This document provides information about chest tube insertion and central venous line procedures. It discusses the indications for chest tube insertion, which include pneumothorax, hemothorax, hydrothorax, and pleural effusions. Contraindications include coagulopathy and pulmonary adhesions. Equipment needed for chest tube insertion is listed. Central venous line procedures are used to administer specific IV drugs or for hemodialysis access when peripheral IV access is not possible. Common insertion sites include the internal jugular, subclavian, and femoral veins. Contraindications include if less invasive IV access is possible or if the patient has an overlying skin lesion or bleeding diathesis.

1. Chest Tube Insertion &
Central Venous Line
Dr Adib Mursyidi Iskandar Mirza
Emergency Department
IIUM Medical Centre

2. What is Chest Tube?
• Tube thoracostomy is the insertion of a tube (chest tube) into the
pleural cavity to drain air, blood, bile, pus, or other fluids.

3. Indication
• Pneumothorax: Open or closed; simple or tension
• Hemothorax
• Hemopneumothorax
• Hydrothorax
• Chylothorax
• Empyema
• Pleural effusion
• Patients with penetrating chest wall injury who are intubated or about to be
intubated
• Considered for those about to undergo air transport who are at risk for
pneumothorax

4. Contraindication
• Relative contraindications include the following:
• Coagulopathy
• Pulmonary bullae
• Pulmonary, pleural, or thoracic adhesions
• Loculated pleural effusion or empyema
• Skin infection over the chest tube insertion site

5. Equipment
• Chest tube drainage device with water seal
(autotransfuser unit is an option)
• Suction source and tubing
• Sterile gloves
• Preparatory solution
• Sterile drapes
• Surgical marker
• Lidocaine 1% with epinephrine
• Syringes, 10-20 mL (2)
• Needle, 25 gauge
• Needle, 23 gauge
• Blade, No. 10, on a handle
• Large and medium Kelly clamps
• Large curved Mayo scissors
• Large straight suture scissors
• Silk or nylon suture, 0 or 1-0
• Needle driver
• Vaseline gauze
• Gauze squares, 4 x 4 in (10)
• Sterile adhesive tape, 4 in wide
• Chest tube of appropriate size: Man - 28-32F;
woman - 28F; child - 12-28F; infant - 12-16F;
neonate - 10-12F

6. Anatomy

7. Central
Venous Line

8. Central Venous Line
• This procedure can be associated with significant complications
and must always be performed under supervision until
competence is attained.
• Commonly used sites
• Internal jugular vein (IJV), subclavian vein and femoral vein, which are all
located close to arteries and nerves that can be damaged by a misplaced
needle
• In addition the subclavian vein lies near the pleura of the lung
with the risk of pneumothorax

9. Indications
• Intravenous administration of specific drugs (e.g. dopamine or
adrenaline)
• Inability to obtain adequate peripheral IV access in the critically
unwell patient, in a timely fashion
• Haemodialysis
• Central venous pressure monitoring, the insertion of a pulmonary
artery (Swan-Ganz) catheter to measure wedge pressure
• Hyperalimentation (TPN administration)
• Cardiopulmonary resuscitation.

10. Contraindication
• Less invasive forms of IV access are possible and adequate
• Overlying skin lesion such as cellulitis or burns
• Uncorrected bleeding diathesis
• Obstruction of the vein by tumour, mass or thrombosis
• Uncooperative patient.

11. Anatomy

12. Guidewire Insertion Length

13. Questions?

14. Thank you