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Clinical Practice Guidelines

RCH>Division of Medicine>General Medicine>Clinical Practice Guidelines>Chest Drain (Intercostal Catheter) Insertion

Chest Drain (Intercostal Catheter) Insertion

  • See also: Primary Spontaneous Pneumothorax
    Needle Aspiration

    Notes

    Fluid or air that accumulates in the pleural space will reduce lung expansion and lead to respiratory compromise and hypoxia.

    Insertion of an intercostal catheter (ICC) enables drainage of air or fluid from the pleural space, allowing negative intra-thoracic pressures to be re-established leading to lung re-expansion.

    Indications:

    • Pneumothorax
    • Haemothorax
    • Pleural effusion

    Contraindications:

    • Need for immediate thoracotomy  

    Complications:

    • Pain
    • Thoracic or abdominal visceral trauma
    • Tension pneumothorax

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    Equipment

    • Special procedures tray
    • Under water sealed drain system (UWSD)
      • use cell saver UWSD for massive haemothorax
    • Intercostal Catheter (guide sizes only)
      • use smaller size for draining air
      • larger size for draining blood/fluid
        • Newborn 8-12 FG
        • Infant   12-16 FG 
        • Child  16-24 FG 
        • Adolescent 20-32 FG
    • Spigot connector / tube adaptor - 2 sizes
    • Suction must be available and working
    • Sterile gloves & gown
    • Mask
    • Sterile towels x 2
    • 500ml bottle of sterile water
    • Antiseptic solution
    • 1% lignocaine + 1:100,000 adrenaline 5mL ampoule 
    • 5ml/10ml syringe and needle
    • Scalpel blade
    • Suture material - black silk or nylon with needle size 3.0 x 2
    • Sleek and Tegaderm x 2

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    Analgesia, Anaesthesia, Sedation

    Local anaesthetic and intravenous analgesia are mandatory, as ICC placement is a painful procedure. The use of sedation should always be discussed with a senior emergency doctor, as it can potentially worsen the patient's clinical condition.

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    Procedure

    Establish patient on continuous cardiac monitoring and pulse oximetry

    • Place conscious patient in a sitting position at 45 degrees with arm of same side placed above head
    • Palpate the fourth or fifth intercostal space just anterior to the mid-axillary line
    • Surgically prepare the area
    • Ensure local anaesthetic is infiltrated from subcutaneous tissue down to pleura. 
    • Select the appropriate size I.C.C. and remove stylet.
    • Incise the skin parallel to the upper border of the rib below the chosen intercostal space. Incise down to the fascia.
    • "Blunt dissect" (using an artery forcep) down to the pleura, enter the pleural space, and then widen the hole by opening the forceps.
    • Sweep the pleural space with a gloved finger to widen the hole and push the lung away from the hole (only possible in older children, beware of rib fractures in injured child).
    • Hold the tip of the catheter with a curved artery clamp and advance it into the pleural space, directing the catheter posteriorly and superiorly.
    • Advance so that all apertures of the tube are in the chest and not visible
    • Attach the tube to UWSD below the patient's chest level
    • Anchor the drain and suture the wound. Tape in place with tegaderm sandwich and anchor the tube to the patient's side.
    • Connect to the UWSD.
    • Watch for "swinging" of water in tube connection.

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    Post-Procedure Care

    Reassess ABCs and ensure ICC is functioning

    • Reassess need for analgesia.
    • In children following the removal of the tube coverage with a large tegaderm is sufficient for closure rather than a formal purse string suture.
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