What position should the chest drainage system be in relation to the client?

The Cardiothoracic Surgery Network

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Tuesday, April 4, 2017

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Chest tube insertion is a procedure commonly performed by residents and fellows throughout their general and cardiothoracic surgical training. Proper placement of a chest tube can effectively evacuate air, fluid, and blood. In many cases, insertion of a chest tube can prevent more invasive procedures. This video will demonstrate tips and tricks for the successful insertion of a chest tube, whether on the floor or in the operating room.

Patient Considerations

• Stability of the patient
• Why is the tube being placed?
  • It is important to note whether the tube is being placed for fluid or air in order to appropriately direct the tube for maximum drainage
  • Tubes placed for fluid should be directed posteriorly, while tubes placed for air should always be directed apically
  • If the collection is loculated, imaging may be used as an adjunct to help plan the chest tube position and ensure that the tube is directed into a precise location
• Factors that can make chest tube placement more difficult
  • Prior chest surgery, previous chest tube placement, prior chest irradiation can all result in adhesions that may complicate a tube thoracostomy, and make it more difficult to direct the tube to the desired location
• Anticoagulation
  • If a patient is anticoagulated, it is preferable to reverse anticoagulation, if possible, prior to performing a procedure
• Always consider your pain management plan ahead of time
  • A dose of pain medication 30 minutes before the procedure can significantly improve patient comfort
  • Liberal use of local with each layer particularly on awake patients

Positioning

• Bump under the back with arm over the head and out of the procedural field
• The chest should be as flat as possible or gently flexed to allow for maximum opening of the spaces between the ribs

Identify Landmarks

• Even in an emergency situation, take a few moments to identify your important landmarks.  It is important for the tube to go into the correct location, particularly in an emergent situation, so taking time to ensure this will be the case is essential.
• The authors spend some extra time during the video reviewing important anatomical landmarks that can be used to assist in tube placement, including:
  • Tip of the scapula
  • Nipple or infra-mammary or pectoral crease
  • Anterior inferior iliac spine
  • 12th rib
  • Mid-axillary line – it is ideal to place chest tubes in front of this line for patient comfort so that they are not laying on the tube
  • Approximate lie of the diaphragm
• Plan your incision
  • It is helpful to use a marking pen to select your incision site prior to prepping and draping to make sure that you have a firm idea of where you plan to place your tube.
  • Always make an adequately sized incision, allowing adequate room to introduce a finger as well as the tube, to allow for the tube to be carefully directed into position.

Time out

• Verify your patient, laterality, equipment, and that you have adequate help in the room
• Have your assistant start setting up the atrium
• Using the buddy system is always a good idea
  • An extra set of hands to prep, drape, hand you instruments, and hold the chest tube while tying into place is ideal.  Always take someone with you if you can!

Pain Management

• For patients who are intubated and asleep you have the benefit of general anesthesia
• For awake patients on the floor, chest tube insertion can be performed in a comfortable manner without the use of sedation team if the local is performed properly.
  • Have all 30 mL drawn ahead of time and ready to use
  • Begin with anesthetizing the skin and allow for adequate time for the agent to take effect  
  • As dissection is carried down to the chest wall, continue to anesthetize each layer encountered while allowing time for the local to take effect
  • It is essential to adequately anesthetize the pleural, as it is highly innervated and can be the most uncomfortable portion of the procedure for the patient

Dissection

• Blunt dissection is carried down to the chest wall. Use your finger to identify the top part of the rib. 
• Remember that the intercostal artery, vein, and nerve run on the underside of the rib, injury to these vessels can result in a significant amount of bleeding.
• The chest should be entered bluntly with a hemostat or curved Kelly clamp
• Brace your dominant hand with your second hand to avoid advancing the clamp too far into the chest and risking injuring the lung or the heart on the left side.
• Dilate the track
• Insert the chest tube using the Kelly clamp or your finger to guide the tube into the desired location
  • The video shows the chest tube advancing into the chest under VATS guidance for the intra-operative patient
  • Remember that there is the benefit of being able to drop the lung
  • In awake patients, a finger can be helpful to direct the chest tube away from the fissure

Secure the Tube

• Secure the chest tube in place with a large silk suture (number 1 or 0)
  • Go around the chest tube several times
  • Cinch down to create a small waist on the chest tube
  • Tie many knots
  • Go around a second time and re-secure chest tubes should never accidentally fall out due to inadequately secured tube
• A second suture should be used to close the incision, if there is additional space to avoid drainage or introduction of air

Dressing

• Chest tube dressing should maintain the tube in a neutral position to prevent kinking at the level of the skin

Disclaimer

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