Inserting a Chest Drain . The Safe Triangle This is a triangle created by: - Mid-axillary line / boarder of latissimus dorsi - Lateral boarder of pec major - Imaginary horizontal line from the nipple And the drain is usually inserted in the 4th, 5th, or 6th intercostal space Find a location in the safe triangle > Alternate locations include 2nd intercostal space mid-clavicular line, and 7th intercostal space, posteriorly, but these are less comfortable for the patient. > Using 10-20ml 1% lidocaine inject down at the pleural level, just above the rib (to avoid the neurovascular bundle), usually the 6th rib > Then attempt to aspirate air of fluid – if you cant, then don’t insert the drain here! Wait 3 minutes, and try again > Then blunt dissect down to the level of the pleura (e.g. using scissors, using the opening action of the scissors to dissect, or using forceps) > Puncture the pleura with scissors or forceps > If you are using a large bore tube, you may need to insert a finger into your dissect to remove any adherent lung > Remove the metal part of the drip before inserting – you should already have done your dissection – don’t force it in! > Advance the drain slowly, using forceps if necessary. Stop if you hit serious resistance > Attached the other end of the drain to the underwater seal *The long tube should be under the water, and should bubble with respiration > Medium and large bore tubes may require suturing around the entry site > Fix the chest drain in place with a tie around the tube > Request CXR to ensure the drain has been placed correctly Clamping a chest drain * This is occasionally performed in the case of pleural effusion, to control the rate of drainage, as draining too fast can result in expansion pulmonary oedema. * You should never clamp a chest drain in the case of pneumothorax Complications - Trauma / injury to thoracic / abdominal organs - Trauma to the long thoracic nerve of bell resulting in wing scapula - Arrhythmia (rare) Things to watch out for * Backwards flow of water seal towards chest cavity. * Prolonged bubbling of the chest drain fluid. * Blockage of the tube due to kinks, blood clot / other. There will be no ‘swinging’ or ‘bubbling’ in the seal fluid. * Wrongly positioned chest drain – check the CXR. Removing the tube * Check there is re-expansion on CXR * In pleural effusion you may want to clamp the drain, as you may want to re-insert it * In pneumothorax, clamping is not necessary as reinsertion is unlikely * Give the patient a strong analgesic (e.g. morphine) * Remove the tube during expiration, and suture the insertion site
Posted on: Tue, 30 Jul 2013 02:03:35 +0000
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