chest drain managment
DESCRIPTION
How to manage chest drain in patients?TRANSCRIPT
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Chest Drain Management
By : Dr. M. Rezaei
Fellowship of Pediatric Pulmonology
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UWSD
Also known as Under Water Sealed Drain (UWSD)
inserted to allow draining of the pleural spaces of air, blood or fluid, allowing expansion of the lungs and restoration of negative pressure in the thoracic cavity.
underwater seal also prevents backflow of air or fluid into the pleural cavity.
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Indications for Insertion of a Chest Drain
Post operatively e.g. cardiac surgery, thoracotomy
Pneumothorax
Haemothorax
Chylothorax
Pleural effusions
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Start of shift checks:
Patient assessment
Vital signs In ICU:
Continuous monitoring
HR, SaO2, BP, RR
In Ward areas:
On insertion of chest drain monitor patient observations of HR, SaO2, BP, RR:
15 minutely for 1 hour
1 hourly for 4 hours
Includes HR, SaO2, BP, RR and temperature
1-4 hourly as indicated by patient condition
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Start of shift checks:
Patient assessment
Pain
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Start of shift checks:
Patient assessment
Drain insertion site
Observe for signs of infection and inflammation and document findings
Check dressing is clean and intact
Observe sutures remain intact & secure (particularly long term drains where sutures may erode over time)
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Start of shift checks:
Patient assessment
UWSD Unit & tubing Never lift drain above chest level
The unit and all tubing should be below patients chest level to facilitate drainage
Tubing should have no kinks or obstructions that may inhibit drainage
Ensure all connections between chest tubes and drainage unit are tight and secure
Tubing should be anchored to the patients skin to prevent pulling of the drain
In ICUs tubing should also be secured to patient bed to prevent accidental removal
Ensure the unit is securely positioned on its stand or hanging on the bed
Ensure the water seal is maintained at 2cm at all times
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Start of shift checks:
Patient assessment
Drainage:
Volume
Document hourly the amount of fluid in the drainage chamber on the Fluid Balance Chart
Calculate and document total hourly output if multiple drains
notify medical staff if there is a sudden increase in amount of drainage
notify medical staff if a drain with ongoing loss suddenly stops draining (Blocked drains are a major concern for cardiac surgical patients due to the risk of cardiac tamponade)
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.
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Start of shift checks:
Patient assessment
Oscillation(Swing)
The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the pneumothorax resolves.
Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked.
Cardiac surgical patients may have some of their drains in the mediastinum in which case there will be no swing in the water seal chamber.
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Chest Drain Dressings
Dressings should be changed if:
no longer dry and intact, or signs of infection e.g. redness, swelling, exudate
Infected drain sites require daily changing, or when wet or soiled
No evidence for routine dressing change after 3 or 7 days
This procedure is a risk for accidental drain removal so avoid unnecessary dressing changes
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Removal of Chest Drains
Indications
Absence of an air leak (pneumothorax)
Drainage diminishes to little or nothing
No evidence of respiratory compromise
Chest x-ray showing lung re-expansion
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Removal of Chest Drains Procedure
Perform hand hygiene
Opening dressing pack and add sterile equipment and 0.9% saline
Remove all dressings around the area
Clamp drain tubing
If there are multiple drains insitu, clamp all drains before removal. Once the required drains are removed, unclamp remaining drains
Clean around catheter insertion site and 1-2cm of the tubing with 0.9% Saline
Remove suture securing drain
Instruct patient exhale and hold if they are old enough to cooperate; if not, time removal with exhalation as best as possible.
If there is no purse string present remove drain and quickly seal hole with occlusive dressing
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Removal of Chest Drains
CXR should be performed post drain removal
Clinical status is the best indicator of a reaccumulation of air or fluid. CXR should be performed if patient condition deteriorates
Monitor vital signs closely (HR, SaO2, RR and BP) on removal and then every hour for 4 hours post removal, and then as per clinical condition
Dressing to remain insitu for 24 hours post removal unless dirty
Complications post drain removal include pneumothorax, bleeding and infection of the drain site
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Complications and Troubleshooting
Pneumothorax
Signs and symptoms include: Decreased SaO2, increased WOB, diminished breath sounds, decreased chest movement, complaints of chest pain, tachycardia or bradycardia, hypotension
Notify medical staff
Request urgent CXR
Ensure drain system is intact with no leaks, or blockages such as kinks or clamps
Prepare for insertion/ repositioning of chest drain
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Complications and Troubleshooting
Bleeding at the drain site
Don gloves
Apply pressure to insertion site
Place occlusive dressing over site
Notify medical staff
Check Coagulation results
Check drain chamber to ensure no excessive blood loss
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Complications and Troubleshooting
Infection of insertion site
Notify medical staff
Swab wound site
Consider blood cultures
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Complications and Troubleshooting
Accidental disconnection of system
Clamp the drain tubing. Clean ends of drain and reconnect. Ensure all connections are cable tied. If a new drainage system is needed cover the exposed patient end of the drain with sterile dressing while new drain is setup. Ensure clamp removed when problem resolved
Check vital signs
Alert medical staff
Accidental drain removal
Apply pressure to the exit site and seal with steri-strips. Place an occlusive dressing over the top
Check vital signs
Alert medical staff.
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Prevent air & fluid from returning to the pleural space
Most basic concept
Straw attached to chest tube from patient is placed under 2cm of fluid (water seal)
Just like a straw in a drink, air can push through the straw, but air can’t be drawn back up the straw
Tube open to atmosphere vents air
Tube from patient
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Prevent air & fluid from returning to the pleural space
This system works if only air is leaving the chest
If fluid is draining, it will add to the fluid in the water seal, and increase the depth
As the depth increases, it becomes harder for the air to push through a higher level of water, and could result in air staying in the chest
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UWSD
For drainage, a second bottle was added
The first bottle collects the drainage
The second bottle is the water seal
With an extra bottle for drainage, the water seal will then remain at 2cm
Tube from patient
Tube open to atmosphere vents air
Fluid drainage
2cm fluid
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UWSD
The two-bottle system is the key for chest drainage
A place for drainage to collect
A one-way valve that prevents air or fluid from returning to the chest
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UWSD
Many years ago, it was believed that suction was always required to pull air and fluid out of the pleural space and pull the lung up against the parietal pleura
However, recent research has shown that suction may actually prolong air leaks from the lung by pulling air through the opening that would otherwise close on its own
If suction is required, a third bottle is added
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UWSD
2cm fluid water seal
Collection bottle
Suction control
Tube from patient
Fluid drainage
Tube open to atmosphere vents air
Straw under 20 cmH2O
Tube to vacuum source
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UWSD
The straw submerged in the suction control bottle (typically to 20cmH2O) limits the amount of negative pressure that can be applied to the pleural space – in this case -20cmH2O
The submerged straw is open at the top
As the vacuum source is increased, once bubbling begins in this bottle, it means atmospheric pressure is being drawn in to limit the suction level
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UWSD
The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator
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From bottles to a box
The bottle system worked, but it was bulky at the bedside and with 16 pieces and 17 connections, it was difficult to set up correctly while maintaining sterility of all of the parts
In 1967, a one-piece, disposable plastic box was introduced
The box did everything the bottles did – and more
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From bottles to a box
Collection chamber
Water seal chamber
Suction control chamber
from patient
Suction control bottle
Water seal bottle
Collection bottle
From patient
To suction
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From box to bedside
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At the bedside
Keep drain below the chest for gravity drainage
This will cause a pressure gradient with relatively higher pressure in the chest
Fluid, like air, moves from an area of higher pressure to an area of lower pressure
Same principle as raising an IV bottle to increase flow rate
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Setting up the drain
Follow the manufacturer’s instructions for adding water to the 2cm level in the water seal chamber, and to the 20cm level in the suction control chamber (unless a different level is ordered)
Connect 6' patient tube to thoracic catheter
Connect the drain to vacuum, and slowly increase vacuum until gentle bubbling appears in the suction control chamber
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Setting up suction
You don’t need to boil spaghetti!
Vigorous bubbling is loud and disturbing to most patients
Will also cause rapid evaporation in the chamber, which will lower suction level
Too much bubbling is not needed clinically in 98% of patients – more is not better
If too much, turn down vacuum source until bubbles go away, then slowly increase until they reappear, then stop