Soft Tissue Surgery: Thoracostomy Tubes (Chest drains) Flashcards
(24 cards)
When is thoracocentesis contraindicated?
- Patient not appropriately stable
- Ongoing haemothorax
- Clinically insignificant volumes
- What lines the pleura?
- What is the purpose of fluid in the pleura?
- Mesothelial cell lining
- Lubriactes for ventilation
What is the problem with pneumothorax?
- Uncouples the coordinated movement of the thoracic wall and lungs during ventilation
- Ventilation/perfusion/V/Q mismatch
How does pleural effusion reduce inspiration?
- Decreases space for lung expansion- decreases tidal volume
- Fluid accumulaiton- reduces diaphragmatic movement- decreasing ventilation
What are the clinical signs of a pleural effusion?
- Increasing severity of signs with rapid progression and/or larger volumes
- Restrictive or paradoxical breathing pattern
- Tachypnoea, dyspnoea/cyanosis
- Orthopnoic posture
- Diminshed cardiac auscultation
- Lung sounds and thoracic percussion- reduced especially ventrally
- Pneumothorax- hyper-resonant
What are the three methods of thoracic cavity drainage?
- Needle thoracocentesis- one off drainage/sampling
Repeated drainage/anticipated
2. Trochar thoractostomy tube
3. Wire guided small more multi-fenestrated thoracostomy tube (MILA)
Describe needle thoracocentesis?
- Pre-oxygenate ± sedation
- IV catheter in place
- Sternal recumbency
- Aseptic preparation of lateral thoracic procecure- 7-9th IC
- Dorsal 1/3rd intercostal: air
- Ventral 1/3rd: fluid
- Consider local: SC lidocaine
- 3 way tap off before insertion
- Butterfly needle parallel to chest wall, slowly advance through intercostal muscles
- Open 3 way tap and aspirate pleural fluid contents
- Turn off 3 way tapp before removing needle
- Post-proceudre radiographs
What equiment is needed for needle thoracocentesis?
- Aseptic preparation equipment
- Butterfly needle or over needle catheter and extension tubing
- 3 way tap
- Syringes
- Tests: EDTA tube (cytology), plain tube (C&S) and smear
- Record volume obtained
What are the complicatoins during placement?
- Lung laceration
- Pneumothorax
- Haemorrhage
- Iatrogenic infection
What angle should the needle for thoracocentesis be inserted at and why?
What should be done if Frank blood is aspirated?
Parallel to the chest
Needle insertion at 90 degrees increases lung laceration risk
Frank blood:
Fresh bright red- iatrogenic haemorrhage will clot
Compare fluid PCV to patient PCV: haemothorax PCV > patients PCV, iatrogenic will =
When should a thoracostomy tube be placed?
- When repeated thoracocentesis is required
- Following thoracic surgery
- Medical managment of pyothorax
What can be done preop before a surgical thoracstomy tube placement?
- Preoxygenate
- Sedation or GA
- Lateral or sternal recumbancy
- Clip and prep from caudal border of scapula to caudal to last rib
- Aseptic technique- risk of iatrogenic pyothorax
How is a thoracostomy tube placed- basicaly for all tubes?
How is tube size selected?
- Insertion into the chest through the 7th or 8th intercostal space
- Cranial border of the rib- intercostal AVN on caudal aspect
- Side of chest based on clinical or imaging findings- bilateral if massive effusion or pyothorax
Tube size:
* Internal diameter- 50% width of the intercostal space
* External diameter- mainstem bronchus diameter
* Length- 2nd to 7th/8th/9th ribs
What are the three tube types used for thoracostomy?
- Trochar-type chest drains
- Jackson Pratt fenestrated drain with trocar
- Guidewire-inserted/MILA
What equipment is needed for thoracostomy tube placement?
- Sterile gloves
- Intercostal nerve block/local anaesthetic/lidocaine
- Scalpel
- Haemostat
- Thumb forceps
- Needle holders
- Scissors
- Tube clamp
- 3-way stopcock
- Tube equipment
How should local be given prior to thoracostomy tube placement?
- Intercostal nerve block > intercostal nerves run caudal to ribs
- Infiltrate puncture site/tunnel
Describe the process of thoracostomy tube placement of a trocar-type chest drain
- Skin incision over 10th or 11th intercostal space and tunneled cranioventrally
- Tube held vertical at 7th or 8th intercostal space in one fist- small portion of sharp end between surgeons hand and thoracic wall
- Tube inserted into the chest- forced into IC space with pressure on stylet
- Tube placed parallel to thoracic wall and advanced off the stylet
How can the trochar tube be inserted without the stylet?
- Tube held between closed tips over 10th or 11th
- Haemostat closed to penetrate thoracic wall pleura at 7th or 8th IC space, haemostat tips open, tube then advaced into thorax
How is the thoracostomy tube held in place?
Fingertrap suture pattern
What post thoracostomy tube placement care is needed?
- Close monitoring for dislodgement or tube disconnection > pneumothroax
- Hard elizabethan collar, body vest at all times
- Multi-modal analgesia: opioids/NSAIDs/local anaesthetic
- Monitor respiratory rate and effort
- Monitor insertion site- subcutaneous emphysema, inflammation, discharge
Describe the process of wire guided thoracostomy tubes?
- Cannula insertion via 7th/8th intercostal space
- Wire threaded into cannula
- Hold wire, cannular removed
- Dilator then fenestrated drain threaded over wire, remove the wire
- Chest drain clamp and cap secured
- Chest drain sutured in place
How can tubes be drained differently?
- Continuous- commercial systems/3 chambered suction apparatus
- Intermittent- manual aspiration
- Active/passive- heimlich valve
What are possible post-placement complications of thoracic tubes?
How can they be prevented?
- Discharge around tube site- aseptic technique, elizabethan collar
- Accidental tube damage/removal (pneumothorax)- elizabethan collar
- Tube blocking/kinking- appropriately secure tube
- Subcutaenous emphysema or pneumothorax- trocar, create subcut tunnel, ensure tube fenestrations in chest
- Damage to intra-thoracic structures- 7/8th IC space
- Pain- analgesia
When should a thoracostomy tube me removed?
- Fluid drained <2ml/kg/day
- Volume of air drained: none
- Decide based on- status, disease process, diagnostics: radiographs, fluid cytology, culture
