North West London Trauma Network. Management of Chest Drains

Transcription

1 North West London Trauma Network Management of Chest Drains Contents Introduction... 2 What is a chest drain?... 2 Indications for insertion:... 2 Insertion of drain:... 3 Equipment:... 3 Procedure... 3 General care... 5 Managing a drain:... 5 Changing a chest drain bottle... 5 Equipment:... 5 Procedure:... 5 Monitoring a drain:... 5 Drain removal... 5 Removal of chest drain... 6 Equipment:... 6 Procedure... 6 Post removal x-ray... 6 References:... 7 North West London Trauma Network 1

2 Introduction These guidelines are intended for use by trained nursing and medical staff within the North West London Trauma Network. It covers the rationale for insertion of a drain, insertion of drains; managing drains post insertion and removal of drains. If there is any doubt about the management of a patient s drain advice should be sought from a senior colleague or member of the medical team responsible for the patient. What is a chest drain? The presence of fluid or air within the pleural space leads to compression of the lung. This can impair patients respiratory function, haemodynamic stability and can ultimately cause a significant risk to life. Chest drains are primarily used to allow fluid, such as blood (haemothorax) or air (pneumothorax) out of the pleural cavity, allowing the lung to re-expand and improve physiological performance. They are a closed system restoring normal negative pressures and allowing drainage in only one direction. Indications for insertion: Pneumothorax Haemothorax Malignant Pleural effusion Empyema or complicated parapneumonic effusion Post-operative Thoracotomy, oesophagectomy, cardiac surgery Table 1: Adapted from BTS guidelines for the insertion of a chest drain (Laws D, 2003) Chest drains are not an uncommon intervention in the hospital setting and can be found in a number of forms: Pigtail: These are thin, small bore, tubes which usually curl post insertion to secure them in place. These are often inserted in interventional radiology under ultrasound guidance. (Havelock T, 2010) Seldinger: These can be of varying diameter and are introduced into the pleural cavity with a guidewire or trochar. They are commonly used in respiratory medical settings. Surgical: Typically used in Trauma. These are large bore tubes (>24F diameter) inserted using blunt dissection, rather than ultrasound guidance or a guidewire, to gain access into the pleural space. (Havelock T, 2010) Chest drains involve the tubing (drain) and a collecting system, which usually comes in the form of a drainage system with an underwater seal. An underwater seal prevents air or fluid North West London Trauma Network 2

3 tracking up the tube and into the pleural space, acting as a one way valve to allow drainage but not entrance. (McMahon-Parkes, 1997) Insertion of drain: These guidelines will cover insertion of large bore chest drains, which are required in a trauma setting (ie >24F). If a drain is being inserted, unless it is a medical emergency, the procedure should be fully explained and verbal consent obtained. If possible premedication of benzodiazepines or opiates should be given to reduce patient distress, as 50% of patients report the procedure as being associated with a pain score of 9-10/10. (Laws D, 2003) Plentiful local anaesthetic administration is crucial. Equipment: 1. Sterile gloves and gown 2. Antiseptic solution 3. Sterile drapes and gauze 4. Green needles x2, Blue needle x ml syringe 6. 20mls of 1% lidocaine 7. Scalpel 8. Forceps 9. Chest drain 10. Connecting tubing 11. Closed drainage system 12. Suture- 2.0 or thicker 13. Dressings Procedure 1. Position patient so they are lying on their back Raise the arm on the effected side above head- usually bent at the elbow and held behind head- this is to expose the patients axilla. 2. Confirm site of drain: Identify the Safe triangle for insertion North West London Trauma Network 3

4 3. Aseptic technique: -Gown and gloves -Fully clean skin -Apply drapes to area 4. Analgesia: Infiltrate skin, over top of rib, aspirate as you infiltrate until you get into the pleural space (bubbles of air will be aspirated into the syringe). Pull back and infiltrate around the pleura. At least 15mls of anaesthetic will be required for an average adult 5. Insertion of drain: Skin incision: should be 2.5 3cm, to allow tube placement and finger manipulation Blunt dissection through muscle layers until hiss or blood Measure length of tube against chest wall to gauge how far to insert. 8 10cm is usually sufficient, insertion should be gentle and not forced. Insert the drain aiming for the apex for pneumothorax, basally for haemothorax. Ensure, with a finger that the drain sits between the chest wall and lung, NOT within the lung parenchyma reposition tube with finger if required. When connected hold the drain at the entry point to the skin securely and release the clamp at the end of the tubing; the water seal should be seen to bubble or blood drain from the chest into the drain. 6. Securing the drain: Purse string sutures are not advised. (Laws D, 2003) The recommendation is for a safe secure technique, which can include inserting two sutures; (Hooper C, 2014) One to close the wound distant from the drain One to both close the wound and act as a holding stitch for the drain 7. Cover the drain site with a sterile dressing. North West London Trauma Network 4

5 General care Managing a drain: 1. The drainage container or device should always be kept below the level of the patient s chest to prevent backflow of fluid into the pleural cavity, including during any transfer. 2. Clamps should not be used 3. Monitoring the insertion site for signs of infection 4. Observing the tubing for signs of blockage and patency 5. Clear documentation of the activity of the drain should be made a. Bubbling- indicates air coming from within the pleural space- ieresidual pneumothorax b. Swinging- indicates correct placement within the pleural space c. Airleak- indicates inadequate closure of skin wound 6. Draining- document volume and colour/type of fluid Changing a chest drain bottle This should be performed by a competent nurse with aseptic technique. Equipment: 1. Sterile gloves 2. Chest drain bottle mls of sterile water Procedure: 1. Explain the procedure to the patient and seek their verbal consent. 2. Place the new drain on a clean dressing trolley and using sterile water fill the drain to the 0 level. 3. Decontaminate hands and put on gloves. 4. Kink the chest drain tubing above the level of the connection to the collecting tube - hold this securely to prevent air leaking into the chest. 5. Disconnect the drain tubing from the old drain and quickly attach the new tubing and bottle as quickly as possible and release the kink in the chest drain tubing. Monitoring a drain: 1. A CXR should be obtained after the insertion of a chest drain 2. Daily checks of the output of the chest drain should be made by medical staff 3. Clinical differences in the patient s presentation should warrant repeat x-ray evaluation 4. When the drain output is <100mls in 24 hours or it is no longer bubbling a repeat CXR should be performed to evaluate the resolution of the intrathoracic pathology. Drain removal The timing of removal is dependent on the original reason for insertion and clinical progress. In all instances this should be clearly documented in the patient notes and communicated to the nurse caring for the patient. Pre removal x-ray should be requested if: 1. Drain output is <150ml in the last 24 hours 2. No longer bubbling North West London Trauma Network 5

6 If the lung is fully inflated and any evidence of a haemothorax is resolved the drain is safe to be removed. Removal of chest drain Without a purse string the drain can be removed by one person, if there is adequate apposition of the wound. This is an aseptic technique: Equipment: 1. Clean dressing trolley 2. Dressing pack 3. Suture cutter 4. Appropriate dressing 5. One waste bag Procedure 1. Seek verbal consent after clarification with medical team that the drain is for removal and blood results show adequate clotting and platelet results. 2. Inspect the wound. If large gaps, place simple sutures BEFORE removal of drain 3. Analgesia can be offered approximately 30 minutes before the procedure to minimise the discomfort to the patient. 4. Set up equipment of clean trolley and put on gloves. 5. a. Cut anchoring suture ABOVE the closure knot. This will allow the drain to be released and the wound will close in a linear fashion. b. If a purse string has been placed (note this should not occur as this converts a linear wound to a circular wound and hence causes pain and scarring to the patient), the anchoring suture should be cut to a length of ~ 5cm, which will allow tying of the suture post drain removal. Tying of the suture will require a second pair of hands 6. Using either a valsalva manoeuver or full exhalation removed the drain in a swift steady movement. 7. The wound will be closed either by the pre-existing suture in a linear wound or by closure of the purse string. 8. Instruct the patient to breath normally. 9. Clean and dress the wound site 10. Dispose of sharps and waste appropriately. 11. Inform medical staff of removal, they will request appropriate imaging. 12. Observe for signs of respiratory distress which may indicate a post removal pneumothorax (chest pain, dyspnoea, tachypnoea, tachycardia, hypotension) Inform medical staff if this occurs. North West London Trauma Network 6

7 Post removal x-ray Currently there is no recommended time frame for a post drain removal. Recent publications have indicated that whilst x-ray identified occult pneumothoraces, clinically significant ones were likely to have been clinically evident prior to an x-ray being performed. (Martino, 1999) (Pacharn, 2002) (Goodman, 2010) Current practice is to obtain a chest x-ray 4 hours post removal, earlier if clinical suspicion of recurrence or expansion of a pneumothorax. References: Laws D, E Neville E and Duffy J (2003) BTS guidelines for the insertion of a chest drain Thorax 58(2) pp Havelock T, Teoh R, Laws D, Gleeson F on behalf of the BTS Pleural Disease Guideline Group (2010) Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Thorax 65(Suppl 2) McMahon-Parkes (1997) Management of pleural drains. Nursing Times; 93: 52, Hooper CE, Welham SA, Maskell NA, on behalf of the British Thoracic Society(2014) Pleural procedures and patient safety: a national BTS audit of practice. Thorax; /thoraxjnl [Epub ahead of print] Martino K, Merrit S, Boyakyw K, et al. Prospective randomized trial of thoracostomy removal algorithms. The Journal of Trauma: Injury, Infection and Critical Care. 1999;46 (3): Pacharn P, Heller DND, Kammen BF, et al. Are chest radiographs routinely necessary following thorocostomy tube removal? Pediatr Radiol. 2002;32:138 Goodman MD, Huber, NL, Johannigman JA, et al. Omission of routine chest x-ray after chest tube removal is safe in selected trauma patients. The American Journal of Surgery. 2010;199: North West London Trauma Network 7