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Chest drain protocol v8
- 1. Chest Drain Checklist for GoogleGlass Beta Version 8 Authors: Tudor Toma, University Hospital Lewisham & Greenwich, London, UK. Open Source: please use and quote this source; please contribute with feedback. Methods: review of pre-published guidelines, beta versions, formation of an expert panel and repeat pilot-testing with googleglass on a simulator Methodological Reference: Int J Qual Health Care. 2008;20(1):22-30. Please email your comments to ttoma@doctors.org.uk
- 2. Settings • Prism: adjust • Tap once to next steps • Slide finger for forward • Read then do • Questions: ask
- 3. Five Main Domains Prepare & Local anaesthetic Set Seldinger Insert drain Secure Clean & Check CXR
- 4. Warnings! One. • Always use ultrasound • Stay in safe triangle
- 5. Warnings! Two. • Skin incision: cut only skin • Dilator does not dilate skin • Perpendicular direction to pleura • Measure distance to pleura with ultrasound
- 6. Warnings! Three. • Large patients - longer needle for anaesthetic • Visualize your actions beyond skin
- 7. Very serious warnings! • No aspirate? Stop • Go perpendicularly, or call for help • Keep a hand on the guide wire at all times
- 8. Start procedure • Please follow the checklist
- 9. Prepare yourself and patient • Indications: check. • Drain necessary? • Clotting (<1.5) & platelets (>90): check • Info: explain • Consent
- 10. Check equipment. Set trolley. • Betadine. Dressing. Gown. Gloves • Drape. Lignocaine. Suture. Mefix • 2-3 10ml syringes. 2 orange 3 green needles • Large syringe-cytology. Specimen bottles. • Seldinger pack. Drain bottle. Sterile water.
- 11. Finalise preparations • Bottle: fill • Patient: set. All sterile • Seldinger pack: do not open • Sharps: beware of injuries
- 12. Local anaesthetic • Skin: clean; orange-infiltrate. • Below skin & around pleura: infiltrate. Green needle. • Aspiration from the pleural space? • Do not inject pleural fluid. • Remember direction and depth
- 13. Set Seldinger pack in the order of use 1. Scalpel 2. Needle: attach to syringe 3. Wire: blue tip off. Set dilator 4. Drain: remove stiffener 5. Tap: off. Check attachment
- 14. Insert drain • Proceed
- 15. Skin incision & insert needle • Skin: cut 0.5 cm. Insert needle • Keep direction like green needle • Advance- Aspirate –Advance • When fluid/air advance further 1cm • Free aspiration: check
- 16. Insert wire • Remove syringe • Thumb over needle • Insert wire. Half length • Remove needle • Hold wire at all times
- 17. Insert Dilator • Thread dilator on wire • Hold wire at all times • Advance by twisting-spiraling • Advanced estimated depth only
- 18. Thread the drain • Remove dilator, keep wire • Hold wire at all times • Thread drain by twisting spiraling • Hold wire at all times • Insert 15cm
- 19. Remove guide wire • Remove wire • Wire outside chest? Check - Check • 3-way tap: attach
- 20. Secure & Connect the drain • Proceed
- 21. Suture • Skin: 2 cm needle bite • Skin other side: come down 2 cm bite. • Tie flat to the skin. • Secure drain: crossover, double knots • Check fixation
- 22. Connect drain to bottle • Cut & place a gauze • Secure gauze with tape • Connect drain to bottle • Aspirate more fluid/samples
- 23. Set a plan • 1.5 litre then clamp • Iatrogenic pneumothorax and a clamped drain? • Reopen after 4h • Free drainage for slower flows
- 24. Clean & check the CXR • You only dispose ALL sharps • Clean bed space • Check swinging
- 25. Document & Check • Document procedure • Label & send fluid • CXR. Check the CXR • Check drain position and swinging • Communicate to nurse & docs
- 26. Procedure Finished • Document in your log book • Follow up patient
Editor's Notes
- +Go to next +Few warnings first +Then procedure checklist
- +Prism: adjust +Tap once to next steps +Slide finger for forward +Read then do +Questions: ask
- +1. Prepare & Anaesthetic +2. Set Seldinger +3. Insert drain +4. Secure. +5. Clean & Check CXR
- +Always use ultrasound +Stay in safe triangle
- +Skin incision: cut only skin +Dilator does not dilate skin +Perpendicular direction to pleura +Measure distance to pleura with ultrasound
- +Large patients - longer needle anaesthetic +Visualise your actions beyond skin
- +No aspirate? Stop +Go perpendicularly, or call for help +Keep a hand on the guide wire at all times
- +Please follow checklist
- +Indications: check. +Drain necessary? +Clotting (<1.5) & platelets (>90): check +Info: explain +Consent
- +Betadine. Dressing. Gown. Gloves. +Drape. Lignocaine. Suture. Mefix. +Syringes. Orange, green needles. +Specimen bottles. +Seldinger pack. Drain bottle. Sterile water.
- +Bottle: fill +Patient: set. All sterile +Seldinger pack: do not open yet +Sharps: beware of injuries
- +Skin: clean; orange-infiltrate +Subcut & around pleura: infiltrate - green +Aspiration from the pleural space? +Do not inject pleural fluid +Remember direction and depth
- +1. Scalpel +2. Needle: attach to syringe +3. Wire: blue tip off. Set dilator +4. Drain: remove stiffener +5. Tap: off. Check attachment
- + Check next
- +Skin: cut 0.5 cm. Insert needle +Keep direction like green needle +Advance- Aspirate –Advance +When fluid/air advance further 1cm +Free aspiration: check
- +Remove syringe +Thumb over needle +Insert wire. Half length +Remove needle +Hold wire at all times
- +Thread dilator on wire +Hold wire at all times +Advance by twisting-spiraling +Advance estimated depth only
- +Remove dilator, keep wire +Hold wire at all times +Thread drain by twisting spiraling +Hold wire at all times +Insert ≈ 15cm
- +Remove wire +Wire outside chest? Check - Check +3-way tap: attach
- +Proceed
- +skin: 2 cm needle bite +skin other side: come down 2 cm bite. +Tie flat to the skin. +Secure drain: crossover, double knots +Check fixation
- +Cut & place a gauze +Secure gauze with tape +Connect drain to bottle +Aspirate more fluid/samples
- +1.5 litre then clamp +Iatrogenic pneumothorax and a clamped drain? +Reopen after 4h +Free drainage for slower flows
- +Dispose yourself ALL sharps +Clean bed space +Check swinging
- +Document procedure +Label & send fluid +CXR. Check CXR +Check drain position and swinging +Communicate to nurse & docs
- +Document your log book +Follow up patient