Chest Tubes

Today we put in a chest tube on a patient with about a 20-25% pneumo. Thought I'd share what I found in my research leading up to placing the tube:

Indications: Pneumothorax, hemothorax, empyema, recurrent pleural effusion
Contraindic.: Bleeding dyscrasia, anticoagulation, empyema caused by AFB
1. Obtain informed consent
2. Check coags / platelets
3. Consider sedating patient (painful)
4. Use 18-20 French tube for pneumothorax, 32-36 French tube for fluid or hemothorax
5. Assemble suction/drainage equipment and connect to suction
6. Position patient in supine position, elevate head of bed 30-60 degrees. Usual insertion site is at anterior axillary line at 4th or 5th intercostals space. Mark site.
7. Prep and drape in sterile fashion. Wear gown and mask.
8. Anesthesia at pleural insertion site: anesthetize skin over rib using 2 gauge needle, 10 cc syringe, 1% lidocaine. Anesthesia at incision site (rib below rib of pleural insertion). Using 22 gauge needle and 1% lidocaine, infiltrate subQ, muscle, periosteum, and parietal pleura.
9. Make 2-4 cm incision through skin and tissues over rib. Extend incision with blunt dissection using Kelly clamp, working towards superior aspect of rib above tunneling the course of the chest tube before entering the chest cavity.
10. Push Kelly clamp through parietal pleura. Inside pleural cavity, open clamp, then withdraw. Air or fluid should rush out.
11. Check to see that pleural space has been entered with finger.
12. Grasp chest tube with curved clamp. Clamp free end of chest tube with another clamp.
13. Place tube in pleural space. Direct tube superior, medial, posterior for fluid drainage. Direct tube superior and anterior for pneumothorax. All ventilation holes need to be in pleural space.
14. Attach end of tube to suction/drainage.
15. Use 1-0 or 2-0 silk or nylon to suture chest tube in place.
16. Cover site with 4x4 gauze (with Y cuts to fit around tube)
17. Tape gauze and tube in place
18. Obtain CXR to confirm placement
19. Remove chest tube when there is less than 150cc of fluid in 24hrs and no air leak.

Source: http://students.washington.edu/aomega/procedures.shtml#chestTube

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