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Insertion of a surgical chest drain
- 1. Surgical chest drain insertion Joshil Lodhia CT1, Cardiothoracic Surgery University Hospital of South Manchester
- 2. Pre-procedural checks • Consent • Clotting • Assess the CXR prior to insertion • Indication alters placement (Apically or basally) • Ensures correct side • Equipment • Giving oral analgesics 20 minutes prior to placement helps optimise pain relief
- 3. Equipment • Chlorhexidine/ Povidone-iodine • Drapes • Gloves, gowns, scrub hat, face mask • 1% Lignocaine 10-20ml (max dose: 3 ml/kg) • 10-20ml syringe • 2x green needles • 1x orange needle
- 4. Equipment cont… • Chest drain kit • 10 blade and handle • 2x curved clamps • Scissors • Chest drain (18-32F depending on indication) • Gauze • Drain tubing • Underwater seal drainage system • Fill to the mark with sterile water • 1-0 Silk suture • Dressings
- 5. Preparation • Placement • Patient at 30-45 degrees • Arm behind his/her head • Safety triangle • Anterior border made by the lateral border of pectoralis major • Posterior border made by the lateral border of latissimus dorsi • Inferior border made by the 5th intercostal space • Scrub, gown, gloves, scrub hat, face mask • Clean skin with prep • Place the drapes
- 6. Anaesthesia • Palpate the ribs and infiltrate with 1% ligocaine just above the rib • Go into pleura above the rib till fluid/air is aspirated • Pull back a small amount till it is no longer aspirating and infilatrate further • Wait 5 minutes and ensure adequate anaesthesia • Create an incision the width of your finger/drain
- 7. Dissection • Place the closed curved clamp through the incision • Curve facing down • Rest on the rib below (dissect above the rib) • Hold the clamp close to the skin to prevent it slipping too far into the chest • Place the clamp in closed then open to dissect • Close and pull the clamp out and repeat • Continue until into the pleural space • Hear a hiss or obtain fluid. • Open the clamp in that space to create a space.
- 8. Drain placement • Place a finger into the pleural space • Sweep 360 degrees to free adhesions and ensure correct placement • Place a holding suture and a vertical mattress suture • The vertical mattress suture is for when the drain is removed • Placing the suture now ensures it does not catch the drain later • Place a clamp on the end of the drain to ensure air does not enter the chest • Place the curved clamp at the tip of the drain to help guidance • Insert the drain • Apex for pneumothoraces • Basally for effusions
- 9. Procedure cont. • Advance the drain till all the drain holes are in the chest cavity • Secure the drain with the previously placed holding suture • Attach the drain tubing • Attach the tubing to the underwater system • Release the clamp from the drain and ensure swinging (and bubbling if pneumothorax) • Make a slit in the gauze and place around the drain and apply the dressings
- 10. Post-procedural checks • Re-examine the patient • Ensure fluid level is swinging • It may also be bubbling in the presence of a pneumothorax • CXR to ensure correct placement and reassess the lung status
- 11. Further tests • If effusion present send sterile samples for • MC&S including Acid fast bacilli • Cytology • Glucose • Protein • LDH • Lactate • pH