INTERCOSTAL DRAINAGE Flashcards
WHAT IS ICD?
Method of draining fluid/blood/air collected in pleural cavity safely, so as to allow the underlying lung to expand
OUTLINE THE PROCEDURE FOR ICD
Patient is placed in the lateral position with the affected side down, and the head of the bed is inclined 10-15 degrees. Pt‘s arm on the affected side is extended forward or above his or her head.
Commonly tube is inserted into 5th ICS slightly anterior to the midaxillary line; but it may be inserted in 6th space, below in haemothorax or empyema or it may be upwards in 4th space in pneumothorax. In this position, muscle bulk is less & so easy to pass intercostal tube. Ideally inserted in 5th IC space
With the skin prepared, 1% lidocaine is infiltrated over 5th or 6th rib in the middle or anterior axillary line.
A 2- to 3-cm transverse incision is made through the skin and subcutaneous tissue. A curved clamp is used to bluntly dissect an oblique tract to the rib.
With careful spreading, the clamp is advanced over the top of the rib. The parietal pleura is punctured with the clamp, and an efflux of air or fluid is usually encountered.
A finger introduced into the tract to ensure passage into the pleural space and to lyse any adhesions at the point of entry.
With the clamp as a guide, the chest tube is introduced into the pleural space. It is directed apically for pneumothorax and basally and posterior for dependent effusions.
A clamp is placed at the free end of the chest tube to prevent drainage from the chest until the tube can be connected to a closed suction or water-seal system.
The chest tube is advanced until the last hole of the tube is clearly inside the thoracic cavity
When the tube is positioned properly and functioning adequately it is secured to the skin with two heavy silk sutures and covered with an occlusive dressing to prevent air leaks.
Some surgeons place a U-stitch around the chest tube to be used as a purse-string suture when the tube is removed.
A chest X-ray is obtained after the procedure to assess re-expansion of the lung and the tube position
WHAT DETERMINES THE SIZE OF A THORACOSTOMY TUBE?
The size of thoracostomy tube needed depends on the material to be drained. Generally a No. 24-28 Fr. Tube directed apically is used for a pneumothorax and a No. 28—32 Fr. Tube, directed basally are used for the evacuation of a Haemothorax and a dependent pleural effusion
OUTLINE THE TRIANGLE OF SAFETY IN ICD
Triangle of safety – British Thoracic Society describes safe zone as;
* Anterior-lateral border of pectoralis major,
* Posteriorly-mid axillary line - (anterior aspect of lattisimus dorsi),
* Apex-just below the axilla,
* Inferior- just below the nipple. This is not reliable in female
WHAT ARE THE CAUTIONS TO BE TAKEN NOTE OF WHEN ISERTING AND CARING FOR AN ICD?
The lung may have adhesions to the chest wall that make insertion and advancement of the thoracostomy tube difficult.
The intercostal neurovascular bundle runs in a groove on the inferior aspect of each rib so the tube should be passed over the top of the rib to avoid injury.
During normal respiration, the diaphragm can rise to the level of the fourth intercostal space so insertion of the chest tube lower than the sixth interspace is to be discouraged.
Profound coagulopathy and bleeding diatheses are a relative contraindication to the placement of chest tubes, and all efforts should be made to correct the coagulopathy before placing the tube
CATEGORISE THE INDICATIONS FOR ICD
(i) Pleural effusion
a. Haemothorax
b. Chylothorax
c. Malignant/Recurrent pleural effusion
d. Empyema thoracis
e. Haemopneumothorax
(ii) Gas in Pleura
a. Pneumothorax
b. In any hypoventilated patient.
c. Tension pneumothorax
d. Persistent recurrent pneumothorax
(iii)Post operations
a. Thoracotomy- to drain pleural cavity
b. Oesophagectomy
c. Cardiac surgery
d. Traumatic lung contusion
(iv) Surprise content
a. Bowel/Gastric content
WHAT ARE THE EARLY COMPLICATIONS OF ICD?
I. Early
(i) Misplacement
a. Subcutaneous- haematoma, seroma, subcutaneous emphysema can occur
b. Intraparenchymal
c. Dissection of extra-pleural plane due to failure to guide the tube into the pleural space. Diagnosis can be a difficult but A-P and lateral CXR should reveal a lung that has failed to re-expand and suggest a chest tube placed outside the thorax. Tube should be removed and placed within thoracic cavity to re-expand the lung
(ii) Injury to organs and other structures
a. Injury to the diaphragm with associated injury to the liver or spleen due to low placement of a chest tube.
b. Parenchymal or hilar injuries or cardiac contusions can occur with overzealous advancement of the tube or dissection of pleural adhesions
c. Injury to the heart
d. Phrenic never injury
e. Neurovascular bundle injury
f. Esophageal perforation- hemorrhage
WHAT ARE THE INTERMEDIATE COMPLICATIONS OF ICD?
II. Intermediate
a. Contralateral pneumothorax
b. Subcutaneous emphysema
c. Re-expansion pulmonary oedema
d. Tube blockage
e. Infection along the chest tube
f. Pain /intercostal neuralgia
g. Clogging of the ICT (40%) - complication which commonly goes unnoticed as the part inside the thoracic cavity gets clogged. Cause retained blood syndrome, tension pneumothorax, effusion, haemothorax.
h. Displacement, dyspnoea, cough, infection can occur
WHAT ARE THE LATE COMPLICATIONS OF ICD?
III. Late
a) Infection along the chest tube tract
b) Empyema
c) Abscess
d) Fistula formation
WHAT BOTTLES ARE USED FOR ICD?
(i) Under water vacuum
(ii) Under water seal
(iii) One way valve apparatus
HOW CAN ONE TELL IF AN ICD BOTTLE IS FUNCTIONAL?
How do you tell it‘s functional?
By moving meniscus
Ask patient to cough and check out bubbles in the bottle
HOW IS A PT WITH ICD TRANSFERRED?
How do you transfer the patient?
i. Clump the tube with an artery forceps
ii. Patient should carry it raised above insertion
iii. When you reach the place, put it down and unclamp
iv. The container should always be below the level of the pt. to avoid backflow of the fluid into the pt. chest
IN WHAT CASES IS A INTERCOSTAL TUBE PLACEMENT CONTRAINDICATED?
Contraindications for ICT placement
1. Traumatic diaphragmatic hernia
2. Refractory coagulopathy
3. Pleural adhesions
4. Emphysematous bullae
OUTLINE THE POST OPERATIVE CARE OF ICD
ICT care is crucial. Observe movement of the column and quantity of fluid collected.
Gently do mechanical manipulation (tapping, milking) to correct kinking, clot inside or to facilitate free flow of fluid but they are painful.
Closed chest tube clearing device using sterile magnetically wired loops can prevent clogging and blocking of tube to prevent formation of retained bld syndrome (haemothorax, pleural effusion, tamponade, atrial fibrillation).
At regular intervals check lung expansion.
Usually ICT is placed for 3–5 days for pneumothorax until lung expands is adequate, which should be confirmed by chest X-ray; for haemothorax for 4-7 days. For bronchopleural fistula ICT should be kept for longer period.
Do respiratory physiotherapy using spirometer or football balloon and breathing exercise.
HOW DO YOU REMOVE AN ICT?
It is done once chest X-ray confirms that the lung has expanded properly, pleural fluid drain becomes serous and less than 25 ml/ day for 3 consecutive days, water column movement becomes less than 1 cm.
It is removed under aseptic precautions; suture is removed; patient is asked to take deep inspiration; often outer end of the tube may be connected to low volume suction. At the summit of deep inspiration, tube is pulled out; wound is cleaned quickly and if sealing suture is present it should be tied firmly; sealed plaster dressing is placed to avoid re-entry of air into the plural cavity
