Blunt dissection

Large bore intercostal catheter >20 Fr

Large bore intercostal catheters should only be inserted by operators who have specific competency in this technique.
The technique of 'finger sweep' to confirm the absence of pleural adhesions is unreliable in inexperienced hands and should be only be performed by experienced operators.
Thoracic ultrasound should be utilized to confirm the position of the pleural collection/ pneumothorax. This may be done immediately prior to the procedure at the bedside (as long as the patient's position during the chest drain insertion remains the same as during the ultrasound) or ultrasound may be performed during the procedure if the machine is appropriately set up before hand and a sterile sleeve is used for the ultrasound probe.
Do not insert pleural drain through breast tissue.
Mark the fifth intercostal space in the mid axillary line (or use the site identified by real time ultrasound). As a rule of thumb in male adults, use a hand's breadth lateral to and no lower than the nipple.
Trocars should not be used.

Immediately prior to the procedure ensure that:

Time Out check has been completed
baseline observations including SpO2 are taken and recorded
the patient has received adequate analgesia
SpO2 continuous monitoring has commenced.

Blunt dissection procedure

Perform hand hygiene.
Aseptic technique - everyone in the room should wear a mask. The operator requires, sterile gown and gloves in addition to a mask.
Clean the skin and apply 2% chlorhexidine skin prep or equivalent from at least the nipple line to the posterior axillary line. Allow the prep to dry fully. Drape widely.
Infiltrate local anaesthetic widely around the incision site and down to the pleural space. Allow five minutes for local anaesthetic to work. If insufficient analgesia, obtain a new syringe of local anaesthetic and re-inject to a maximum of 20mL of 1% solution (healthy 70kg adult male).
Do not inject into the tissues once fluid has been aspirated into the local anaesthetic syringe.
Do not proceed without further imaging if air/fluid is not confirmed at the time of local anaesthetic infiltration in the pleural space.
Incise the skin (along the rib or perpendicular to the rib) to a sufficient length to allow passage of finger or tube.
Place two sutures in the optimal position in preparation for securing the drain following insertion.
Blunt dissect tissue to pleural space using Harrison-Cripp forceps. When dissecting, it is helpful to imagine where you want the tip to lie once it is placed, and to make your dissection in that direction as the tube will generally follow the tract that you have prepared for it.
It is difficult to anaesthetise the parietal pleura. Addition of more clean local anaesthetic (total within the maximum volume limit) at this point may be required.
Blunt dissect into the pleural space. Take care at this stage to ensure that you are dissecting towards the same intercostal space. It is easy for the skin to ride up or down one space.
Insert the tube into the tract formed by blunt dissection. It may help to clamp the tube using the distal part of the forceps to achieve insertion. In spontaneous breathing patients clamping the UWSD end of the tube may also be helpful to prevent loss of fluid or air whilst securing the connections.
Insert the tube to ensure the most distal tube hole is within the pleural space. If possible, direct the tube tip basally to collect fluid or apically to collect air but this is not critical if there are no areas of loculation
Attach the tube to an UWSD which has been set up per manufacturer's instructions.
Release the clamp (if used) from the distal tube once connected to UWSD.
Suture the skin to close any gaping. A mattress suture or sutures across the incision are usually employed and, whatever closure is used, the stitch must be of a type that is appropriate for a linear incision. Complicated purse string sutures are not to be used as they convert a linear wound into a circular one that is more painful for the patient and may leave an unsightly scar.
A horizontal mattress suture straddling the tube should be tied loosely with a significant length of suture. The tube should be secured using a deep suture tied at the skin, and then with the two ends wrapped tightly around the tube.
Secure the tube to the patient in two places using a suture at the skin insertion site and secure taping at another site on the patient's body.
In the case of a pleural effusion, fluid may be collected for diagnosis
- pH - blood gas syringe
- blood culture - 2x blood culture bottles
- cytology - 2x heparinised cytology bottles
- microbial culture and sensitivity (MC&S) - 2x MC&S yellow jars 1 red, + purple/yellow blood tubes.
Apply a sterile occlusive dressing.
Secure all connections with zinc tape or equivalent.
Observe the five moments of hand hygiene.

Confirm drain position

A chest x-ray should be performed within one hour and be reviewed by the inserting MO within four hours to confirm the tube position, exclude new pneumothorax and confirm the successful drainage of air or fluid.

Document procedure in patient's medical record and medication chart

Sedation given and total local anaesthetic instilled.
Depth of insertion and any complications.
Type of tube inserted including serial number and barcode.
Method of fixation and wound closure.
Sutures that are required to be removed before tube removal.