This document provides instructions for surgically inserting a chest drain. It outlines the necessary pre-procedural checks, equipment, patient preparation, anesthesia technique, dissection and drain placement steps. Key steps include identifying the correct intercostal space using anatomical landmarks, infiltrating the skin and pleura with local anesthetic, making an incision and dissecting into the pleural space, placing a holding suture, inserting the drain tube until the holes are in the chest cavity, securing and attaching it to a drainage system, and doing post-procedure checks including a chest x-ray. Samples of any effusion should also be sent for microbiological and biochemical analysis.

1. Surgical chest drain insertion
Joshil Lodhia
CT1, Cardiothoracic Surgery
University Hospital of South Manchester

2. Pre-procedural checks
• Consent
• Clotting
• Assess the CXR prior to insertion
• Indication alters placement (Apically or basally)
• Ensures correct side
• Equipment
• Giving oral analgesics 20 minutes prior to placement helps optimise
pain relief

3. Equipment
• Chlorhexidine/ Povidone-iodine
• Drapes
• Gloves, gowns, scrub hat, face mask
• 1% Lignocaine 10-20ml (max dose: 3 ml/kg)
• 10-20ml syringe
• 2x green needles
• 1x orange needle

4. Equipment cont…
• Chest drain kit
• 10 blade and handle
• 2x curved clamps
• Scissors
• Chest drain (18-32F depending on indication)
• Gauze
• Drain tubing
• Underwater seal drainage system
• Fill to the mark with sterile water
• 1-0 Silk suture
• Dressings

5. Preparation
• Placement
• Patient at 30-45 degrees
• Arm behind his/her head
• Safety triangle
• Anterior border made by the lateral border of pectoralis major
• Posterior border made by the lateral border of latissimus dorsi
• Inferior border made by the 5th intercostal space
• Scrub, gown, gloves, scrub hat, face mask
• Clean skin with prep
• Place the drapes

6. Anaesthesia
• Palpate the ribs and infiltrate with 1% ligocaine just above the rib
• Go into pleura above the rib till fluid/air is aspirated
• Pull back a small amount till it is no longer aspirating and infilatrate further
• Wait 5 minutes and ensure adequate anaesthesia
• Create an incision the width of your finger/drain

7. Dissection
• Place the closed curved clamp through the incision
• Curve facing down
• Rest on the rib below (dissect above the rib)
• Hold the clamp close to the skin to prevent it slipping too far into the
chest
• Place the clamp in closed then open to dissect
• Close and pull the clamp out and repeat
• Continue until into the pleural space
• Hear a hiss or obtain fluid.
• Open the clamp in that space to create a space.

8. Drain placement
• Place a finger into the pleural space
• Sweep 360 degrees to free adhesions and ensure correct placement
• Place a holding suture and a vertical mattress suture
• The vertical mattress suture is for when the drain is removed
• Placing the suture now ensures it does not catch the drain later
• Place a clamp on the end of the drain to ensure air does not enter the
chest
• Place the curved clamp at the tip of the drain to help guidance
• Insert the drain
• Apex for pneumothoraces
• Basally for effusions

9. Procedure cont.
• Advance the drain till all the drain holes are in the chest cavity
• Secure the drain with the previously placed holding suture
• Attach the drain tubing
• Attach the tubing to the underwater system
• Release the clamp from the drain and ensure swinging (and bubbling
if pneumothorax)
• Make a slit in the gauze and place around the drain and apply the
dressings

10. Post-procedural checks
• Re-examine the patient
• Ensure fluid level is swinging
• It may also be bubbling in the presence of a pneumothorax
• CXR to ensure correct placement and reassess the lung status

11. Further tests
• If effusion present send sterile samples for
• MC&S including Acid fast bacilli
• Cytology
• Glucose
• Protein
• LDH
• Lactate
• pH