Intercostal Catheter (Chest Drain)
OVERVIEW
- tube inserted into pleural space to allow drainage of contents
USES
- drainage of air/fluid from pleural space
- pleural lavage (e.g. rewarming in severe hypothermia)
METHOD OF INSERTION AND/OR USE
Anatomy
- insertion should take place on same side of haemothorax (ie. left)
- landmarks = “triangle of safety”: anterior to mid axillary line, posterior to pectoral groove, above 5th intercostal space
- layers that must be breached (superficial to deep) = skin, subcutaneous tissue, intercostal muscles, parietal pleura
- awareness of the intercostal bundle sitting on the inferior aspect of the ribs
Equipment
- sterile clothing (gloves, gown, hat, mask, facial shield)
- chlorhexidine in 80% alcohol
- sterile drapes
- lignocaine 1%
- 22G long needle
- scalpel
- curved forceps
- chest drain (>24 French for blood)
- suture material
- underwater seal drain
- dressing
Technique
- explain procedure, obtain consent, sterile environment with equipment ready, skilled assistant, adequate analgesia, adequate resuscitation equipment and recovery facilities
- check coagulation profile, Hb, platelet number -> transfuse accordingly
- in this patient it will be important to check urea as this will probably be elevated and will cause platelet dysfunction
- position patient (supine or 30 degrees head up) with arm abducted & elbow flexed
- sterile preparation of area
- identify rib spaces (4th to 7th) on left and anterior – mid axillary line
- skin infiltration with lignocaine 1%
- infiltrate down to parietal pleura (ensuring needle travels over the top of the chosen rib to protect neurovascular bundle)
- continuous aspiration of needle should reveal blood once in the pleural space
- make an incision following line of ribs with scalpel (1 to 2cm long)
- blunt dissection with finger or blunt forceps (this will ensure adherent lung is moved from insertion site)
- once parietal pleura breeched there should be a rush of blood
- dilate with finger
- load chest drain onto curved forceps (orientated towards the apex)
- use forceps to allow the clamped drain to follow the true lumen that has been created
- insert drain until an adequate length is within the pleural cavity (will depend of patient habitus)
- suture in place and dress with a sterile dressing
- connect to underwater seal drain (connections should be stable and easy to attach in a sterile manner)
- CXR should be formed to check adequate positioning and detect complications
OTHER INFORMATION
- connected to underwater seal drain (see separate CCC entry)
COMPLICATIONS
Insertion
- pain
- damage to local structures
- pulmonary injury and bronchopleural fistula
- bleeding
- insertion into a vascular structure (pulmonary artery or left ventricle)
- infection
Use
- tube blockage
- tube displacement
- dislodgement
- infection
- misuse of drainage system leading to introduction of air or fluid into pleural cavity
Removal
- recurrence of underlying condition
- wound dehiscence
- scarring
VIDEOS
Insertion of intercostal catheter
Removal of intercostal catheter
Insertion of pigtail catheter using obturator and Seldinger technique
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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