1. Surgical chest drain insertion
Joshil Lodhia
CT1, Cardiothoracic Surgery
University Hospital of South Manchester

2. Pre-procedural checks
• Consent
• Clotting
• Assess the CXR prior to insertion
• Indication alters placement (Apically or basally)
• Ensures correct side
• Equipment
• Giving oral analgesics 20 minutes prior to placement helps optimise
pain relief

3. Equipment
• Chlorhexidine/ Povidone-iodine
• Drapes
• Gloves, gowns, scrub hat, face mask
• 1% Lignocaine 10-20ml (max dose: 3 ml/kg)
• 10-20ml syringe
• 2x green needles
• 1x orange needle

4. Equipment cont…
• Chest drain kit
• 10 blade and handle
• 2x curved clamps
• Scissors
• Chest drain (18-32F depending on indication)
• Gauze
• Drain tubing
• Underwater seal drainage system
• Fill to the mark with sterile water
• 1-0 Silk suture
• Dressings

5. Preparation
• Placement
• Patient at 30-45 degrees
• Arm behind his/her head
• Safety triangle
• Anterior border made by the lateral border of pectoralis major
• Posterior border made by the lateral border of latissimus dorsi
• Inferior border made by the 5th intercostal space
• Scrub, gown, gloves, scrub hat, face mask
• Clean skin with prep
• Place the drapes

6. Anaesthesia
• Palpate the ribs and infiltrate with 1% ligocaine just above the rib
• Go into pleura above the rib till fluid/air is aspirated
• Pull back a small amount till it is no longer aspirating and infilatrate further
• Wait 5 minutes and ensure adequate anaesthesia
• Create an incision the width of your finger/drain

7. Dissection
• Place the closed curved clamp through the incision
• Curve facing down
• Rest on the rib below (dissect above the rib)
• Hold the clamp close to the skin to prevent it slipping too far into the
chest
• Place the clamp in closed then open to dissect
• Close and pull the clamp out and repeat
• Continue until into the pleural space
• Hear a hiss or obtain fluid.
• Open the clamp in that space to create a space.

8. Drain placement
• Place a finger into the pleural space
• Sweep 360 degrees to free adhesions and ensure correct placement
• Place a holding suture and a vertical mattress suture
• The vertical mattress suture is for when the drain is removed
• Placing the suture now ensures it does not catch the drain later
• Place a clamp on the end of the drain to ensure air does not enter the
chest
• Place the curved clamp at the tip of the drain to help guidance
• Insert the drain
• Apex for pneumothoraces
• Basally for effusions

9. Procedure cont.
• Advance the drain till all the drain holes are in the chest cavity
• Secure the drain with the previously placed holding suture
• Attach the drain tubing
• Attach the tubing to the underwater system
• Release the clamp from the drain and ensure swinging (and bubbling
if pneumothorax)
• Make a slit in the gauze and place around the drain and apply the
dressings

10. Post-procedural checks
• Re-examine the patient
• Ensure fluid level is swinging
• It may also be bubbling in the presence of a pneumothorax
• CXR to ensure correct placement and reassess the lung status

11. Further tests
• If effusion present send sterile samples for
• MC&S including Acid fast bacilli
• Cytology
• Glucose
• Protein
• LDH
• Lactate
• pH