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CHEST TUBE AND FUHRMAN CATHETER INSERTION

 

 

Indications

 

1.                  Drainage of hemothorax, or large pleural effusion of any cause

2.                  Drainage of large pneumothorax (greater than 25%)

3.                  Prophylactic placement of chest tubes in a patient with suspected chest trauma before transport to specialized trauma center

4.                  Flail chest segment requiring ventilator support, severe pulmonary contusion with effusion

 

Contraindications

 

1.                  Infection over insertion site

2.                  Uncontrolled bleeding diathesis

 

 

Materials

 

1.                  Chest tube with or without trocar; OR Fuhrman catheter

2.                  Chest tube suction unit (PleurevacR or SaharaR), tubing, wall suction hookup

3.                  Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver, scissors

4.                  Packet of 0 or 1.0 silk suture on a curved needle

5.                  Tape, gauze

6.                  2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration

7.                  Sterile prep solution; mask, gown and gloves

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Size of Chest Tube

 

 

 

Adult or Teen Male

 

 

             28-32 Fr

 

 

Adult or Teen Female

 

 

             28 Fr

 

 

Child

 

 

 

             18 Fr

 

Newborn

             12-14 Fr

 

 

Preprocedure patient education

 

1.                  Obtain informed consent

2.                  Inform the patient of the possibility of major complications and their treatment

3.                  Explain the major steps of the procedure, and necessity for repeated chest radiographs

 

 

Procedure

 

NOTE: Conscious sedation during this procedure is an option for those patients who are clinically stable.

 

1.                  Examine the patient and assess need for placement of a thoracostomy tube. Obtain pre-procedure chest Xray

2.                  Select site for insertion: mid-axillary line, between 4th and 5th ribs…this is usually on a line lateral to the nipple

3.                  Don mask, gown and gloves; prep and drape area of insertion. Have patient place ipsilateral arm over head to “open up” ribs

4.                  Widely anesthetize area of insertion with the 2% lidocaine. Infiltrate skin, muscle tissues, and right down to pleura

 

 

 

Fuhrman catheter insertion:

 

      -remove catheter, dilator, introducer wire, and introducer needle from bag

-insert introducer needle into the thoracic cavity. Withdraw air with a       syringe to confirm placement

-Thread introducer wire through needle into chest. Remove needle leaving introducer wire running into chest

-Thread dilator over introducer wire, and advance into chest, dilating a tract for catheter. Remove dilator

-Thread Fuhrman catheter over the wire fully into chest. Remove wire. Tape or suture catheter in place

-Attach catheter to suction unit

-Obtain post procedure chest Xray

 

     Chest tube insertion

 

-After infiltrating insertion site with local anesthetic, make a 3-4 cm incision through skin and subcutaneous tissues between the 4th and 5th ribs, parallel to the rib margins (Figure 1)

 

 

 

Figure 1: Incising the chest wall

 

-Continue incision through the intercostal muscles, and right down to the pleura

-Insert Kelly clamp through the pleura and open the jaws widely, again parallel to the direction of the ribs (this “creates” a pneumothorax, and allows the lung to fall away from the chest wall somewhat, See Figure 2)

 

 

 

 

 

 

 

Figure 2: Opening the incision with a Kelly clamp

 

 

-Insert finger through your incision and into the thoracic cavity. Make sure you are feeling lung (or empty space) and not liver or spleen

-Grasp end of chest tube with the Kelly forcep (convex angle towards ribs), and insert chest tube through the hole you have made in the pleura. After tube has entered thoracic cavity, remove Kelly, and manually advance the tube in (Figure 3).

 

 

Figure 3: Using a Kelly clamp to guide insertion of the chest tube

 

 

 

 

 

If the tube is of the trocar variety, grasp tube with one hand close to the sharp trocar end and guide the tube slowly and gently through the hole in the pleura into the chest cavity (Figure 4). Remove trocar once tube has just entered the cavity, and feed tube in approximately 1/2 to 2/3 of its length, until all the fenestrations of the tube are within the chest

 

 

 

Figure 4: Inserting a trocar chest tube

 

 

 

-Clamp outer tube end with Kelly

-Suture and tape tube in place

-Attach tube to suction unit

-Obtain post procedure chest Xray for placement; tube may need to be advanced or withdrawn slightly

 

 

Complications, Prevention, and Management

 

1.                  Puncture of liver or spleen. This is entirely preventable; insertion site is in the nipple line, between 4th and 5th ribs!

2.                  Bleeding; this usually ceases

3.                  Cardiac puncture. Again preventable, carefully control the tube going in, and remove the trocar early!

4.                  Passage of tube along chest wall instead of into chest cavity. In this case, widen and deepen the dissection between the ribs, and make sure the insertion of the tube follows this path

 

Documentation in the Medical Record

 

1.                  Consent if obtained

2.                  Indications and contraindications for the procedure on this patient

3.                  Procedure used (trocar vs. non-trocar)

4.                  Any complications, or “none”

5.                  Who was notified of any complication (family, attending physician)

 

 

Items for evaluation of person learning this procedure

 

1.                  Anatomy of the chest, lungs, pleura

2.                  Indications, and contraindications of this procedure

3.                  Use of sterile technique and Universal Precautions

4.                  Technical ability

5.                  Appropriate documentation

6.                  Understanding of potential complications and their correction