Thoracic Surgical Treatments Flashcards
what is a thoracocentesis?
procedure involving the puncture of the pleural space for diagnostic and/or therapeutic purposes
what should you prioritise when performing a thoracocentesis?
- safety
- sterile skin prep
- gloves
- sterile drape
what equipment do you need for a thoracentesis?
- Oxygen
- Short-acting local anaesthetic +/- anxiolytic
- Sterile prep (clippers, scrub, surgical spirit, sterile gloves +/- drape)
- Needle / IV catheter / butterfly catheter. Butterfly catheters available 20/22g for cats/small dogs &
18/20g for larger dogs - IV catheters
- Needles / Butterflies
- Assistant
- 3-way tap
- 20ml syringe – size determined by volume expected
- +/- Extension set
- Kidney dish / jug
what is a chest drain?
A tube placed into the
pleural space to allow
ongoing, continuous or
intermittent therapeutic
drainage
When is a chest drain usually placed?
➢ Intermittent thoracocentesis not working
➢ Following thoracotomy
➢ Long term pleural drainage required
➢ Instillation of medication
why might an intermitten thoracentesis not work?
- Too much air/fluid being produced
- Fluid too thick to come through butterfly
- Proving too risky – causing lung trauma
why might you place a chest drain after thoracotomy?
- Remove fluid/air introduced during surgery
- Detect fluid/air being produced due to the underlying condition
- Detect fluid/air being produced due to complications of surgery
what medication can be put through a chest drain?
- Local anaesthetics
- Saline for lavage of pyo
- Antibiotics
- Chemotherapy
what types of chest drain are there?
- Large bore
- Narrow bore
what techniques are there to place a chest drain?
- Trocar
- Seldinger technique
how would you select a chest drain?
- Type
- Size - 6Fr - 20Fr
- Placement method - closed or open chest
- Site - unilateral or bilateral? fenestrations all in chest?
- Connectors -
- Securing & protecting
what are trochar style chest drains?
- Fenestrated with/without stylet. Stylets blunt or sharp.
- Most commonly placed under GA
- Need a subcutaneous tunnel as air leaks common
- Rigidity means easy to place where you want them
- Higher risk of tube-associated complications such as lung damage on insertion / pneumothorax»
complication rates up to 58%
what are the benefits of a trochar sytle chest drain?
- lots of different sizes available
- Versatile, good for air or fluid, large bore means less likely to block
- Robust / don’t collapse
- Once learned, easy to place
- Most transparent so easy to monitor for stuff that could clog the tube
what are the disadvantages of trochar style chest drains?
- Typically need a GA to place
- Likely to have higher complication rate than narrow bore though published evidence minimal
- Needs careful training
- Need to learn a good suture technique for anchoring (2nd technique to learn)
- Less comfy than narrow-bore
what are narrow bore/seldinger technique chest drains?
- May cost more for the actual tube than a trocar , but may be cheaper to place as no GA
- Not as important to have a subcutaneous tunnel as placement technique less invasive / air leaks less likely
- Lots of fiddly bits in the packet
what are the advantages of using narrow bore / Seldinger technique chest drains?
- No GA
- Easy to place
- Easy to secure
- Versatile
- More comfy
what are the disadvantages of using narrow bore/seldinger technique chest drains?
- May not cope with pleural fluid / block e.g. pyothorax
- Smaller sizes difficult in our patients as can be overlong meaning either too much inside the chest (prone to
kinking) or too much outside (vulnerable to patient interference) - Not as rigid can end up in weird placement: can be difficult to position cranioventrally as not as rigid as the trocar drains
- May not be able to do the normal SQ tunnel in a large patient as introducer catheters not that long
what are pleuralport chest drains?
the ones that look a bit like a stethoscope, used for palliatve care
what equipment will you need for closed chest placcement of a drain?
- Sterile prep (clippers, scrub, surgical spirit, sterile gloves +/- drape)
- Anaesthetic kit and monitoring as appropriate
- Local for narrow bore
- General for trocar
- Assistant
- Chosen chest drain, pre-measured for length
- Scalpel & blade
- Basic instrumentation (Rat-toothed forceps, needle holders, scissors, sterile swabs)
- Fenestrated drape
- 3-way tap
- Syringes (size depends on volume to be drained)
- Extension set
- Kidney dish / jug
- Suture
how do you secure a chest drain?
in-built anchor flanges and simple interrupted sutures
external drain-securing sutures
how do you manage a chest drain?
- Nursing
- Drainage
- Infection
- Analgesia
what types of drainage is there for chest drains?
intermittent and continuous
what is intermitten drainage of the chest?
drained usually every 4-6 hours depending on RR/dysponoea
what is continuous drainage of chest drains?
drain is continously draining
how do youreudce the risk of infection for a patient with a chest drain?
- Aseptic technique at all times
- Good bandage hygiene
- Early identification for culture rather than just giving antibiotics
what analgesia can be given for a hospitalised patient with a chest drain?
- Local e.g. lidocaine
- Systemic opioids e.g. methadone / buprenorphine
- Local down the chest drain e.g. bupivacaine
- CRIs e.g ketamine / lidocaine (no lidocaine in cats)
- Paracetamol injection (dog only)
what analgesia can you give to a patient who has gone home with a chest drain?
NSAID or oral paracetamol for dogs
what are there complications that can arise from a patient with a chest drain?
- Failure to place
- Failure to drain
- Patient
- Iatrogenic
- Introduction of infection
why might a drain failure to drain after placement?
- Inadvertent /accidental removal (kennel door, stood on by patient)
- Tube disconnection
- Tube obstruction (e.g. pleural, mediastinum, clots, pus)
- Tube kinking
- Tube slipped out a little. care not to break sterility
what issues can arise with placement of a drain?
- Unable to place
- Incorrect placement (went caudal not cranial; didn’t enter the thorax; stuck in mediastinum)
- Logical to check X-Ray post placement
what patient interference can cause a drain not to drain properly?
- Removal / chewing!
- Whole thing or part? Foreign Body? Chewing a hole in it?
what iatrogenic reasons might there be if a drain isnt draining properly?
- Haemorrhage / Haemothorax check PCV & look for a difference
- Heart / lung damage
- Inappropriate / premature removal»_space; recurrence
- Nerve damage – Phrenic / Horners
- Pneumothorax
- check connectors
- check fenestration
- Pyothorax - aseptic technique
- Seroma
- Subcutaneous emphysema
- Often around skin incision, can use antibiotic ointment to plug! Care with size of incision, should be snug
- Check position of fenestrations
- Self-resolves once tube removed (air reabsorbed)
why might you keep a chest drain in?
- Ongoing treatment via the drain
- Clinically significant production of fluid/air
why might you remove a chest drain?
- Complications
- Resolution of issue
- Ongoing need for drainage
what are the four main options for thoracic surgery?
- Left, lateral, intercostal thoracotomy
- Right, lateral, intercostal thoracotomy
- Ventral, sternal thoracotomy / sternotomy
- Thoracoscopy
what are the important notes to rememebr with a intercostal thoracotomy?
- defined next by numbered rib space
- Less painful than sternotomy
- Need to be sure that condition can be treated with unilateral surgery
- Need to be sure of the correct side to approach
- Need to be sure of the correct intercostal space to use
- Left vs right
- Where the organ is more accessible e.g. distal oesophagus (FB) => left side; PDA => left side
what are the things to rememeber with a sternotomy?
- More painful
- Better for exploratory thoracotomy
- Better for bilateral conditions
- Not so good for if the problem is in dorsal thorax
what are the things to remember with a thoracoscopy?
- Least painful
- Steep learning curve
- Specialised equipment
- Some limitations in which procedures can be safely completed using a scope.
- rapid recovery
- reduced visualisation
how would a sternotomy be performed?
- Dorsal recumbency
- Midline approach
- Osteotomy with saw blade
- Exploration of left and right sides
- Place chest drain under visual guidance
- Closure with metal wire or sutures
how would you lcip for a lateral thoracotomy?
- Clip correct side of chest
- Wide clip, long cranial –caudal
how would you clip for a sternotomy?
from thoracic inlet to mid abdomen
how would you clip for a thoracoscopy?
fully clipped in case have to convert to open
how would you position for lateral thoracotomy?
- Front legs +/- back legs loosely tied out of the way
- +/- sandbag under chest
how would you position for a sternotomy?
- Dorsal recumbency
- Legs tied loosely out of the way
- May need cradle and/or sandbags to stabilise if narrow chested
how would you position for a thoracoscopy?
- Can be done in both lateral and dorsal recumbency depending on the procedure
what are sternotomy instruments used for?
breaking through bone
what are tissue forceps used for?
- For atraumatic tissue handling
- For atraumatic, fine dissection
- For clamping vessels prior to ligation
what types of retractors are there?
handheld or self-retaining
what miscellaneous equipment would you need for thoracic surgery?
▪ Laparotomy swabs
▪ Wire or thick suture (1 PDS, 0 PDS)
▪ Suction
▪ Pre-selected chest drain & connectors
▪ Tourniquet
▪ Pledget sutures
▪ Vessel loops
what types of lung lebectomies can be done?
- Partial lobectomy (part of a lobe)
- Total lobectomy (one entire lobe)
- Pneumonectomy (one half of the lungs) = surprising how well they manage with only half a lung > expands to
fill the chest
how would you leak test a lung during surgery?
- Fill the chest with warm saline
- Suction on standby
- IPPV
- Check for air bubbles
- Suction fluid back out once happy
