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Closed drainage bottle + connection tubing + 1L sterile water
Walk to patient
Wash hands
Open the chest drain kit to form a large sterile field on the top of the trolley
Open packets (without touching the instruments themselves) and drop sterile instruments neatly into the sterile field
Prepare drainage bottle (non-sterile)
Open bottle packaging, remove inlet cap and pre-fill to ‘prime’ mark (usually at ̴ 200ml) with the sterile water
Open connection tubing and attach the distal end into the bottle’s inlet, leaving the proximal end in the sterile packet
Place bottle on floor and the proximal end of the tube in its packet on the patient’s bed so it is accessible
NOTE: the distal end of the connection tube must be underwater so that air cannot track up the tube and into the pleural cavity during inspiration where negative intra-thoracic pressure creates suction
Seldinger chest drain kit
In order
Patient part
Positioning and exposure
Expose patient’s chest
Position patient
For effusion: sitting upright on edge of bed with crossed arms leaning on an elevated bedside table; or lying at 45˚ with their arm raised behind their head
For pneumothorax: lying on bed sideways with pneumothorax side upwards and their arm rested superiorly on their head, and you standing in front of them)
Place incontinence pad below site on bed (to catch spillage) if effusion
Locate insertion point:
Within the safe triangle formed by
Anterior border of latissimus dorsi
Lateral border of pectoralis major
Horizontal line from the nipple (5th intercostal space)
Just above a rib (to avoid neurovascular bundle)
Use different site if there is overlying infection
Confirm effusion is present at proposed entry site
Effusion: using portable ultrasound scanner (different sites may be used if there is more fluid elsewhere)
Pneumothorax: using clinical examination
Mark insertion point with a skin pen/indentation
Preparation
Wash hands using Chlorhexidine solution, then apply sterile gown and gloves using the surgical scrub technique
Sterilize area
Work from middle outwards in one spiral motion (using cleansing snap-sponge)
Repeat this with 2nd cleansing snap-sponge
Discard used snap-sponges as they are no longer sterile, but note all equipment used after this (including all needles) can be returned to the sterile field after use
Apply the sterile drape over the patient’s body so that the hole is in the correct place to allow access to the insertion site (or apply 4 drapes centred around exposed insertion site if no holes)
Anaesthetise tract
Ask assistant to snap open lidocaine bottle and hold open upside-down
Draw up lidocaine using drawing-up needle on 20 ml syringe and expel any air
Change to the orange needle and insert at an acute angle to form a single subcutaneous bleb around insertion site in order to anaesthetise the skin
Change to the green needle and insert perpendicular to the skin to anaesthetise the insertion tract
This is done by instilling lidocaine in small increments of increasing depth – only anaesthetise the intercostal muscles and pleura (the fat in between has no nerves)
Always aspirate when advancing the needle (so you know when you get to the pleural cavity) and aspirate before injecting lidocaine (to check you are not in a vessel)
When fluid or air (from pleural cavity) is aspirated, withdraw 2mm and anaesthetise pleura up, down, right and left (NB: you should not continue anaesthetising after aspirating fluid in a potentially malignant effusion because it can seed malignant cells)
DO NOT PROCEED if you do not get an aspirate with the green needle!
Now wait 1 minute for the anaesthetic to work, while you prepare the Seldinger equipment and put in order:
Scalpel: remove cap
Introducer needle: remove insert (if present) and attach syringe
Guidewire: remove plastic cap (if present) and straighten the J-tip it using the plastic nozzle – depending on the kit, this is either done by slightly retracting the guidewire in its sheath or by separating the sheath and the plastic nozzle
Dilator: remove the safety guard (if present)
Drain
3-way tap: remove the cap from the drain end i.e. threaded end (if present) and close that port, put the bung on the middle opening and attach the drainage tubing adaptor to opposite end (NB. if there are male and female adaptors, select the one that will fit on to the end of the bottle’s drainage tubing)
Seldinger insertion procedure
Make a 5mm skin incision (with the scalpel perpendicular to the skin, press the scalpel blade straight in and out)
Introducer needleinsertion
Point the bevel toward lung apex if pneumothorax, or to lung base if effusion
Slowly advance the needle through the insertion tract aspirating during infiltration until fluid or air is aspirated
Holding the needle steady by the skin with one hand, detach syringe
Guidewire insertion
Place the guidewire nozzle into the end of the needle and use your thumb to seed the guidewire out of its sheath directly into the end of the needle, so half the wire is in the chest
From now on, keep hold of the guidewire at all times with one hand, as close to the skin as possible – you can hold it in a loop to make things easier
Note exactly how far the introducer needle is in the chest (it has cm demarcations) then withdraw the needle and thread it right the way off the end of the guidewire, ensuring the guidewire remains in place
Note: if you need to move the hand holding the guidewire to the other side of an instrument on the wire, then ensure your other hand has hold of the guidewire temporarily while you move it so you never let go of the guidewire
Tract dilation
Compare the introducer needle depth of entry with the dilator and hold it at (or, if present, move the safety marker to) that point +1cm so you cannot insert the dilator too deep
Thread the dilator over the guidewire and insert into the chest (up to the safety marker/your finger) with a rotational movement
Withdraw the dilator and thread right the way off the end of the guidewire, ensuring the guidewire remains in place
Larger drain kits will have 3 dilators – repeat the process with each dilator, in increasing width
Drain insertion
Thread the drain over the guidewire until the tip is near the skin
Now retract the guidewire slowly until the end comes out of the end of the drain
Holding the end of the guidewire, insert the drain into the chest (point curve toward lung apex if pneumothorax, or to lung base if effusion)
Insert the drain to the depth of 2x the chest wall diameter (usually ̴ 12cm)
When the drain is in place, remove guidewire and then the central stiffener of drain and end cap
Attach the threaded end of the closed 3-way tap (hold finger over end of drain to stop spillage until this is attached)
Securing drain
Suture in place
Perform a simple hand stitch just above the drain site
Insert the needle through the superficial skin ̴ 1cm length
Pull through so that half the length of the thread is on either side of the skin
Cut off the needle using scalpel
Tie ends together with three simple knots – final knot should be tight but loose to skin (consider tying knot around the dilator)
Wrap suture ends in opposite directions around drain and tie a tight simple knot so the drain tube kinks – repeat this three times as close as possible to each other
Cut the loose ends of the suture off
Complete circuit
Attach the proximal drainage bottle tubing to end of 3-way tap via the tubing adaptor (NB. if there was only a male drainage tubing adaptor in the kit and the drainage bottle tubing also has a male end, the proximal bottle connection tubing may need to be cut with the scalpel so it will fit on to the male adaptor)
Retract drape over tubing
Dress the drain (example)
Place a gauze between the drain and the chest wall below and apply a tegaderm film over the top
Place a second gauze below the three way tap (so it doesn’t dig in)
Apply tegaderm films over the tubing above and below the 3-way tap
Open the 3-way tap and confirm drainage (i.e. pleural fluid draining in effusion or air bubbling in pneumothorax)
Check the drain is swinging (i.e. the fluid in the chest drain tubing rises with inspiration and falls with expiration due to changes in thoracic pressure – ask patient to breathe in and out and/or cough) and, if pneumothorax drain, bubbling
Collect and send pleural fluid samples if required
Thank patient and cover them
Bin waste and gloves, dispose of sharps safely in sharps bin, clean trolley and wash hands
Patient: ensure the chest drain bottle is kept upright and is below the level of their umbilicus at all times; tell nurse if they experience pain/SOB/cough
Nurse: in effusion, clamp drain after 1L removed or if pain/SOB/cough (may be re-expansion pulmonary oedema)
Don’t drain >1L fluid at a time (usually drain 1L then clamp for 1hour – this cycle can be repeated multiple times)
Never clamp a pneumothorax drain (even during removal)
Prescribe post-insertion analgesia
Order a post-insertion CXR (check positioning and for pneumothorax)
Fully document procedure in patients notes
Re-review patient later
Removing a chest drain
Remove sutures
Ask patient to perform Valsalva manoeuvre or expire fully, then briskly pull drain out while an assistant applies steri-strips over wound (for Seldinger drains) or ties the previously placed closure (usually placed for large bore trauma chest drains)
Apply pressure for 5 minutes
Check bleeding has stopped then apply impermeable dressing.
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