Intercostal Drain Insertion


  • 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


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


  • 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


  • 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)

CCC 700 6

Critical Care


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.

| INTENSIVE | RAGE | Resuscitology | SMACC

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