Inter costal drainage nusing

care

 Achest tube(chest drain,thoracic catheter,tube thoracostomy,

orintercostal drain)isaflexibleplastictubethatisinsertedthrough
thechestwallandintothepleural space or mediastinum.

Indications
Chylothorax:Collectionoflymphfluidinthepleuralspace
Haemothorax: Collectionofbloodinthepleuralspace
Pneumothorax :Collectionofairinthepleuralspace
Tension Pneumothorax:Onewayvalveeffectallowingairtoenterthepleural

space,butnottoleave.Airbuildsupforcingamediastinalshift.Thisleadsto
decreasedvenousreturntotheheartandlungcollapse/compressioncausing
acutelife-threateningrespiratoryandcardiovascularcompromise.Ventilated
patientsareparticularlyhighriskduetothepositivepressureforcingmoreairinto
thepleuralspace.Tensionpneumothoraxcanresultinrapidclinicaldeterioration
andisanemergencysituation

 Pleural effusion:Exudateortransudateinthepleuralspace
Under Water Seal Drain (UWSD):Drainagesystemof3chambers

consistingofawaterseal,suctioncontrol&drainagecollection
chamber.UWSDaredesignedtoallowairorfluidtoberemoved
fromthepleuralcavity,whilealsopreventingbackflowofairorfluid
intothepleuralspace.
Flutter valve (e.g. pneumostat, Heimlich valve):Onewayvalve

systemthatissmall&portablefortransportorambulantpatients.
Allowsairorfluidtodrain,butnottobackflowintopleuralcavity.

Management
Chest drains should not be clamped
Thereisariskofthepatientdevelopingatensionpneumothoraxifa
drainisclampedwhileanairleakispresent

Patient Assessment
Vital signs
PICUandNNUpatientsshouldbeoncontinuousmonitoring

HR,SaO2,BP,RR
Routinevitalsigns:
Forwardareas:
OninsertionofchestdrainmonitorpatientobservationsofHR,
SaO2,BP,RR:
15minutelyfor1hour
1hourlyfor4hours
IncludesHR,SaO2,BP,RRandtemperature
1-4hourlyasindicatedbypatientcondition

Pain
Chesttubesarepainfulastheparietalpleuraisverysensitive.
Patientsrequireregularpainreliefforcomfort,andtoallowthemto
completephysiotherapyormobilise
Painassessmentshouldbeconductedfrequentlyanddocumented

Drain insertion site

Observeforsignsofinfectionandinflammationanddocument
findings
Checkdressingiscleanandintact
Observesuturesremainintact&secure(particularlylongtermdrains
wheresuturesmayerodeovertime)

UWSD Unit & tubing

Never lift drain above chest level
Theunitandalltubingshouldbebelowpatientschestlevelto
facilitatedrainage
Tubingshouldhavenokinksorobstructionsthatmayinhibit
drainage
Ensureallconnectionsbetweenchesttubesanddrainageunit
aretightandsecure
Connectionsshouldhavecabletiesinplace

 Tubingshouldbeanchoredtothepatientsskintopreventpullingof

thedrain
InPICUandNNUtubingshouldalsobesecuredtopatientbedto
preventaccidentalremoval
Ensuretheunitissecurelypositionedonitsstandorhangingonthe
bed
Ensurethewatersealismaintainedat2cmatalltimes

 Suction
Suctionisnotalwaysrequired,andmayleadtotissuetraumaand

prolongationofanairleakinsomepatients
Ifsuctionisrequiredordersshouldbewrittenbymedicalstaff
Someclinicalareasmayusetheorange'ChestDrainOrders"
sticker.Thisshouldbeplacedinthepatientprogressnotes.

Wallsuctionshouldbesetat>80mmHgorhigher
SuctionontheDrainageunitshouldbesettotheprescribedlevel
-5cmH20iscommonlyusedforneonates
-10cmH20to-20cmH20isusuallyusedbyconventionfor
children

 Tochecksuction:
AtriumOasisUWSD:

Thebellowsshouldbeouttothe'?'mark@20cmH20
Anyvisibleexpansionofthebellowsisadequateforsuction
<20cmH20
Ifthebellowsdeflate,checkthewallsuctionisstillworking,set
to>80mmHgandthatthesuctiontubingisnotkinked
AtriumOceanUWSD:
Thewaterlevelinthesuctionchambershouldbeatprescribed
level
Thelevelmaydropduetoevaporation,topupasper
manufacturersinstructions

Drainage
Milkingofchestdrainsisonlytobedonewithwrittenordersfrommedicalstaff.Milking

drainscreatesahighnegativepressurethatcancausepain,tissuetraumaand
bleeding
Volume

Documenthourlytheamountoffluidinthedrainagechamberonthe

FluidBalanceChart
Calculateanddocumenttotalhourlyoutputifmultipledrains
Calculateanddocumentcumulativetotaloutput
Notifymedicalstaffifthereisasuddenincreaseinamountof
drainage
greaterthan5mls/kgin1hour
greaterthan3mls/kgconsistentlyfor3hours

Blocked drains are a major concern for cardiac

surgical patients due to the risk of cardiac tamponade

notify medical staff if a drain with ongoing loss suddenly

stops draining

If the chamber tips over and blood has spilt into next

chamber, simply tip the chamber up to allow blood to

flow to original chamber

Colour and Consistency

Monitor the colour/type of the drainage. If there is a
change eg. Haemoserous to bright red or serous to
creamy, notify medical staff.

Air Leak (bubbling)

Anairleakwillbecharacterisedbyintermittentbubblinginthewater
sealchamberwhenthepatientwithapneumothoraxexhalesor
coughs.
Theseverityoftheleakwillbeindicatedbynumericalgradingonthe

UWSD(1-smallleak5-largeleak)
Continuousbubblingofthischamberindicateslargeairleakbetween

thedrain&thepatient.Checkdrainfordisconnection,dislodgement
andlooseconnection,andassesspatientcondition.Notifymedical
staffimmediatelyifproblemcannotberemedied.
DocumentonFluidBalanceChart

 Oscillation (swing)
Thewaterinthewatersealchamberwillriseandfall(swing)with

respirations.Thiswilldiminishasthepneumothoraxresolves.
Watchforunexpectedcessationofswingasthismayindicatethe
tubeisblockedorkinked.
Cardiacsurgicalpatientsmayhavesomeoftheirdrainsinthe
mediastinuminwhichcasetherewillbenoswinginthewaterseal
chamber.
DocumentonFluidBalanceChart

 Other Considerations
Referraltophysiotherapistshouldbemadetoenhancechest

movementandpreventachestinfection
Patient Positioning
Patientswhoareambulantpostoperativelywillhavefewer
complicationsandshorterlengthsofstay.Considerconvertingtoa
portablefluttervalvesystemsuchasthepneumostattofacilitatethis
Ifchestdrainwillberequiredforprolongedperiod
Ifapatientisonstrictbedrestorisaninfant,regularchangesin
positionshouldbeencouragedtopromotedrainage,unlessclinical
conditionpreventsdoingso

 Patient Transport
Ifthepatientneedstobetransferredtoanotherdepartmentoris

ambulant,thesuctionshouldbedisconnectedandleftopentoair.
DO NOT CLAMP THE TUBE
Clampsmustnotbeusedonthepatientfortransportbecauseof
theriskoftensionpneumothorax
Ensurethechamberisbelowthepatientschestlevelduring
transport
FlutterValvesystems(pneumostat,Heimlich)maybeusedfor
patientinterhospitaltransfers(e.g.NETSandPETS)

 Chest Drain Dressings

Dressingsshouldbechangedif:
nolongerdryandintact,orsignsofinfectione.g.redness,

swelling,exudate
Infecteddrainsitesrequiredailychanging,orwhenwetor
soiled
Noevidenceforroutinedressingchangeafter3or7days
Thisprocedureisariskforaccidentaldrainremovalso
avoidunnecessarydressingchanges

 Exacttypeofdressingmaydependontreatingmedicalteam
Forcardiacsurgicalpatientswithdrainsinsertedintraoperatively:

usesplitgauze&mefixdressing
ensuredressingdoesnotcommunicatewithsternotomy
dressingorwound
Forallotherchestdrains
Sandwichbetweenocclusivedressing
Allowssitevisibility&preventspressureonskin
Ifsiteoozingdresswithsplitgauzeandocclusivedressing
Ensuredrainissecure
Topreventitfallingoutusea'tag'oftapetosecuretoskin
Applycomfeelorsimilartoprotectfragileskinfrom'tag'oftape

 Complications and Troubleshooting

Pneumothorax
Signsandsymptomsinclude:DecreasedSaO2,increasedWOB,

diminishedbreathsounds,decreasedchestmovement,complaints
ofchestpain,tachycardiaorbradycardia,hypotension
Notifymedicalstaff
RequesturgentCXR
Ensuredrainsystemisintactwithnoleaks,orblockagessuchas
kinksorclamps
Prepareforinsertion/repositioningofchestdrain

 Bleeding at the drain site

Dongloves
Applypressuretoinsertionsite
Placeocclusivedressingoversite
Notifymedicalstaff
CheckCoagulationresults
Checkdrainchambertoensurenoexcessivebloodloss

 Infection of insertion site

Notifymedicalstaff
Swabwoundsite
Considerbloodcultures
Accidental disconnection of system
Clampthedraintubing.Cleanendsofdrainandreconnect.Ensure

allconnectionsarecabletied.Ifanewdrainagesystemisneeded
covertheexposedpatientendofthedrainwithsteriledressingwhile
newdrainissetup.Ensureclampremovedwhenproblemresolved
Checkvitalsigns
Alertmedicalstaff

 Accidental drain removal

Applypressuretotheexitsiteandsealwithsteri-strips.Placean

occlusivedressingoverthetop
Checkvitalsigns
Alertmedicalstaff.