Intercostal Drain Insertion

PREPARATION

exclude contraindications
consent
IV access (analgesia, resuscitation medications or products)
monitoring (SpO2, ECG, BP)
confirm affected side (clinically + CXR)
position: supine with arm abducted and hand under head
local anaesthesia: lignocaine with adrenaline = 7mg/kg

EQUIPMENT

chlorhexidine
drape
scalpel
forceps
clamp
2.0 suture
gauze
dressing
32 Fr drain (blood)
underwater seal drainage system (primed)

INSERTION

full asepsis (G/G/H/M/C)
landmarks = anterior to mid-axillary line, 5th IC space, nipple line (T4), palpate ribs and ICS
2-3cm transverse incision on top of rib
blunt dissection down to pleura (just superior to rib -> avoid neurovascular structures)
end point: pleural cavity (hiss or blood)
sweep with finger
insert clamped drain using curved forceps to guide in
connect to UWSD
check for drainage and respiratory swing
suture
sterile dressing

POST INSERTION

CXR
watch for complications:

-> not draining (check for kinking)
-> organ injury (lung, liver, spleen, heart, vessel) – careful insertion
-> blood loss– careful observation
-> surgical emphysema (small hole and good suturing)
->infection (sterile technique)

Features of a Pleural Drainage System

modern drains incorporate three separate bottles into one unit
bottle A = fluid trap
bottle B = underwater seal drain
bottle C = allows suction to be attached

Safety features:

1. first tube connecting drain to drainage bottles must be wide to decreased resistance
2. volume capacity of this tube should exceed ½ of patients maximum inspiratory volume (otherwise H2O may enter chest)
3. volume of H2O in bottle B should exceed ½ patients maximum inspiratory volume to prevent indrawing of air during inspiration
4. drain should always stay at least 45cm below patient (prevention of removed fluid or H2O refluxing into patient)
5. clamp drain when moving
6. H2O level above tube in bottle C determines the amount of suction applied before air drain through tube (safety suction limiting device)