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Indications: therapeutic drainage of a pneumothorax (primary pneumothorax if >2cm/symptomatic; asymptomatic secondary pneumothorax 1-2cm)
Open sterile pack to form a sterile field on the top of the trolley
Open packets (without touching the instruments themselves) and drop sterile instruments neatly into the sterile field
Pick up waste bag from sterile pack without touching anything else and stick to side of trolley
Patient part
Positioning and exposure
Expose patientβs chest
Position patient lying supine at 45Λ
Locate insertion point:
2nd intercostal space, mid-clavicular line
Just above the 3rd rib (to avoid the neurovascular bundle on the inferior rib surface of the 2nd rib above)
Use different site if there is overlying infection
Confirm pneumothorax is present at proposed entry site
Percuss chest to confirm hyper-resonance and auscultate for reduced breath sounds
Mark insertion point with a skin pen/indentation
Preparation
Wash hands
Apply sterile gloves using sterile technique (open pack on a side surface)
Sterilize area
Work from middle outwards in one spiral motion (using cleansing snap-sponge)
Repeat with second 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 patientβs body so that the hole is in the correct place to allow access to the insertion site (or apply 2-3 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 10 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 β 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 air is aspirated, note entry depth, then withdraw the needle
Aim to leave around 2ml lidocaine in the syringe
DO NOT PROCEED if you do not get an aspirate!
Wait 1 minute to work
Pneumothorax aspiration
Expel the air from the lidocaine syringe and attach it to the end of the cannula
Inert cannula perpendicular to the skin into the insertion tract
Aspirate during infiltration
When air is aspirated (bubbles seen through the lidocaine left in the syringe), advance the needle 1-2mm further (to ensure the cannula tip has fully entered the intercostal space)
Advance the cannula body off the end of the needle, whilst holding the needle still
Ask the patient to exhale and then remove the needle and syringe, leaving the cannula tubing in place
Immediately cover the cannula opening with your thumb (to stop air entering the pleural cavity)
Attach the tubing of the 3-way stopcock to the cannula opening (ensure all caps are removed and the pleural cannula port is closed)
Now attach the 50ml syringe to the back-port of the 3-way stopcock
Aspirating
Close the side-port of the 3-way stopcock
Aspirate 50ml of air from the pleural cavity
Close the pleural cannula port and expel the 50ml of air (it will come out via the side port into the environment
Close the side port again to repeat the aspiration
Continue this cycle (asking the assistant to count the number of syringes aspirated) until there is no longer any air to aspirate or 2.5L has been aspirated (signifies air leak)
Note the closed tap of the 3-way stopcock should be alternated between the pleural cannula port and the side port (the 50ml syringe port or the stopcock side with no port should never be closed as this would allow air to communicate between the environment and the pleural cavity, which could allow air to enter the pleural cavity)
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