Drainage

The amount and appearance of fluid is recorded on UWSD chart.

Table 2: How to measure and record drainage

Draining of a large metastatic or pneumonic pleural effusion

• A large effusion should be drained in maximum volumes of 1000 -1500 mls at one time, with lesser volume limits applicable dependent on patient weight and physical condition. Greater drainage than the defined maximum amount may lead to re-expansion pulmonary oedema.
• Typical clinical signs of re expansion pulmonary oedema include shoulder tip pain, coughing, a sudden drop of blood pressure and/or oxygen saturations and increased respiratory rate and distress.
• Normal practice is to drain a pre- determined amount, then clamp or turn off drain for 15 minutes and reassess the patient. If patient observations show no deterioration, unclamp and continue to drain.
• If signs of patient deterioration, call for urgent MO review or escalate for clinical review or call for a rapid response as applicable.
• The drain should not be left clamped over prolonged periods of time with haemorrhagic or pus effusion as it may lead to a blocked drain.

Tube patency

Ensure adequate tube length to allow safe movement but avoid looping of tubing which could lead to a 'fluid lock' in the tube.

Ensure patient does not lie on the tube.

Check tubing for presence of clots or fibrinous material each time observations are performed. If present follow specialized unit or facility protocol in relation to orders for:

• flushing (pleural effusion or empyema only)
• changing the drain
• milking - gently and intermittently compressing and releasing the ICC between fingers whilst moving toward drainage bottle.

Check connections

All pleural drains and UWSD connections should all be checked each time the observations are performed to ensure the tube has not dislodged and that all connections remain secure and taped.

Surgical emphysema

Surgical emphysema is the presence of air under the subcutaneous layer of the skin and is often present in patients with a pneumothorax but rarely in large amounts in normal circumstances.

It is characterised by the feeling of 'crackling' or 'rice bubbles' on palpation and/or a change in voice.

Surgical emphysema starts at the site of insertion of the drain and can spread.

Tracing a line around the border of the subcutaneous emphysema can be used, in combination with other observations, to indicate progression or resolution.

Surgical emphysema must be checked for each time UWSD observations are performed and reported to a MO immediately if newly present or enlarging.

Surgical emphysema (in severe cases) can cause changes to a patient's voice and facial appearance. It is vital that staff reassure the patient and carers that their upper airway will not obstruct.

Surgical emphysema may be treated conservatively, or by applying suction, or a new pleural drain may need to be inserted. In the surgical setting applying suction to the drainage system is almost always required.

Pleural drain emergencies

If an intercostal catheter (ICC) falls out
Do not attempt to re-insert the existing pleural drain.

1. Pinch the skin edges together with a gloved hand.
2. Ring for assistance.
3. Redress drain site with Vaseline infused gauze and an appropriate dressing
   • occlusive pressure for pleural fluid.
   • gauze dressing secured on three sides for pneumothorax.
4. Notify MO.
5. Document incident and vital signs especially respiratory rate.
6. Observe and reassure the patient.

If the bottle or ICC becomes disconnected

1. Cross clamp the tubing closer to the patient than the disconnection.
2. Reconnect system to a new drainage bottle.
3. Unclamp ICC.
4. Notify MO.
5. Observe and reassure the patient.
6. Document vital signs especially respiratory rate.