Not all chest drains have to be inserted ASAP so time should be taken to ensure patient comfort, sterility and accurate placement of drains.

Preparation

•Two doctors should be present where possible; one to supervise sedation and the other to insert the drain

•Gather all necessary equipment before embarking on the procedure (see insertion packs below)

•Administer oxygen by mask.

•Insert IV, attach pulse oximeter.

•Sedate the patient: A carefully titrated dose of Midazolam will reduce patient anxiety. Do not use in conjunction with a narcotic. (Propofol is ideal if an anaesthetist is present).

•Ensure that Narcan and Anexate are present in the room to counter any unwanted sedation. Wait till sedation has taken effect

•Place the patient in a semi-recumbent position rolled slightly away from the operator with the arm raised across the head. (It may need to be supported during the procedure).

•Prepare the skin with suitable antiseptic (Chlorhexidine is probably the most efficacious)

•Choose site for skin incision (see below ‘triangle of safety’).

•Inject local anaesthetic along a line of 3 cm parallel to the ribs. Inject deep into fat, intercostal muscle and, if possible, the pleura.

Insertion of drain

•Make a 3 cm incision through the skin.

•Bluntly dissect the fat and fascia to the level of the rib with medium sized artery forceps. Aim to create a subcutaneous track by running over the top of the rib one intercostal space above the skin incision, keeping away from the intercostal vessels which run inferior to the rib. Use a blunt instrument or a finger to enter the pleura.

•Perform a "digital pleural examination" - examine the lung, chest wall and diaphragm with a finger to ensure you are in the right place. It also makes a hole big enough for the drain.

•Insert a drain large enough to drain the contents of the pleural space. There is no evidence that a small drain is less painful. There is evidence that small drains frequently fail due to blockage with fibrin or thrombus. Number 28 and 32 French drains are recommended for most adult situations.

•Direct the drain to the appropriate position using either a blunt trocar or a finger.

•The drain may be clamped to allow connection to the underwater seal container.

Securing drains and dressing the wounds

•Before tying the drain bring the arm down to the side while ensuring the drain position within the chest does not change.

•Using a heavy 1 Mersilk suture, fasten the drain to the skin securely.

•Secure the drain to the skin separately with a loop of tape about 10 cm from the suture. This takes the weight off the skin suture.

•Place a horizontal mattress ‘pursestring’ suture around the drain using absorbable 2/0 Vicryl. This will be used at removal to seal the wound.

•Using 2/0 silk close the rest of the wound snugly round the drain to prevent leakage around it.

•A light dressing is all that is required. It does not need to be airtight. A small ‘Mepore’ dressing incised to fit around the drain should be sufficient.

•Ensure all sharps are placed in the appropriate container.

•Request a portable chest Xray to ensure the drain is in the right place.

•Continue SaO2 monitoring till patient is fully recovered.