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Y4 SA - Soft tissue surgery > Thoracotomy tube placement > Flashcards

Thoracotomy tube placement Flashcards

1
Q

For what reasons do we drain the thorax?

A
  • Diagnostic and therapeutic removal of clinically significant volumes of air or fluid accumulated within the pleural space when frequent drainage is expected or required
  • Air
  • Effusions
  • Following thoracic surgery (removal of haemorrhage, fluid and air, delivery of intrapleural local anaesthetic)
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2
Q

Air in the thorax is termed?

A

Pneumothorax

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3
Q

Name the 5 effusion types that can be found in the thorax

A
  1. Pyothorax
  2. Chylothorax
  3. Haemothorax
  4. Serosanguinous effusions
  5. Neoplastic effusions
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4
Q

When in drainage of the thorax contraindicated?

A
  • If patient is not appropriately stable
  • Ongoing haemothorax (trauma or coagulopathy)
  • Clinically insignificant volumes (no effect on respiratory function)
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5
Q

Describe the pathophysiology of the normal pleural cavity

A
  • Potential space within the thoracic cavity that sits around the heart and lungs
  • Mesothelial cell lining
  • Small volume of pleural fluid: lubricates lungs & pleural surfaces to facilitate ventilation
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6
Q

Describe the pathophysiology of a penumothorax

A
  • Uncouples the coordinated movement of the thoracic wall & the lungs during ventilation
  • Lung collapse -> atelectasis
  • Ventilation/perfusion (V/Q) mismatch
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7
Q

Describe the pathophysiology of pleural effusions

A
  • Decreases space for lung expansion during inhalation which decreases tidal volume
  • Fluid accommodation -> diaphragmatic expansion -> decreases diaphragmatic movement -> decreases ventilation
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8
Q

What are the clinical signs of a pneumothorax/pleural effusion?

A
  • Increasing severity of signs with rapid progression and/or larger volumes
  • Restrictive or paradoxical breathing pattern
  • Tachypnoea/dyspnoea/cyanosis
  • Orthopnoic posture
  • Diminished cardiac auscultation
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9
Q

Compare lung sounds and thoracic percussion in a pneumothorax vs pleural effusion

A

Pneumothorax: reduced
Pleural effusion: Increased lung sounds & hyper-resonant percussion DORSALLY, decreased ventrally due to “fluid line”

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10
Q

How would you drain the thorax for patient stabilisation/’one off’ drainage/sampling?

A

Needle Thoracocentesis

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11
Q

How would you drain the thorax for repeated draining/anticipated drainage?

A
  • Trocar thoractostomy tube
  • Wire guided small bore multi-fenestrated thoracostomy tubes (e.g. MILA)
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12
Q

How is a patient prepped for needle thoracocentesis, describe where the prep site is?

A
  • Pre-oxygenate +/- sedation
  • IV catheter in place
  • Sternal recumbency
  • Aseptic preparation of lateral thoracic procedure site (15cm2): 7th-9th intercostal space (dorsal 1/3 if air, ventral 1/3 if fluid, middle 1/3 if both)
  • Consider local anaesthesia: SC (lidocaine) or EMLA cream
  • 3 way tap OFF before insertion
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13
Q

Once prepped describe the needle thoracocentesis procedure

A
  • Butterfly needle inserted on CRANIAL aspect of rib, BEVEL UP
  • Flatten needle parallel to chest wall, slowly advance through intercostal muscles
  • OPEN 3 way tap & aspirate pleural fluid contents
  • Must turn 3 way tap “OFF” before detaching syringe or removing needle from thorax
  • Post-procedure thoracic radiographs
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14
Q

List 4 complications that can occur during needle thoracocentesis?

A

Lung laceration
Pneumothorax
Haemorrhage
Iatrogenic infection

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15
Q

During needle thoracocentesis why do you want the needle inserted parallel to the chest rather than 90 degrees to the chest?

A

Decreases lung laceration risk

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16
Q

When is thoracostomy tube placement indicated?

A
  • Repeated thoracocentesis required
  • Following thoracic surgery
  • Medical management of pyothorax
17
Q

How is a patient prepped for thoracostomy tube placement, describe where the prep site is?

A
  • Preoxygenate
  • Sedation or general anaesthesia?
  • Lateral or sternal recumbency?
  • Clip and prep from caudal border of scapula to caudal to last rib
18
Q

Describe the thoracostomy tube placement procedure

A
  • Insertion into the chest through the 7th or 8th intercostal space regardless of tube type
  • CRANIAL border of the rib (intercostal AVN on the caudal aspect of the rib)
  • Side of the chest: Based on clinical or imaging findings - Bilateral is preferred if massive effusion or pyothorax
19
Q

Describe how you would select an appropriate tube size for a thoracostomy tube placement?

A

Internal diameter= 50% width of intercostal space
External diameter=mainstem bronchus diameter
Length=2nd to 7th/8th/9th ribs

20
Q

List the equipment needed for a thoracostomy tube placement

A
  • Sterile gloves!
  • Intercostal nerve block / local anaesthetic / lidocaine
  • Scalpel handle / blade
  • haemostat
  • Thumb forceps
  • Needle holders
  • Scissors
  • Tube clamps
  • 3-way stopcock
  • Tube equipment
21
Q

Describe the local anaesthesia used in a thoracostomy tube placement

A

Local anaesthesia/analgesia
Intercostal nerve block > intercostal nerves run caudal to ribs
Infiltrate puncture site/tunnel

22
Q

Describe the procedure for inserting a trocar-type chest drain

A
  • Skin incision over 10th or 11th intercostal space and drain tunnelled cranioventrally under skin
  • Tube held vertical at 7th or 8th intercostal space in one fist – small portion of sharp end between surgeon’s 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
23
Q

How is a thoracostomy tube secured?

A

Fingertrap suture pattern

24
Q

What should be carried out one a thoracostomy tube has been placed?

A

Drain pleural cavity
Radiograph thorax to check positioning

25
Q

Describe post-placement care following thoracostomy tube placement

A
  • Close monitoring for dislodgement or tube disconnection > pneumothorax
  • HARD Elizabethan collar, body vest at ALL TIMES
  • Multi-modal analgesia: Opioids/NSAIDS/local anaesthetic into pleural cavity via tube (post thoracotomy)
  • Monitor respiratory rate and effort
  • Monitor insertion site: subcutaneous emphysema, inflammation, discharge
26
Q

Compare continuous vs intermittent post-placement drainage

A

C = commercial systems / 3-chambered suction apparatus
I = manual aspiration (q4hrs or as necessary)
Must record volumes of AIR and FLUID retrieved
Calculate: ml/kg/hr over each 12 hr period to monitor trends

27
Q

List some possible post-thoracostomy tube placement problems?

A
  • Discharge around the tube site
  • Accidental tube damage/removal -> pneumothorax
  • Tube blocking/kinking
  • Subcutaneous emphysema
  • Damage to intra-thoracic structures
  • Pain
28
Q

How are post-thoracostomy tube placement problems prevented?

A
  • Asepsis
  • Elizabethan collar
  • Appropriately secure tube
  • Analgesia
29
Q

When can a thoracostomy tube be removed?

A
  • Volume of fluid drained <2ml/kg/day (fluid production due to presence of the chest drain)
  • Volume of air drained: none
  • Patient status, disease progress, diagnostics

Y4 SA - Soft tissue surgery (8 decks)

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