Consent and pre medication
Explain the procedure and associated risks to the patient.
Obtain written consent for the procedure (may waiver in emergency situation and critical care areas).
Consider the need for intravenous (IV) access prior to commencing the procedure.
Record baseline observations - temperature, blood pressure, respiratory rate, pulse and oxygen saturation.
To reduce the pain associated with insertion of a pleural drain, analgesia should be administered as a premedication if required, and should be prescribed for all patients with a pleural drain in place.
Pre-medication should consist of an opioid to achieve adequate analgesia prior to the commencement of the procedure and if required benzodiazepine for reducing anxiety unless there are contraindications to use. Aim to avoid giving further opioids once benzodiazepine has been administered.
Where both an opioid and benzodiazepine are used, the procedure and immediate post insertion care is recommended to occur in a close observation unit or critical care area.
If formal sedation is to be used during the procedure, this should be given in line with recommendations of the Australian and New Zealand College of Anaesthetists for conscious sedation which includes the need for IV access, adequately trained staff and monitoring including oximetry throughout the procedure9.
Sedation minimum requirements:
- patient triage and risk assessment
- someone to monitor the airway
- some with bag and mask ventilation skills
- Lignocaine 1% with or without adrenaline, should be infiltrated prior to the procedure paying particular attention to the skin, periosteum and the pleura. Do not exceed the maximum volume of lignocaine.
- Lignocaine 1 % without adrenaline
- Maximum dose is 3 mg / kg
- 50 kg adult - 150 mg - 15 ml
- 70 kg adult - 210 mg - 21 ml
- 90 kg adult - 270 mg - 27 ml
- Lignocaine 1 % with adrenaline (1:100 000)
- Maximum dose is 7 mg / kg
- 50 kg adult - 350 mg - 35 ml
- 70 kg adult - 490 mg - 49 ml
- 90 kg adult - 630 mg - 63 ml
- Lignocaine 2% should not be used.
- Particular care should be taken in relation to the dose of lignocaine where a pleural drain is required soon after another procedure for which local anaesthetic has been used (especially bronchoscopy or fine needle airway biopsy).
- Infiltrating local anaesthetic. Make sure the patient has no allergies. Using 2-5mls infiltrate the area where the skin incision is to be made. Then pass the needle vertically over the top of the rib (so as to avoid the intercostal nerve/neurovascular bundle), while maintaining a negative pressure on the plunger, until air or fluid is aspirated into the syringe. Withdraw the needle slowly until air or fluid just stops being aspirated. The tip of the needle is now in the extrapleural plane. Withdraw the needle slowly injecting the remaining local anaesthetic as you go. Allow sufficient time for local anaesthetic (LA) to take effect before commencing insertion.