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Chest Drain insertion and management (Technical point of view) By Farid Gerges Learning outcomes • General principles to consider • Indications and contraindications for chest tube insertion • Safety measures for chest tube insertion • Technical facts • Checking efficiency of chest tube and postinsertion care • Hands on• General Principles: - Chest drain to be inserted by competent staff members which achieves 3% early complications and 8% late complications (Collop 1997). - It is consultant-led decision in non-emergency setting. It is the responsibility of the consultant to identify adequately trained physician to perform it and the level of supervision. - It is the responsibility of the most senior doctor in emergency setting. - Team work is required - OOH, avoid chest drain insertion for fluid if the patient is clinically stable. - Ultrasound guided VS Surgical open insertion to be thought. - Equipment and Size of Tube§ General points to be considered: - ABCDE for trauma patients and should follow the ATLS guidelines - Discussion with other specialities if needed (cardiothoracic, medical, etc) - Check for coagulopathy - Communication with the team and the patient/ patient family - Consent to be obtained whenever possible - Type of anaesthesia, 50% of patients experiencing pain levels of 9-10 on a scale of 10 (Luketich, 1998) - Location of procedure (A&E, Theatres, Ward)? - Aseptic techniqueIndications for chest tube insertion: It is a combination of context (pathology & mechanism of injury), clinical picture and imaging. - Pneumothorax: Persistent or recurrent after simple aspiration Tension pneumothorax ( Relief with a cannula can be achieved initially) Traumatic Large secondary pneumothorax > 2 cm Iatrogenic In ventilated patients with pneumothorax - Fluid Malignant, Empyema, simple effusion - Traumatic haemothorax - Perioperative in Thoracic proceduresContraindications for chest tube insertion For careful considerations • Pulmonary adhesions from previous operations, trauma or pulmonary disease • Coagulopathy • Diaphragmatic herniaTechnical aspects: Patient position Triangle of safety Targeting the correct intercostal space The intercostal space Reaching the pleural cavity Tube insertion and fixation Drainage system Post-insertion measuresPatient position - 45 degree or supine - Lateral Triangle of safety: Latissmus dorsi, Pectoralis major, Apex of axilla & 5 intercostal spaceTargeting the correct intercostal space The intercostal spaceReaching the pleural cavity and Tube insertion - Release of pleural contents - Finger dilatation and Blunt dissection of adhesions - Blunt insertion of the tube with forceps with direction consideration - Tube fixation & sampling if needed - Connect, Drainage system (Under water seal)Drainage systemPost-insertion measures: - Is it working? - CXR - Plan? - Drain care and removal - Positioning of the drainage system and patient transferComplication?HANDS ON