Practical procedures: Chest drain

Question 1

Chest drain: size

Answer 1

28 Fr

Question 2

Chest drain: What would you use to prime underwater seal?

Answer 2

Saline, not sterile water
Means any blood drained can be used for cell salvage

Question 3

Chest drain: Positioning

Answer 3

Lying flat or at 45 degrees, with their hand behind head

Question 4

Chest drain: Marking the site

Answer 4

Find the second intercostal space
Count down to fifth intercostal space
Slide finger laterally in this space, to the mid-axillary line
Mark the site

Question 5

Chest drain: Sedation

Answer 5

IV opioids/benzos

Question 6

Chest drain: Points to consider before starting:

Answer 6

-Ensure pt marked and consented
-Ensure drain indicated
-Ensure colleague is concentrating on pt and pt’s monitor
-Ensure pt is not on any anticoagulants/does not have coagulopathy

Question 7

Chest drain: Preparation:

Answer 7

Prep area with iodine/chlorhexidine
Drape pt avoiding face

Question 8

Chest drain: Infiltrate anaesthesia

Answer 8

Anaesthetise the skin
Aspirate air or blood
–> stop if can’t aspirate air/blood and reconsider diagnosis
Anaesthetise pleura and chest wall
Maximum 3 mg/kg 1% lignocaine

Question 9

Incision and blunt dissection

Answer 9

Incise the skin
Blunt dissection with curved clamp
Pierce the pleura
Widen the pleural breach
360 finger sweep

Question 10

Chest drain: inserting the drain

Answer 10

Mount the chest drain on a clamp
Insert chest drain (8-10 frail, 10-12 normal, 12-14 large)
Ensure proximal drain hole lies within chest cavity
Attach connecting tube to the underwater seal

Question 11

Chest drain: what is fogging of the tube?

Answer 11

Confirm that the drain lies within the chest wall cavity by noting fogging of the tube.

Question 12

Secure drain

Answer 12

Horizontal mattress suture
Knot the suture 10 cm high
Wrap the two ends firmly around the drain
Pull the knot underneath the horizontal suture
Loop around the drain and tie

Question 13

Things to check as part of post procedural care

Answer 13

Check XR: check that the proximal hole of the tube (as demarcated by a break in the tube’s radiopaque linear line) lies medial to the lateral rib border on the chest x-ray

Check for swinging: indicates drain is in correct position

Do not clamp tube or apply suction: leave this for CTS

Question 14

Chest drain procedure summary

Answer 14

Ensure consented and marked
Positioning
Sedation
Check indication/site correct, ensure have someone monitoring pt
Prep
Infiltrate local anaesthesia
Incision and blunt dissection
Insert drain
Check fogging of tube
Check XR

Question 15

Chest drain indications

Answer 15

-moderate or large pneumothorax
-visible haemothorax
-hemo/pneumothorax.

Question 16

Chest drain equipment

Answer 16

1. 3 sterile drapes
2. Skin antiseptic solution e.g. iodine or chlorhexidine
3. Needle and syringe
4. 1% lidocaine
5. Scalpel
6. Instrument for blunt dissection (e.g. curved clamp)
7. A chest drain
8. Rocket underwater seal
9. Suture (1’0 silk)

Other:
-Gauze
-Cotton wool

Question 17

PPE for procedure

Answer 17

Sterile surgical gown
Check pt’s ID badge