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Procedural Skills (SLO6)
A 65 year old patient, who has smoked all his life, presents to ED complaining of a sudden pain in his right chest and shortness of breath. A chest x-ray shows a large right sided pneumothorax. The patient has a chest drain inserted using the Seldinger technique. On assessment of the drainage system, you note continuous bubbling in the water seal chamber. Which is the next correct management step?
Answer:
- Bubbling
- An air leak will be characterised by intermittent bubbling in the water seal chamber when the patient with a pneumothorax exhales or coughs. Continuous bubbling of this chamber indicates large air leak between the drain and the patient. Check drain for disconnection, dislodgement and loose connection, and assess patient condition.
Chest Drain Insertion: Seldinger Technique
Procedural Skills (SLO6)
Last Updated: 1st February 2023
Indications
- Pneumothorax
- In any ventilated patient
- Tension pneumothorax after initial needle relief
- Persistent or recurrent pneumothorax after simple aspiration
- Large secondary spontaneous pneumothorax
- Malignant pleural effusions +/- pleurodesis
- Empyema and complicated parapneumonic pleural effusion
- Haemothorax
- Post-surgical (e.g. thoracotomy, oesophagectomy, cardiac surgery)
Contraindications
- Absolute contraindications
- Nil
- Relative contraindications
- Anticoagulation or coagulopathy
- Overlying infection
Procedure
- Positioning the patient:
- Pleural ultrasound should be used to identify a safe site for aspiration and the site marked. Direct US guided aspiration or immediately prior to the aspiration are better than the ‘X marks the spot’ method.
- The preferred patient position for standard drain insertion is on the bed semi-reclined, slightly rotated, with the arm on the side of the lesion behind the patient’s head or on the hips to expose the axillary area or in the lateral decubitus position. An alternative is for the patient to sit upright leaning over an adjacent table with a pillow under the arms.
- Insertion should be in the safety triangle (the triangle is bordered anteriorly by the lateral edge of pectoralis major, laterally by the lateral edge of latissimus dorsi, inferiorly by the line of the fifth intercostal space and superiorly by the base of the axilla), unless an area is specifically identified under image guidance.
- Prior to insertion of an intercostal drain for pleural effusion an attempt to aspirate the pleural contents should be made; if this is not possible then intercostal drainage should not be attempted.
- Inserting the chest drain:
- Prepare for aseptic procedure with full aseptic technique including gowns, drapes, sterile gloves and sterilisation of skin.
- Infiltrate skin and proposed track with lidocaine 1% (maximum dose 3 mg/kg).
- Guide the access needle through the chest wall while aspirating with attached syringe. It is very important to guard against over insertion by gripping the access needle between thumb and index finger 1 cm from its tip. Stop and hold position as soon as air or fluid can be aspirated. Do not aspirate any more that is necessary to ascertain that the needle is in the pleural cavity as this may increase the risk of lung injury.
- Make a small incision in the skin. This must be larger than the circumference of the drain.
- Insert guide wire into needle with the help of the white plastic introducer. Watch for the mark on the wire which indicates adequate level of insertion when it is just entering the hub of the needle. If resistance is felt when inserting guide wire stop and remove wire and needle.
- While maintaining the wire in position, remove the needle.
- While maintaining the wire in position, introduce dilator over the wire and dilate the entry track with a gentle twisting motion. N.B. it is only necessary to insert the dilator until the widest point of the tapered end passes through the skin. This can be assured by holding the dilator about 1.5 cm from the tip, thus avoiding any deeper insertion. Remove the dilator.
- While maintaining the wire in position, feed the catheter over the wire and through the entry track with a gentle twisting motion. When the catheter has been inserted 1-2 cm beyond the drainage holes the guide wire can be removed.
- Fix in place with sutures and occlusive dressings, taking care to avoid kinking at the point of entry to the chest wall.
- Luer lock the 3 way tap to the catheter and attach, in-line, to tubing adapter and drainage system.
- Setting up the drainage system:
- A chest drain should be connected to a drainage system that contains a valve mechanism to prevent fluid or air from entering the pleural cavity. The most common system is the underwater seal bottle.
- The closed underwater seal bottle is a system in which a tube is placed under water at a depth of approximately 3 cm with a side vent with allows escape of air or may be connected to a suction pump. This enables the operator to see air bubble out as the lung re-expands in the case of pneumothorax or fluid evacuation rate in empyemas, pleural effusions or haemothorax. The inspiratory swing in the tube is useful for assessing tube patency and confirms the position of the tube in the pleural cavity.
- The disadvantages of the underwater seal system include the obligatory inpatient management, difficulty of patient mobilisation and the risk of knocking the bottle over.
- Managing the chest drain:
- A chest-x-ray should be obtained to check position of the chest drain.
- All patients with chest drains should be cared for by a medical or surgical team experienced with their management and nursed on a ward familiar with their care.
- Drains should be checked daily for wound infection, fluid drainage volumes and documentation for swinging and/or bubbling.
- The underwater seal bottle should always be kept below the level of the patient's chest.
- A bubbling chest tube should never be clamped; clamping a chest drain in the presence of a continuing air leak may lead to tension pneumothorax.
- A maximum of 1.5 L should be drained in the first hour after insertion of the drain (and no more than 4 L over 24 hours). Drainage of a large pleural effusion should be controlled to prevent the potential complication of re-expansion pulmonary oedema.
- There is no evidence to recommend or discourage the use of suction in a medical scenario, however it is common practice especially in the treatment of a non-resolving pneumothorax.
- Removing the chest drain:
- The chest tube should be removed once the fluid drainage has decreased to less than 200 ml per day, resolution of the pneumothorax or when the drain is no longer functioning.
Complications
- Persistent or recurrent pneumothorax/pleural effusion
- Improper placement of tube
- Tube dislodgement
- Kinking/compression of tube
- Obstruction of tube with blood, tissue or fluid
- Large primary air leak (air leak rate greater than air evacuation by tube)
- Disconnection from underwater-seal apparatus
- Bleeding
- Local bleeding
- Haemothorax (lung or intercostal artery injury)
- Haemoperitoneum (liver or spleen injury)
- Organ laceration or puncture
- Stomach, colon or diaphragm
- Lung
- Liver or spleen
- Infection
- Local infection
- Empyema
- Other
- Pain at site
- False passage
- Subcutaneous emphysema
- Re-expansion pulmonary oedema
- Intercostal or long thoracic nerve injury
- Anaphylactic or allergic reaction to surgical preparation or anaesthesia
Intercostal Artery Injury
Injury to the intercostal artery (ICA) is an infrequent but potentially life-threatening complication of all pleural interventions. Pleural haemorrhage is reported to occur in up to 2% of thoracocenteses, up to 13% of intercostal drain insertions and up to 4% of thoracoscopies.
Anatomy:
Current recommendations for chest drain insertion suggest that drains should be inserted in the ‘safe triangle’ in order to avoid the heart and the mediastinum and be above the level of the diaphragm. The safe triangle is formed anteriorly by the lateral border of the pectoralis major, laterally by the lateral border of the latissimus dorsi, inferiorly by the line of the fifth intercostal space and superiorly by the base of the axilla. Imaging guidance also aids in the safety of the procedure. Traditional anatomy teaching describes the ICA as lying in the intercostal groove, protected by the flange of the rib. This is the rationale behind the recommendation to insert needles just above the superior border of the rib.
Recognition:
ICA injury may be obvious at the time of the procedure: for example, during thoracoscopy, on pleural fluid aspiration or during image-guided intervention. However, the presentation may be delayed and injury may only be diagnosed when the patient becomes clinically unstable. It is therefore critical to have management protocols in place for the detection of haemorrhage. These include communication with the nursing staff that a procedure has been performed, regular post procedure observations and performing an early chest radiograph and repeat thoracic ultrasound.
Management:
Standard resuscitative measures should be followed by specific measures to control the haemorrhage, particularly direct external pressure over the intercostal space through which the pleura was punctured. Most patients with a haemothorax can be adequately treated with chest tube insertion, fluid resuscitation and/or transfusion of blood products. However, if the bleeding is not self-limiting, definitive management may require thoracic surgery or radiological intervention. Using angiographic techniques, it is possible to accurately localise the site of ICA haemorrhage and embolise the bleeding vessel.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
