Intercostal catheter insertion

1. Intercostal
Catheter Insertion
Dean Fulford
SCGH
26TH April 2018

2. PRINCIPLES
GUIDELINES
PROCEDURE
THE END

3. WHAT ARETHE ISSUES
• Indications & Contraindications
• When to insert
• Site of insertion
• Choosing the drain
• Technique
• After care
• Complications
• Disposition

4. INTERCOSTAL CATHETER
INSERTION
• Allows drainage of air
or fluid from the pleural
space, allowing
negative intra-thoracic
pressures to be re-
established leading to
lung expansion

5. INDICATIONS
• Drainage of a pneumothorax
• Under tension
• With respiratory distress or failure
• With significant emphysema
• With failed aspiration or recurrent collapse after
aspiration
• Drainage of a large haemothorax of pleural
effusion
• Drainage of an empyema
• Prophylactic insertion in a patient with chest
injuries, prior to PPV or aeromedical transport
• Pleural lavage (eg rewarming)

6. CONTRA-INDICATIONS
• In ED all relative
• Lung adherent to chest wall
• Uncorrected coagulopathy
• Loculated
• Infection over insertion site

7. DEPARTMENT POLICY
• Consultant supervision for all insertions
JUNIOR COMPETENCY CONSULTANT INPUT
0 Does procedure
1 Does procedure assisted by junior
2 Consultant watches
3 Informed and available if needed
4 Only post fellowship

8. AREA AND STAFF
• Monitored resusitation cubicle
• 1 doctor performing procedure
• 1 procedure assistant
• If procedural sedation required then a 2nd
doctor dedicated to ABC
• 1 nurse for observations and tend to the
patient

9. EQUIPMENT
• Sterile pack/gown
• Chlorhexadine with alcohol
• Chest drain set
• Scalpel with blade
• blunt dissectors
• 10ml syringe with 25G (or 27G) + 21G needles
• Suture set
• Suture material: 00 or 0 nylon
• Dressing: drain swabs and occlusive dressing
• Underwater sealed chest drain unit prepared
with sterile saline

10. TUBE SIZE (SCGH)
• Adult:
• Simple pneumothorax: 20 – 24F
• Effusion, Haemothorax,
Haemopneumothorax, Empyema: 28 – 36F
• Child:
• 18 – 24F
• Infant:
• 14 – 20F
• Neonate:
• 8 – 12F

11. DRUGS
• Lignocaine 1% 20ml (max 3mg/kg)
• Morphine 2.5-5mg IV boluses (if analgesia
required despite local anaesthesia)
• Midazolam 1-2mg IV boluses (if anxiolysis or
sedation required)

12. PROCEDURE
• Anterior = lateral
edge of pectoralis
major
• Lateral = edge of
latissimus dorsi
• Inferior = line of the
fifth intercostal
space
• Superior - base of
the axilla

14. PROCEDURE
• Blunt:
https://www.youtube.com/watch?v=qR3
VcueqBgc&t=51s (0:44)
• Seldinger:
https://www.youtube.com/watch?v=h1g
Si9BX8KU (1:45)

15. COMPLICATIONS &TREATMENT
• Early:
• Haemorrhage
• Trauma to heart, lung, diaphragm, liver or
spleen
• Malposition (extra-thoracic or extra-pleural),
subcutaneous emphysema
• Late:
• re-expansion pulmonary oedema
• Infection and empyema

16. AFTER CARE
• Keep the underwater seal below the level of
the heart at all times
• Check XR
• Intially ½ hr obs (Pt and drain)
• Swinging with respiration?
• Bubbling with pneumothorax?
• Fluid increasing?
• Disposition: ward where NS familiar with care
of ICC

17. BTS GUIDELINES 2010
• Supervision:
• Griffiths 2005: doctors asked where to insert,
45% outside safety triangle
• Timing: in hours except emergency
• Clotting: correct INR >1.5 or APTT >1.5x
• Consent: pain, infection, dislodgement,
blockage & visceral injury
• Antibiotics: no (but consider in penetrating
traumatic pneumothorax)

18. BTS GUIDELINES cont..
• Size of drain
• 1st line US guided Small bore (empyema flush),
large bore for traumatic haemothorax
• Premedication
• Titrate Midaz 2mg or 2.5mg morphine as 50%
Pts c/o 9/10 pain
• Aspirate expected contents or don’t
continue
• No larger than green or 20G needle

19. BTS GUIDELINES cont..
• Imaging
• CXR. US guidance for all drains for pleural fluid
• Site
• Triangle of safety
• Advise against 2nd ICS
• Loculated by US guide (radiologist)
• Anaesthesia
• 1% lidocaine: better than 2% and no evidence
for adrenaline

20. BTS GUIDELINES cont..
• Technique
• Seldinger. No force, dilator no further than 1cm
in from skin,
• Blunt dissection in trauma and use large-bore
• NO trocars
• Suture drain: 0 or 1-0 silk
• Check position
• if malposition suspected then CT
• Can withdraw but never push
• Never replace through same hole

21. BTS GUIDELINES cont..
• Drainage: valve mechanism
• Rate of drainage
• Never clamp bubbling tube
• Max 1.5L fluid drained in 1st hour – this
should be controlled to prevent re-
expansion pulmonary oedema
• Suction:
• no evidence for or against
• Common in non-resolving pneumothoraces

22. BTS GUIDELINES cont..
• Removal
• Bell at al: no difference in inspiration or
expiration withValsalva
• If suction then period of water seal only
then remove

23. THE END

24. References
• Griffiths JR, Roberts N. Do junior doctors know where to insert
chest drains safely? Postgrad Med J 2005;81:456–8. (2−).
• http://scghed.com/2017/06/chest-drain-insertion-guideline-
052009/
• Luketich JD, Kiss M, Hershey J, et al. Chest tube insertion: a
prospective evaluation of pain management. Clin J Pain
1998;14:152–4. (2+).
• BTS guidelines: Pleural procedures and thoracic ultrasound:
British Thoracic Society pleural disease guideline 2010
http://thorax.bmj.com/content/65/Suppl_2/i61
• Bell RL, Ovadia P, Abdullah F, et al. Chest tube removal: end-
inspiration or end-expiration? J Trauma 2001;50:674–7.
(1−).PubMedWeb of ScienceGoogle Scholar