Healthcare and Medicine Reference
In-Depth Information
10
Remove the introducer needle whilst keeping hold of the
guidewire.
Take the dilator and slide it over the guidewire to enlarge the
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tract (Figure 17.6f). Ensure that you keep hold of the end of the
guidewire whilst inserting the dilator. The dilator only needs to
be inserted a short distance into the pleural cavity. The depth
can be judged by the size of the initial needle used to aspirate
fl uid or air. For larger chest drains there may be more than one
dilator in the pack. In this case, start with the smallest dilator
and progress to the largest.
Slide the drain over the guidewire and into the pleural cavity
12
(Figure 17.6g). Once the drain is in the pleural cavity the
guidewire can be removed. The three-way tap should be kept
covered (Figure 17.6h) or in the closed position until the drain
is attached to the underwater seal bottle (Figure 17.6i).
Place a suture through the skin adjacent to the drain and tie the
Figure 17.5 Equipment required for insertion of a Seldinger chest drain.
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suture into the skin and subsequently around the drain until it
is secure (Figure 17.6j).
Finally place a dressing over the drain insertion site. If the drain
1
Verify the correct side by clinical examination, review of the CXR
and ultrasound.
Consider premedication with a benzodiazepine or opioid to
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2
is correctly positioned it should swing with respiration and
drain fl uid or air.
Ask for a CXR after the procedure and ensure that adequate
reduce patient distress but beware of respiratory depression.
Use a strict aseptic technique. Wear sterile gloves and gown;
3
15
consider also a facemask with visor. Prepare the skin with
antiseptic solution and allow to dry. Apply a sterile drape
(Figure 17.6a).
Infi ltrate the skin with local anaesthetic using a blue (23G) or
analgesia is prescribed.
Step-by-step guide: insertion of a trocar chest drain
Carry out steps
4
1
1 to 4 as described above (Figure 17.7a). Your trol-
ley should be set up with the equipment listed in Box 17.2. Prepare
the underwater seal bottle by fi lling the bottle with sterile water up
to the marked point on the bottle and by attaching the tubing.
Make a skin incision parallel to the rib slightly larger in size to the
orange (25G) needle (Figure 17.6b). Then use a green needle
(21G) to infi ltrate deeper and anaesthetise the parietal pleura
(Figure 17.6c). The needle should be inserted just above the
upper border of the rib to avoid the intercostal neurovascular
bundle. Always aspirate before injecting local anaesthetic to
ensure that you are not in a blood vessel. Verify that the site is
correct by aspirating fl uid or air with a green needle (21G). If this
is not possible do not proceed with drain insertion and consider
image-guided drainage.
Whilst giving the local anaesthetic time to work, prepare the
2
diameter of the tube being inserted (Figure 17.7b).
Put a horizontal mattress suture (see Figure 17.8) across the
3
incision to assist with later closure.
Perform blunt dissection using blunt forceps (e.g. Spencer Wells)
4
(see Figure 17.9).
Insert the forceps through the skin incision and separate the mus-
5
5
Seldinger chest drain pack. This will usually consist of an intro-
ducer needle, 10-mL syringe, guidewire, dilator(s) and drain.
Also prepare the underwater seal bottle by fi lling the bottle with
sterile water up to the marked point on the bottle and by attach-
ing the tubing. Different types of bottle exist so it is important
to familiarise yourself with the equipment available at your
hospital.
Attach the introducer needle to the 10-mL syringe. Insert the
cle fi bres by opening and withdrawing the forceps (Figure 17.7c).
Do not close the forceps as this may cause damage. Continue
blunt dissection through the intercostal muscles and parietal
pleura. The tract should be explored with a fi nger to ensure that
there are no underlying organs that may be damaged by drain
insertion (including the lung itself!) (Figure 17.7d).
Remove the trocar from the drain.
6
The trocar should never be used
to insert a chest drain. Hold the end of the chest drain with blunt
forceps and guide the drain into the pleural cavity. Excessive
force should not be needed. If resistance is felt then further blunt
dissection is required. Some manufacturers provide an introducer
to aid with insertion of the drain (Figure 17.7e). The tip of the
drain should be aimed apically for a pneumothorax and basally
for an effusion, but functioning tubes should not be repositioned
purely because of their radiological position.
Connect the drain to the underwater seal bottle.
6
needle through the area of skin and pleura which has been
anaesthetised and aim just above the upper border of the rib
(Figure 17.6d). Confi rm correct positioning within the pleural
space by aspirating fl uid or air. Once in the pleural space do not
advance the introducer needle further.
Remove the 10-mL syringe from the end of the introducer needle
7
and place your sterile-gloved thumb over the end to prevent air
entering the pleural cavity.
Smoothly insert the guidewire through the introducer nee-
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8
8
Place a suture through the skin adjacent to the drain and tie the
dle (Figure 17.6e). There should not be any resistance felt if
positioning is correct.
Using the scalpel make a small 'stab' incision at the base of the
suture into the skin and subsequently around the drain until it is
secure (Figure 17.7f,g).
Carry out steps
9
9
14 to 15 as described above. Figure 17.10 shows a
large intercostal drain in situ.
needle.
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