Tube Thoracostomy (ICD insertion)

Procedure:

1. Position of Patient:

2. Site:

3. Apply antiseptic solution to a wide area of the chest wall and drape

4. Local anesthesia:

-Use the 25-G needle to inject 5 mL of the local anesthetic solution into the skin overlying the region of initial skin incision

-Use the longer needle to infiltrate about 5 mL of the an subcutaneous tissue superior to the expected initial incision

-Redirect the needle to the expected course of the chest tube (following the upper border of the rib below the fifth intercostal space), and inject approximately 10 mL of the anesthetic solution into the periosteum (if bone is encountered), intercostal muscle, and the pleura

-Aspiration of air, blood, pus, or a combination thereof into the syringe confirms that the needle entered the pleural cavity

5. Steps to insert the tube:

• The skin incision is made in between the midaxillary and anterior axillary lines over a rib that is below the intercostal level selected for chest tube insertion with the help of 11 no. blade. The incision is made 4 cm long

• Use a hemostat or Kelly clamp to bluntly dissect a tract in the subcutaneous tissue by intermittently advancing the closed instrument and opening it

• Palpate the tract with a finger as shown, and make sure that the tract ends at the upper border of the rib above the skin incision. Insertion of the chest tube as close as possible to the upper border of the rib (minimize the risks of injury to the nerve and blood vessels that follow the lower border of each rib)

• Use a closed large Kelly clamp to pass through the intercostal muscles and parietal pleura and enter into the pleural space

• It should be done in a controlled manner so that instrument does not enter too far into the chest, which could injure the lung or diaphragm

• Upon entry into the pleural space, a rush of air or fluid should occur. Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions. Rotate the finger 360º to appreciate the presence of dense adhesions that cannot be broken and require placement of the chest tube in a different site

• Measure the length between the skin incision and the apex of the lung to estimate how far the chest tube should be inserted

• Grasp the proximal (fenestrated) end of the chest tube with the large Kelly clamp and introduce it through the tract and into the thoracic cavity as shown. Clamp the distal end of the tube with a hemostat

7) Connect the chest tube to the drainage device as shown (the distal end of the chest tube can be cut to facilitate its connection to the drainage device tubing). Release the cross clamp that is on the chest tube only after the chest tube is connected to the drainage device

8) Secure the chest tube to the skin using 0 or 1-0 silk or nylon stitches. For securing sutures, two separate through and through, simple, interrupted stitches on each side of the chest tube are recommended

This technique ensures tight closure of the skin incision and prevents routine patient movements from dislodging the chest tube

Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again (but not piercing the tube)

9) Create an occlusive dressing to place over the chest tube by turning regular gauze squares (4 x 4 in) into Y shaped fenestrated gauze squares and using 4-in adhesive tape to secure them to the chest wall. Make sure to provide enough padding between the chest tube and the chest wall