Healthcare and Medicine Reference
In-Depth Information
Pectoralis major
Diaphragm
Latissimus
Figure 17.3 A Seldinger chest drain.
Pneumothorax in a ventilated patient.
Empyema and complicated parapneumonic effusions (pleural
fl uid pH<7.2).
Haemothorax.
Figure 17.4 The 'triangle of safety'.
Malignant pleural effusion for symptomatic relief (and for
performing pleurodesis).
Large pleural effusions of other aetiology.
Box 17.1 Equipment for insertion of a Seldinger chest drain
Dressing pack and solution (we recommend 2%
Contraindications to intercostal drain insertion
Inexperience with technique.
chlorhexidine/70% isopropyl alcohol) for cleansing of the skin
Sterile gloves
Refusal by a competent patient.
Sterile drapes
Deranged INR/platelets (stop warfarin and correct any
Gauze
coagulopathy).
Lung adherent to the chest wall.
1 or 2% lidocaine
10-mL syringe for local anaesthetic
One blue needle
Drainage of a post-pneumonectomy space should only be carried
One green needle
out after consultation with a cardiothoracic surgeon.
Scalpel
Seldinger chest drain pack
Types of chest drain
Chest drain bottle and tubing
Sterile water for drain bottle
Trocar chest drains consist of a plastic drain with a radio-opaque
stripe along their length surrounding a metal rod with a sharp end.
They are available in a variety of sizes.
Seldinger (Figure 17.3) chest drains are usually smaller drains
which are inserted by advancing the drain over a guidewire. Studies
have shown that smaller chest drains (10-14F) are often as effective
as larger-bore drains and are better tolerated by patients.
Large-bore drains are recommended for acute haemothorax to
monitor blood loss and may also be necessary if a pneumothorax
has failed to resolve despite a smaller drain.
Suture (e.g. size 1 silk)
Dressing for site of drain insertion
Ultrasound guidance
Recent research regarding the morbidity and mortality of chest
drain insertion strongly recommends insertion of chest drains
under ultrasound guidance. The ultrasound training required for
this is beyond the scope of this text, but healthcare professionals
who intend to perform this procedure should familiarise them-
selves with this.
Anatomy and positioning of patient
Step-by-step guide: insertion of a Seldinger chest
drain
Chest drains should be inserted within the 'triangle of safety' which
has the following borders (see Figure 17.4):
anteriorly - anterior axillary line, lateral border of pectoralis major
posteriorly - anterior border of latissmus dorsi
Give a full explanation to the patient in simple terms and
inferiorly - at the level of the nipple.
ensure they consent to the procedure.
Set up your trolley (Box 17.1 and Figure 17.5).
Ideally the patient should be positioned on the bed at 45° with
their arm held behind their head to expose the axillary area.
Alternatively, the patient could be sitting forwards and leaning over
a table.
Prepare your trolley as a sterile fi eld. Wear a plastic
disposable apron and sterile gloves, and take alcohol hand
rub with you.
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