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Chest Drain

From Mediwikis

Michael Edwards

Last edited 15 05 2017.

LocSSIP Insertion of Chest Drain.png


Chapter 1.00 What is a LocSSIP?

A LocSSIP is a Local Safety Standard for Invasive Procedures.


First of all, a Safety Standard is an agreed way of doing something safely.

https://www.bsigroup.com/en-GB/standards/Information-about-standards/what-is-a-standard/


An Invasive Procedure is one where the patient's body is entered, such as by an operation, by needling, or by pushing in a tube.


To reduce errors made during Invasive Procedures, in 2105, NHS Improvement in the UK set up Safety Standards for Invasive Procedures at a national level. (NatSSIPs).

https://www.england.nhs.uk/patientsafety/never-events/natssips/


NatSIPPs aimed to guide hospitals in setting up their own Safety Standards at local level. (LocSSIPs).


BUT


NatSSIPs do not contain any information about safe ways of performing the invasive part of the procedures.


Most LocSSIPs contain very little.

https://improvement.nhs.uk/resources/examples-local-safety-standards-invasive-procedures/


However, the LocSSIP you are looking at now is based on MHDOS (Mastercript High Detail Operating System).


MHDOS enables the LocSSIP to provide all the information that an expert uses to perform an invasive procedure safely.

http://mediwikis.com/wiki/index.php/MHDOS_Masterscript_High_Detail_Operating_System


This includes all the WHO pre- and post-operative Surgical Safety Checks, plus how to perform them to the highest standard.

http://mediwikis.com/wiki/index.php/ACRONYMS_FOR_CHECKING_PATIENTS_BEFORE_OPERATIONS


Plus the multitude of per-operative safety checks, all scenarios and all the what ifs.

http://mediwikis.com/wiki/index.php/MHDOS_Masterscript_High_Detail_Operating_System


Chapter 2.00 Introduction to chest drain insertion

The procedure involves passing a tube drain between the ribs into the pleural space.

Overview of chest drainage.png

The pleural space lies between the ribs and the lungs.

Pleural space 17 12 2016.png

Abnormal fluid in the pleural space (gas or liquid) drains out through the tube.


It is collected in a bottle which has a non-return valve to prevent the fluid draining back into the patient.


Correct insertion of a chest drain (also called pleural drainage or thoracostomy) can save lives.


If performed incorrectly or when contraindicated:


At best, it is ineffective or risks introducing infection.


At worst, it can cause lethal injuries to the lung, heart, liver, spleen, and stomach.


In 2008, the National Patient Safety Agency reported 27 cases of death or serious injury associated with faulty chest drain insertion.


Chapter 3.00 This LocSSIP covers:

Insertion of chest drain for:


  • Chylothorax – liquid that leaked into the pleural space from a damaged lymph duct.


  • Haemothorax– blood in the pleural cavity often caused by trauma.


  • Malignant effusion– liquid in the pleural cavity from malignant deposits in the wall of the pleural space.


  • Pneumothorax– air in the pleural cavity usually leaking slowly from the lung.


  • Tension pneumothorax – air under pressure in the pleural cavity from a large leak from the lungs.


  • Postoperative pleural effusion with or without a pneumothorax.


    • Often caused by a leak from an operation to join the stomach to the oesophagus in the chest.


  • Patients with bleeding disorders are not excluded as long as the conditions are controlled.


  • Chest drain during thoracotomy.
    • Here the drain is pushed through the chest wall from inside to out, instead of from outside to in as in all the above.

Chapter 4.00 This LocSSIP does not cover:

  • Empyema drainage – this condition is best treated with VATS (Video Assisted Thorascopic Surgery). See on.


  • Seldinger technique - a way of making the path for the tube into the pleural cavity using a series of progressively

larger diameter needles.


  • Flap valve drainage


Chapter 5.00 Layout of Operation Sections and Steps

(MHDOS – Masterscript High Detail Operating System)


One of the fundamentals of safe invasive procedures is expert information.


These LocSSIPs contain all the information that an expert uses to perform an operation plus all the What ifs, per-operative safety checks, all

scenarios and all the what ifs.


Nothing is left to doubt.


The structure of a MHDOS/ LocSSIP consists of an unlimited number of Chapters.


Each Chapter is divided into an unlimited number of small Steps.


Each Step consists of an unlimited amount of information.


The information comes in one or more categories.


There are 3 main categories of information.


Basic information.


Problem- preventing information.


Problem- solving information.


Each category of information is divided into further sub categories.

http://mediwikis.com/wiki/index.php/MHDOS_Masterscript_High_Detail_Operating_System


Chapter 6.00 Anatomy review

The anatomy centres around the pleural space.

Pleural space 17 12 2016.png

This is a potential space, on each side of the chest, between the inside of the ribs, the lungs and the diaphragm.


The mediastinum with the heart, great vessels, lower trachea and bronchi lie between the two pleural spaces.


Each pleural space is completely lined by a thin sheet of tissue, the pleura.


The part of the pleura covering the lungs is called the visceral pleura. It is insensitive.


The pleura covering the inside of the rib cage is called the somatic pleura. It is very sensitive.


The pleura also lines the fissures that separate the lobes of each lung.


The pleural cavity is normally just a potential space filled with a few millilitres of tissue fluid.


Disease processes lead to the space filling with various fluids, both gases and liquids.


The organs surrounding the pleural space can be damaged by insertion of chest drains.


Previous surgery or infection in the pleural space nay lead to adhesions between the visceral and somatic pleura.


The ribs


The intercostal arteries, veins and nerves run in grooves on the lower, inner sides of the ribs.


They can be damaged by dissecting and inserting chest drains too close to the lower margins of the ribs.


A safer route is over the rib below the intercostal space and through the pleura well below the neuro-vascular bundle.

Ribs.png

The drain tube makes a softer curve, unlikely to kink.


This also makes a tunnel that will close when the drain is removed later.


A direct puncture may lead to a channel for air to enter the pleural space on drain removal.


The periosteum of the ribs is very sensitive.


The lungs, great vessels and heart


These organs can be damaged by chest drainage if the pleural space is only moderately expanded by fluid.


Liver and spleen


The domes of the diaphragm curve acutely upwards. They place the liver and spleen at risk of damage by dissecting or inserting a chest drain through the diaphragm.


Chapter 7.00 Pathology review

Different types of fluid in the pleural space are usually named as a Something-thorax. An exception is pus in the pleural space - empyema


Chylothorax


Chyle is fat-laden lymph from the bowel.


It runs through the cisterna chyli and lymph ducts in the posterior mediastinum.


It enters the venous system near the left subclavian vein.


If the lymph ducts are damaged by oesophageal surgery, the lymph will build up in the pleural space.


The leakage in most patients will seal off spontaneously with chest drainage for a week or more.


The patient will need dietary and fluid replacement of the losses from a draining chylothorax.


Empyema


An old term, meaning pus in the pleural cavity.


It is a complication of lobar pneumonia.


The pleural near the pneumonia is inflamed and thickened with a fibrinous exudate and pus filling the pleural space.


The consistency of the pus can be like thick porridge.


The pus can be loculated and involve the fissures between the lobes of the lungs.


The condition can progress to dense thickening of the pleura with possible rupture into the lung to form a broncho- pleural fistula


Aspiration is not feasible.


Chest drainage of the pus and loculi is not usually successful.


Videoscopic Assisted Thoracic surgery (VATS) is the treatment of choice before the adhesions are too dense.


Decortication of the lung may be needed for failed tube drainage or delayed VATS.


Haemothorax and Haemo/pneumothorax


Bleeding usually follows trauma to the chest (including iatrogenic trauma).


Rib fractures.


Lung injuries.


Great vessel and heart injuries.


In severe cases, there may be a haemothoraxes on both sides, needing bilateral chest drainage.


Minor haemothoraxes are usually managed by chest aspiration.


Malignant effusion


Deposits of tumour on the pleura may provoke an effusion of serous fluid in the pleural cavity.


Mucus secreting tumours may produce thick mucus that needs chest drainage.


Pneumothorax and tension pneumothorax.


Puncture of the lung by fractured ribs, gunshot wounds, knife wounds and explosions.


Rupture of a bulla on the surface of the lung.


Rupture of oesophagus.


Leak from oesophageal anastomosis.


Leak from necrotic intra- thoracic stomach.


Postoperative pleural effusion


Leak from an anastomosis between oesophagus and stomach or small bowel.


Leak from a necrotic intrathoracic stomach.


Food solids and liquids, saliva and swallowed air will empty into the pleural space.


Chapter 8.00 Instruments and materials review.

Management of chest trauma can be a fast changing scenario, with spillage of pleural fluid and even rapid escalation to a thoraco-laparotomy.


The success of the procedure depends on correct instruments and materials being present, assembled, checked and in working order before the


procedure begins.


Dress


All the team should wear sterile operating gowns with aprons and rubber boots, masks and visors.


Equipment


Hair clippers


Instrument trolley


Sterile suction on table.


Sterile trolley cover.


Sterile drapes


Gauze swabs 20


Sponge holders 2


Drain tube


  • 28 French gauge outside diameter. Ie 28 mm. circumference and 9 mm. external diameter.


  • Circumference is pi (3.142) times the diameter.


  • Non kinking when curved.


  • End hole.


  • Side drainage holes.


  • Radio-opaque lining strips in the wall of the tube.


Strip interrupted by the side holes to show position of the drain on post operative chest X ray.


Remove any metal central rod from the drain and discard. Danger of damage to intrathoracic and intra abdominal organs.


Smaller drain tubes require just as large a skin incision as for a 28, and are more likely to kink and block.


Connecting tubing


  • 28 French gauge outside diameter.


  • 90cm. long to reach from chest to floor.


Connectors 3 Very important


  • 1 to connect drain to connecting tube.


  • 1 to connect connecting tube to Under water seal bottle.


  • 1 to connect Under water seal to wall suction tubing.


Medium artery forcep 1 to perform the blunt dissection.


Large artery forceps 2.


1 to clamp the non-patient end of the chest drain.


1 to support the other end of the chest drain during insertion into the pleural cavity.


Stitch scissors


Kidney dish


Skin preparation eg 5% aqueous Povidone iodine.


Gallipot for skin preparation.


Local anaesthetic syringe 10ml.


Local anaesthetic needles 15 and 21 swg.


Local anaesthetic 1% lidocaine. 30ml. available.


Scalpel Swann and Morton no 10.


Aspiration needle 18 swg and 20ml. syringe.


Skin suture no1 silk ( breaking strength 3000gm) on a cutting hand needle. Eg Ethicon W 799.


Underwater seal bottle with top sterilised and sealed.


2 Artery forceps to clamp connecting tube when moving patient or changing

    bottles.


Mop


Bucket


Chapter 9.00 Operation review

Under normal circumstances, the procedure below will take 5 - 10 minutes to perform as long as all the preparation and checks on equipment and

materials have been performed.


In an emergency (eg severe tension pneumothorax), a relieving insertion of a wide bore spinal needle eg 18 swg can be performed within 1 minute,


to be followed by a formal chest drain insertion.


The procedure consists of:


Positioning and draping.


Incision site anaesthesia.


Incision

  • Skin


  • Fat and intercostal muscles are opened by blunt dissection.


Needle the pleural space to confirm presence of fluid


Open the pleura by blunt dissection.


Take samples of fluid for bacteriology and cytology/ histology.


Insert drain tube.


The drain tube is attached via the connecting tube to the underwater seal bottle.


Drainage is confirmed.


The drain tube is sutured in place.


Wound closure.


Postoperative checks


Chapter 10.00 Environment

Check the room.


Ideally an operating theatre has the necessary space, cleanliness and resources for insertion of a chest drain.


If no complications are expected:


A dedicated, spacious and clean side ward is satisfactory.


A normal ward lacks these features usually and should not be used.


Check the bed/operating table


A bed may be too wide for easy insertion of a drain into the 5th intercostal space.


An operating table will be needed if the procedure may progress to thoraco-laparotomy.


Chapter 11.00 Check the personnel

Operator


Assistant


Scrub nurse


Runner


Nurse to hold patient’s hand and provide comfort.


Senior medical staff member available to advise and assist as needed.


Chapter 12.00 WHO Sign in and Time Out and Preliminaries

These checks are complementary to the preliminaries checks in masterscripts.


Step 12.01 WHO Sign in and Time Out before the induction of anaesthesia


□ patient has confirmed


identity


site


procedure


consent


□ site marked/not applicable


□ anaesthesia safety check completed


□ pulse oximeter on patient and functioning


Does patient have a known allergy?


□ no


□ yes


Difficult airway/aspiration risk?


□ no


□ yes, and equipment/assistance available


Risk of >500ml blood loss (7ml/kg in children).


□ no


□ yes, and adequate intravenous access and fluids planned


Time out


A short meeting of the team before the skin incision


Confirm all team members have introduced themselves by name and role


□ surgeon, anaesthesia professional and nurse verbally confirm


patient


site


procedure


Anticipated critical events


□ surgeon reviews: what are the critical or unexpected steps,


Operative duration, anticipated blood loss?


□anaesthesia team reviews


Are there any patient-specific concerns?


□ nursing team reviews


Has sterility (including indicator results) been confirmed?


Are there equipment issues or any concerns?


Has antibiotic prophylaxis been given within the last 60 minutes?


□ yes


□ not applicable


Is essential imaging displayed?


□ yes


□ not applicable


Step 12.02 Preliminaries.


Check the relevant investigations.


Chest X-ray


Ultrasound


CT scan
  
Weight


Step 12.03 Check the operator has agreed the technique with his/ her senior.


For a trauma patient:


Be prepared for chest drains on both sides.


Be prepared for emergency thoracotomy and major thoracic surgery


Step 12.04 Check there is no other procedure to do


Step 12.05 Check the incision site


Step 12.06 Identify the Triangle of Safety


The triangle of safety is an area on the patient’s chest wall which does not carry high risks of damaging underlying intrathoracic organs.


It lies:


Behind the pectoral muscles.


In front of the latissimus dorsi, in the mid axillary line.


Down to the 6th rib.


The triangle of safety is not always the best site if there is a localised effusion below this level.


It is at the level of the nipple in a male and at the level of the inframammary skin-crease in a female.


In practice, the 6th rib is the essential landmark.


Step 12.07 Check the under water seal bottle.


The diagram below shows the simplest underwater seal system.

Underwater seal for chest drainage.png

Other more elaborate versions follow the same principles as here.


Make sure you understand how the system you are using works.


Step 12.08 Check the connecting tubing and chest drain connections.


Add connectors as needed.


Note that connectors narrow the effective diameter of the tubing of the system.


Step 12.09 Check the reservoir of saline in the bottle.


Pour 2 litres of saline into the bottle.

Check that the lower end of the longer (patient) tube lies 5cm. below the surface of the saline


This is the under-water seal.


Step 12.10 Mark and date the saline level on the bottle.


Use a sticky label or a permanent marker.


Step 12.11 Check the connecting tubing.


Check the patient end of the connecting tubing will fit onto the chest drain.


Use a connector/ adaptor as needed.


Check the other end will fit onto the longer bottle tube.


Check the connectors between the drain tube and the connecting tube.


Step 12.12 Check 2 arterial clamps are available to clamp the connecting tube when changing the underwater seal bottles.


Step 12.13 Check the tray for the bottle to stand in to prevent damage by kicking.


Step 12.14 Check the syringe for aspirating the chest.


20 ml syringe with 18 swg needle.


Step 12.15 Check the cytology bottle and laboratory form.


Step 12.16 Check the bacteriology bottle and laboratory form.


Step 12.17 Check request form for a post insertion Chest Xray.


Postero- anterior erect.


Step 12.18 Check the adhesive bandage to stabilise the connecting tube.


Step 12.19 Check the thoracotomy general instruments are available if needed.


Alert thoracic team.


Step 12.20 Check bucket and mop available for spillages.

Chapter 13.00 Position

Supine at 45 degrees if patient can tolerate it.


If not:


Patient may have to have the procedure performed sitting almost upright.


Arm abducted and hand placed behind head.


The arm may need support from a non-scrubbed person.


NB. This is an uncomfortable position to be held for more than 10 minutes or so.


Make sure the procedure is finished within this time.

Chapter 14.00 Check the skin marking.

Finding the triangle of safety.


Identify the fifth intercostal space in the mid axillary line.


Count down from the 1st interspace under the clavicle.


Continue counting down in the triangle of safety.


Mark the site of the 6th rib


The incision will be into the skin over the 6th rib to make an oblique upward path for the drain tube up to the 5th intercostal


space.


Use a skin marker that will not wash off or fade with the skin preparation or tattoo. Eg Magic Marker

Chapter 15.00 Scrub up

Operating team scrub up, gown up and put on sterile gloves.


Chapter 16.00 Stance

Operator stands on side of drain insertion.


If both sides are to be drained:


Stand on side of greatest injury and drain that side first.


Assistant stands at the patient’s side near the operator.


Scrub nurse with instrument trolley nearest to operator’s dominant hand.


Chapter 17.00 Skin Preparation

Clip hairs as needed.


Clip hairs from the hemithorax and axilla.


This will allow good adhesion of Elastoplast that will be holding the connecting tubing to the patient’s chest at the end of the


operation.


Clip both sides for traumatic haemothorax/ pneumothorax


Clean the skin.


Use gauzes in sponge holders


Use 2 applications of eg Povidone iodine (Betadine).


Dry off, especially for self adhesive drapes.

Chapter 18.00 Towelling up

Place sterile towels around a 15 cm. area centred on the incision site.


Fix with towel clips or use self adhesive drapes.


Arrange the drapes so that any fluid spilling from the wound will run down into a bucket.

Chapter 19.00 Check the on-table instruments and materials.

Check the scalpel eg Swann Morton No 10 or 15


Check the 2 artery forceps for the blunt dissection.


Check the drain tube


28 French Gauge ie Circumference is 28mm.


The diameter is about 9mm. (about 1/3 of the circumference or to be precise 1/pi which is 1/ 3.142).


For trauma use 40 French Gauge ie 40mm. in circumference


Remove any metal rod and discard


Clamp patient end of drain tube with one artery forcep


Fix other artery forcep onto distal end of tube


Check the needle and suture


Check the scissors

Chapter 20.00 Local anaesthesia

Use a 10ml. syringe.


A 20 ml. syringe may not give enough pressure.


Fix a green 21 swg (0.8mm. diameter) needle onto the syringe.


Push needle onto the Luer lock and twist until creaking stops.


Draw up local anaesthetic.


Use 1% plain Lidocaine.


NB A 1% solution is 10 mg. per ml. NOT 1 mg. per ml.


Maximum dose of Lidocaine is 3mg./ kg.


Ie a maximum volume of 1% Lidocaine for a 70 kg. patient is 20 ml.


Change to an orange 25 swg (0.5mm.) needle.


Raise a skin bleb.


Infiltrate the skin slowly.


Use 5ml. Lidocaine


Change back to a green needle and secure .


Infiltrate 5ml. Lidocaine slowly into the fat and intercostal spaces.


Wait 5 minutes for the anaesthetic to take effect.


For an obese patient:


Infiltrate more anaesthetic if you reach sensitive tissue.


Recheck the incision site


Test the incision site for numbness.


Tap the skin with the end of the needle


If sensitive:


Wait another 3 minutes.


Give more Lidocaine


Problems with local anaesthesia


Overdose leading to:


Bradycardia and asystole


Respiratory arrest


Convulsions


Unconsciousness


Treatment


Supportive until anaesthetic has worn off


Oxygen, ventilation, IV fluids, anticonvulsants, ephedrine


Anaphylactic reactions leading to:


Sweating


Urticaria


Tachycardia


Bronchospasm


Syncope


Treatment


Adrenaline 1mg. subcutaneously.


Chapter 21.00 Make the incision.

Step 21.01 Skin


4cm. long incision to accommodate index finger later.

(The index finger will be larger than the drain tube.)


8cm. is the circumference of an average index finger.


Ie The two sides of the incision add up to 8 cm.


A shorter incision will not allow the finger through the skin incision.


A longer incision may be difficult to make airtight or liquid tight on closure.


Step 21.01 Fat and intercostal muscle


Use blunt dissection.


Push closed forcep jaws into the wound until resistance is felt.


Open jaws wide.


Pull out jaws, still wide open.


Close jaws and reinsert.


Repeat until pleura is met.


A pinky sheet running between the ribs of the intercostal space.


Thickened inflamed tissues suggest an empyema or malignancy


If painful:


Wait 3 minutes for anaesthetic to act.


Use more anaesthesia as needed

Chapter 22.00 Needling the pleura.

Insert an aspiration needle.


2cm. through the pleura.


If air is withdrawn:


Continue with opening the pleural space


Prepare to release a pneumothorax. See on.


If air is under pressure:


Air leak from the lung, bronchus or trachea.


Let air release slowly to prevent a mediastinal shift.


If frothy blood is aspirated:


You may have needled adherent lung.


Remove the needle.


Insert the needle in another part of the pleura.


Prepare for a very cautious opening of the pleural space.


If the aspirated fluid is blood:


Bright arterial blood means major damage to the chest wall, left side of the heart and the aorta.


Prepare for emergency thoracotomy.


Insert a chest drain on the other side as well.


Dark venous blood suggests damage to chest wall, major veins or right side of the heart.


Continue with chest drain insertion.


Emergency thoracotomy may be needed.


For a malignant effusion


The fluid may be serous, mucous or bloody.


Continue with opening the pleural space.


Be prepared to feel nodules inside the pleural cavity.


Biopsy the pleura if thickened


For chylothorax


Milky white fluid.


Continue with insertion of the chest drain.


If no fluid is obtained:


The fluid may be too thick for the needle.


Eg Clotted blood.


Thick pus in an empyema.


Continue with careful opening of the pleural space – see on


Call for advice from the senior person on standby.


If air and mixed with pus and food/liquid is aspirated:


Prepare for drainage of a leak from an oesophageal anastomosis.


Continue with opening the pleural space


If smelly liquid is aspirated:


Suspect a necrotic intrathoracic stomach.


Continue with opening the pleural space.

Chapter 23.00 Opening the pleural space.

Use blunt dissection with your index finger.


NB.Have the chest drain with its 2 forceps attached and ready to insert at this stage, in case it is needed rapidly.


Cut the non-patient end of the drain transversely.


This will make connection to the connecting tube secure.


Clamp the non-patient end of the drain across with one large artery forcep.


Grasp the patient end of the drain obliquely with the forcep.

Grasp the chest end of the drain.png

This will stiffen the end of the drain for insertion and for positioning it in the pleural space.


Make sure the forcep makes a smooth shape with the end of the drain.


Be prepared for:


The finger suddenly entering the pleural space in an uncontrolled manner.


Brace yourself against the operating table for security.


A sudden gush of liquid and/or air.


Check the drapes will allow liquid to run into the bucket on the floor.


Have your assistant hold the kidney dish against the patient’s chest below the incision.


Have the scrub nurse holding the sucker.


Continue finger dissection.


You will feel your finger popping through the pleura.


There may a spillage of liquid.


Use the sucker.


Collect any overspill in the kidney dish.


Get your assistant to place a finger over the wound.


Get the chest drain.

Place your index finger on the joint on the forcep to prevent the tube and forcep suddenly going in too far.

If you do not come across fluid.


Push your finger in further.


If the tissues are too dense.


Call a more experienced operator.


If not done before:


Take samples of the liquid for bacteriology and cytology.


Chapter 24.00 Inserting the drain.

Examine inside the pleural cavity with your index finger.


Feel where the lung is.


Open a space big enough for insertion of the chest drain at least beyond the drainage holes in the tube.


Ideally ¾ of the length of the drain.


If the space is too small for the drainage holes to lie in the pleural cavity:


Call a more experienced clinician.


Cutting some of the chest end of the drain containing some of the drain holes may be adequate for drainage.


Remove the artery forcep.


Make sure the drain stays in the pleural cavity.


Push the drain into the space as far as 5cm. beyond the most proximal side hole.

For a pneumothorax:


Direct the drain towards the apex of the thorax.


For all other conditions:


Direct the tube downwards for dependent drainage.


Chapter 25.00 Suture the drain.

Use no 1 silk on a hand cutting needle eg Ethicon W 399.


Weaker sutures may break.


Insert the first stitch into the skin and fat.


Tie off with 4 throws.


4 throws around the drain at skin level.


Tight enough to make a minimal waist on the drain and prevent slipping.


A lattice pattern of the suture round the tube will usually slip.


Stitch through the skin and fat again.


4 throws to finish the knot.


This will prevent the drain slipping out.


Cut the ends 4cm. long for easy removal later.


Dress the wound with gauze swabs cut half way across to go round the tubing.


Secure the dressings with 4 inch Elastoplast.


Chapter 26.00 Connect to Under Water Seal system

Connect the drain tube to the connecting tube.


Use connectors as needed.


Release the clamps on the connecting tubes.


Keep the bottle below the level of the patient to prevent reflux of fluid into the chest.


Place the bottle in the tray to prevent accidental kicking.


Look for:


Air bubbles


Check for leaks in the tubing including the drainage holes.


Suspect leakage from the lung or other intrathoracic organs.


Liquid level in bottom of the waterseal tube swings with respiration.


If not:


Check the tubing is not kinked.


Look for liquid flowing.


Ie Collecting in the bottle.


Debris visible flowing along the tubing.


If not:


Check for tubing kinking.


Check for clots in the tubing.


Kink and squeeze a length of tubing to pump blood clot along.


Call a more experienced person.


Sudden release of gas may indicate lung damage from the dissection.


Continue the procedure and manage such a leak conservatively initially.


Estimate and record the drainage.


Reposition the fluid level marker on the bottle after each recording.


Be prepared to replace the bottle with another (containing 2 litres of saline) if the bottle contains more than 3 litres of fluid.


Curve the connecting tube onto the patient’s chest.


Make sure it does not kink.


Secure with 4 inch Elastoplast.


This will protect against:


Painful traction on the skin.


Kinking.


Blockage of the tubing.


Accidental knocking of the tubing.


Chapter 27.00 Final Touches and WHO Surgical Safety Checklist Sign Out .

Step 27.01 Check swab, needle and instrument counts.


Step 27.02 Clean up the patient and the operating area.


Step 27.03 Write records and sign.


Step 27.04 WHO Surgical Safety Checklist Sign Out


Nurse verbally confirms with the team:


The name of the procedure recorded


That instrument, sponge and needle counts are correct (or not applicable).


How the specimen(s) are labelled (including patient name).


Whether there are any equipment problems to be addressed


Surgeon, anaesthesia professional and nurse review the key concerns for recovery and management of this patient.


Chapter 28.00 Postoperative care

Step 28.01 Look out for:


Air leak


Mediastinal shift.


Sudden chest pain and breathlessness during too speedy release of fluid from the pleural space.


Partly clamp the connecting tubing to slow the flow.


Tubes blocking or kinking.


Try milking the blocked tubing.


Apply gentle suction to the under water seal suction tube.


Call a more experienced clinician.


Consider reinserting the drain.


Connections detaching.


Secure the connectors more tightly.


Bottle over filling.


If blood:


Suggests serious bleeding.


Call a more experienced clinician.


Step 28.02 Observations


Hourly for the first 6 hours, then 4 hourly.


Pulse


Blood pressure


O2 saturation.


Respiratory rate.


Drainage volume and colour.


Presence/ absence of bubbles.


Step 28.03 Prescribe Analgesia


As needed.


Step 28.04 Write a report in the case notes and sign.


Ie. What was found, what was done and what the plans are.


Step 28.05 Letter to GP, referring consultant and copy to patient


Step 28.06 Fill in Audit form


Step 28 .07 Order a chest X-ray erect postero-anterior.


Look at the films for:


Correct tube position.


Progress of reduction of remaining fluid


Chapter 29.00 Equipment and materials

Hair clippers

Instrument trolley

Sterile suction on table.

Sterile trolley cover.

Sterile drapes

Gauze swabs 20

Sponge holders 2

Scalpel Swann-Morton no 10 or 15

Drain tube

28 French gauge outside diameter.

Ie 28 mm. circumference and 9 mm. external diameter.

Circumference is pi (3.142) times the diameter.

Non kinking when curved.

End hole

Side drainage holes.

Radio-opaque lining strips in the wall of the tube.

Strip interrupted by the side holes to show position of the drain on post operative chest X ray.

Remove any metal central rod from the drain and discard.

Danger of damage to intrathoracic and intra abdominal organs.

Smaller drain tubes require just as large an incision as for a 28, and are more likely to kink and block.

Connecting tubing

28 French gauge outside diameter

90cm. long to reach from chest to floor.

Connectors 3

Very important

1 To connect drain to connecting tube.

1 To connect connecting tube to Under water seal bottle.

1 To connect Under water seal to wall suction tubing.

Medium artery forcep 1

To perform the blunt dissection.

Large artery forceps 2.

1 to clamp the non-patient end of the chest drain.

1 to support the other end of the chest drain during insertion into the pleural cavity.

Stitch scissors

Kidney dish

Skin preparation 5% aqueous Povidone iodine.

Gallipot for skin preparation.

Local anaesthetic syringe 10ml.

Anaesthetic needles 15 and 21 swg.

Local anaesthetic 1% lidocaine. 30ml. available.

Aspiration needle 18 swg and a 20 ml. syringe.

Skin suture no1 silk ( breaking strength 3000gm) on a cutting hand needle.


Eg Ethicon W 799. 
 

Underwater seal bottle


2 Artery forceps to clamp connecting tube when moving patient or changing bottles.

Mop

Bucket

Chapter 30.00 Feedback, Comments and Audit

Date 24 12 2106 Name M H Edwards Hospital Friarage Hospital Department Surgery Comment

Chapter 31.00 Alterations, Additions, and Amendments

31 August 2017 Use ultrasound guidance for chest drain insertion whenever possible. British Medical Journal Best Practice 2106

Chapter 32.00 Insertion of chest drains during thoracotomy.

This procedure entails insertion of the 2 chest drains backwards from the inside of the pleural space to the skin.


Step 32.01 Cut the non patient end of the first drain obliquely at 45 degrees.


Step 32.02 Get ready to grasp the long lip of the obliquely cut drain with the large artery forceps.


This will make a smooth passage of the drain through the tissues.


Step 32 .03 Place one hand inside the bottom of the pleural space.


Step 32.04Identify the anterior part of the 10th intercostal space.


Step 32 05 Make a 2cm. incision over skin of the 10th intercostal rib.


Step 32 .06 Burrow down to the 10th rib.


Use a large artery forcep.


Step 32 .07 Burrow over the top of the 10th rib to enter the pleural space.


Step 32.08 Place the drain in the pleural space via the thoracotomy wound.


Grasp the long lip of the patient end of the chest drain.


Use the long artery forceps.


Step 32 .09 Pull the drain though the intercostal space from inside to out.


Keep the side holes of the drain in the pleural space.


Step 32.10 Place the patient end of the drain in the apex of the pleural space.


Step 32.11 Remove the artery forcep from the drain.


Step 32.12 Cut the non patient end of the drain transversely.


Step 32 .13 Suture the drain.


Use no 1 silk on a hand cutting needle eg Ethicon W 399.


Weaker sutures may break.


Insert the first stitch into the skin and fat


4 throws around the drain at skin level.


Tight enough to make a minimal waist on the drain.


Stitch through the skin and fat.


Tie off with 4 throws.


Cut the ends 4cm. long.


This is the Anterior Apical chest drain secured.


Step 32.14


Repeat for the Basal drain at the Back of the 10th intercostal space.


GO TO: Chapter 25.00 Connect to Under water seal system