Procedures

Question 1

What is demonstrated below? What are the indications for use?

Answer 1

1. Chest drain
2. Indications: (Fluids - air; blood; water / lymph; infection; effusion)
   
   1. Pneumothorax
   2. Haemothorax
   3. Hydro / Chylothorax
   4. Empyema
   5. Pleural Effusion

Question 2

What is the technique for chest drain insertion?

Answer 2

1. Size tube; generally fluids require larger diameter than air to drain.
2. Triangle of safety: patient supine at 45deg, ipsilateral hand behind head. Triangle: mid axilliary line, lateral pectoralis major, 5th ICS.
3. Incise: prepare skin with chlorhexidine, infiltrate with local anaesthetic (1% lidocaine), incision and blunt dissection (using Kelly clamp). May perform a finger sweep prior to insertion.
4. Insertion: insert the chest drain without trochar (some supplied with sharp trochar, originally intended to aid insertion), and connect to drainage device (wet or dry suction-control, closed drainage system)
5. Checks:
   
   1. ​respiration related swing in fluid level of water seal; should be condensation within the tube on respiration.
   2. secure with sutures and sealing suture
   3. occlusive dressing
   4. CXR

Question 3

What are the risks of chest drain insertion?

Answer 3

1. Tube misplacement: most common complication; require senior support - do not remove until a second functioning tube has been placed.
2. Organ injury: most commonly lung, but other (heart, spleen, liver etc.) all reported. Delayed perforation may also occur.
3. Bleeding: haemothorax; haemoperitoneum
4. Infection: pneumonia and empyema complicate 1-3%. Risk increased with duration and retained haemothorax
5. Tube dislodgement
6. Re-expansion Pulmonary Oedema: potentially life threatening, after rapid re-expansion of large pneumothorax or large pleural fluid drain.

Question 4

What is the difference between the standard technique and seldinger technique for tube thoracostomy?

Answer 4

1. Standard: as previously described
2. Seldinger:
   
   1. Chest tube placed over a guidewire; useful for smaller bore tubes draining air and nonviscous fluids.
   2. Typically perfomed with ultrasound or fluoroscopy guidance to confirm placement and position.
   3. Disadvantage: inability to assess presence of adhesions between lung and pleural surface during tube insertion; tube may inadvertantly pass into parenchyma

Question 5

What information should be recorded following insertion of a chest drain?

Answer 5

1. Technique Used
2. Length of drain inserted
3. CXR position

Question 6

What is the device below, what are the indications for use?

Answer 6

1. Diagnostic:
   
   1. Collection of sterile urinary specimen
2. Monitoring:
   
   1. Perioperative monitoring of urinary output
   2. Aid to abdominal / pelvic surgery
   3. Monitoring of the critically ill patient
3. Therapeutic:
   
   1. Acute and chronic urinary retention
   2. Bladder dysfunction and incontinence

Question 7

What is the technique for insertion of a urinary catheter?

Answer 7

1. Preparation:
   
   1. Size: typically 14 - 16 French for short-term indwelling catheterization, larger (20-24) for haematuria or clots
   2. Patient: supine - women “frog-legged” to maximuse periurethral exposure.
   3. Clean hands, don sterile gloves. Place drapes, cleans periurethral region:
      
      1. Men: foreskin retracted with non-dominanat hand, tension towards ceiling to straighten to urethra
      2. Women: non-dominant hand spreads labia; facilitates cleansing and visualises urethral meatus
2. ​Insertion:
   
   1. Lubricant applied of water-soluble anesthetic jelly
   2. Gloved dominant hand passes cathether into urethral meatus with steady gentle pressure. Resistance at external sphincter in men - pause before continuing
   3. Balloon inflated with 10mL water only when flow of urine seen
   4. Attach to bag; may be connected to leg with tape to prevent traction on urethral meatus

Question 8

What are the risks of urethral catheterization?