INTERCOSTAL DRAINAGE :

Fluid or air that accumulates in the pleural space will reduce lung expansion and lead to respiratory compromise and hypoxia.

Insertion of an intercostal catheter (ICC) enables drainage of air or fluid from the pleural space, allowing negative intra-thoracic pressures to be re-established leading to lung re-expansion.

Indications:

Pneumothorax

Haemothorax

Pleural effusion

Contraindications:

Need for immediate thoracotomy  

Complications:

Pain

Thoracic or abdominal visceral trauma

Tension pneumothorax

Equipment

Special procedures tray

Under water sealed drain system (UWSD)

use cell saver UWSD for massive haemothorax

Intercostal Catheter (guide sizes only)

use smaller size for draining air

larger size for draining blood/fluid

Newborn 8-12 FG

Infant   12-16 FG 

Child  16-24 FG 

Adolescent 20-32 FG

Spigot connector / tube adaptor - 2 sizes

Suction must be available and working

Sterile gloves & gown

Mask

Sterile towels x 2

500ml bottle of sterile water

Antiseptic solution

1% lignocaine + 1:100,000 adrenaline 5mL ampoule 

5ml/10ml syringe and needle

Scalpel blade

Suture material - black silk or nylon with needle size 3.0 x 2

Sleek and Tegaderm x 2

Analgesia, Anaesthesia, Sedation

Local anaesthetic and intravenous analgesia are mandatory, as ICC placement is a painful procedure. The use of sedation should always be discussed with a senior emergency doctor, as it can potentially worsen the patient's clinical condition.

Procedure

Establish patient on continuous cardiac monitoring and pulse oximetry

Place conscious patient in a sitting position at 45 degrees with arm of same side placed above head

Palpate the fourth or fifth intercostal space just anterior to the mid-axillary line

Surgically prepare the area

Ensure local anaesthetic is infiltrated from subcutaneous tissue down to pleura. 

Select the appropriate size I.C.C. and remove stylet.

Incise the skin parallel to the upper border of the rib below the chosen intercostal space. Incise down to the fascia.

"Blunt dissect" (using an artery forcep) down to the pleura, enter the pleural space, and then widen the hole by opening the forceps.

Sweep the pleural space with a gloved finger to widen the hole and push the lung away from the hole (only possible in older children, beware of rib fractures in injured child).

Hold the tip of the catheter with a curved artery clamp and advance it into the pleural space, directing the catheter posteriorly and superiorly.

Advance so that all apertures of the tube are in the chest and not visible

Attach the tube to UWSD below the patient's chest level

Anchor the drain and suture the wound. Tape in place with tegaderm sandwich and anchor the tube to the patient's side.

Connect to the UWSD.

Watch for "swinging" of water in tube connection.

Post-Procedure Care

Reassess ABCs and ensure ICC is functioning

Reassess need for analgesia.

In children following the removal of the tube coverage with a large tegaderm is sufficient for closure rather than a formal purse string suture.