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  • • Prolonged drainage of air or fluid (eg, empyema, hemothorax) from the pleural space.

    • Definitive treatment of a tension pneumothorax (after needle decompression).

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Relative

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  • • Bleeding diathesis.

    • Mechanical ventilation.

    • Presence of adhesions: may require pleurodesis.

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  • • Sterile gloves, mask, and gown.

    • Iodinated skin preparation with sterile sponges.

    • Sterile towels.

    • Local anesthetic (1% lidocaine without epinephrine).

    • 5-mL syringe with 25-gauge needle.

    • 18-gauge 2-inch needle.

    • #10 scalpel with handle.

    • Chest tube and Kelly clamp for large bore insertion.

    • Pleurevac or other drainage system, including all connectors necessary to connect to chest tube and to suction.

    • Suction.

    • Needle holder.

    • Suture scissors.

    • 2-0 silk suture.

    • 4 × 4 gauze.

    • Transparent occlusive dressing.

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  • • Bleeding.

    • Infection.

    • Pain.

    • Pneumothorax.

    • Puncture of organ (ie, lung, liver, spleen).

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  • • Patient should have intravenous access.

    • Oxygen should be available.

    • Monitor oxygen saturation with pulse oximetry.

    • Younger patients may need sedation or anesthesia for procedure, especially with large bore chest tube insertion.

    • Explain procedure in a developmentally appropriate manner before and during procedure.

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  • • Patient lying on bed with head of table elevated 30 degrees with arm above head.

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Figure 21–1.
Graphic Jump Location

Anatomy of the neurovascular bundle.

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Prepare Sterile Field

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  • • Cleanse area in sterile fashion.

    • Drape surrounding area with sterile towels.

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Numb the Area

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Table Graphic Jump Location
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• The fifth or sixth intercostals space in the anterior axillary line is the target for numbing the area.
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  • • Use 25-gauge needle and 5-mL syringe to infiltrate skin and make wheal under skin.

    • Change needle to 18 gauge with 2-inch needle.

    • Infiltrate through wheal, over top of rib, to anesthetize the periosteum, and into pleural space.

    • • Be sure to aspirate first, and know when you are in the pleural space.

      • The pleura needs to be anesthetized, but, to avoid a puncture of the lung, do not advance the needle further.

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Insertion of Chest Tube by Seldinger Technique

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  • • Pass guidewire through needle into pleural space (Figure 21–2B).

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  • • Remove needle (while always maintaining a hold on the guidewire).

    • Make small incision at site of insertion (large enough to pass chest tube) (Figure 21–2C).

    • Starting with smallest dilator, insert dilator over guidewire using a twisting motion (while always maintaining a hold on the guidewire) (Figure 21–2D).

    • Repeat with larger dilators over guidewire until track is large enough to ...

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