higher using a conventional classification than with the CD classification. The additional recorded complications in the conventional classification do not result in clinically significant morbidity or interventions. Severity‑based classification for complications using the CD framework provides a more nuanced representation of patient harm and may improve the quality of future research in this area. This study supports the continued selective utilisation of pigtail catheters as a safe and less invasive alternative to ICCs.