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Intercostal Drain Insertion 6/8/10 SP Notes PREPARATION - exclude contraindications consent IV access (analgesia, resuscitation medications or products) monitoring (SpO2, ECG, BP) confirm affected side (clinically + CXR) position: supine with arm abducted and hand under head local anaesthesia: lignocaine with adrenaline = 7mg/kg EQUIPMENT - chlorhexidine drape scalpel forceps clamp 2.0 suture gauze dressing 32 Fr drain (blood) underwater seal drainage system (primed) INSERTION - full asepsis (G/G/H/M/C) landmarks = anterior to mid-axillary line, 5th IC space, nipple line (T4), palpate ribs and ICS 2-3cm transverse incision on top of rib blunt dissection down to pleura (just superior to rib -> avoid neurovascular structures) end point: pleural cavity (hiss or blood) sweep with finger insert clamped drain using curved forceps to guide in connect to UWSD check for drainage and respiratory swing suture sterile dressing POST INSERTION - CXR - watch for complications: -> not draining (check for kinking) -> organ injury (lung, liver, spleen, heart, vessel) – careful insertion -> blood loss– careful observation -> surgical emphysema (small hole and good suturing) ->infection (sterile technique) Jeremy Fernando (2011) Features of a Pleural Drainage System - see diagram modern drains incorporate three separate bottles into one unit bottle A = fluid trap bottle B = underwater seal drain bottle C = allows suction to be attached Safety features: 1. first tube connecting drain to drainage bottles must be wide to decreased resistance 2. volume capacity of this tube should exceed ½ of patients maximum inspiratory volume (otherwise H2O may enter chest) 3. volume of H2O in bottle B should exceed ½ patients maximum inspiratory volume to prevent indrawing of air during inspiration 4. drain should always stay at least 45cm below patient (prevention of removed fluid or H2O refluxing into patient) 5. clamp drain when moving 6. H2O level above tube in bottle C determines the amount of suction applied before air drain through tube (safety suction limiting device) Jeremy Fernando (2011)