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Chest drains in the neonate

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Chest Drain insertion sites

  • insertion sitesFor pneumothoraces, the tube is usually placed on the anterior axillary line between the 3rd and 4th intercostal space. 
    Occasionally, for anterior pneumothoraces which are difficult to drain, a tube may be placed in the mid clavicular line between the 1st and 3rd intercostal space. (Only one drain is usually necessary). 
  • For effusions, the tube should be placed in the mid-axillary line between the 4th and 5th intercostal spaces, and directed posteriorly.

  

Complications

Include:

  1. haemorrhage 
  2. lung perforation and infarction 
  3. phrenic nerve damage

Preparation of equipment and baby for Pigtail Catheter or Trochar chest drain insertion

A Pigtail Catheter is the first preference for insertion of a Chest Drain for a Neonate but there may be circumstances where a Trochar Cannular is used. Please ascertain from the NSANP/Dr which drain they will require.

1 Dr/NS-ANP to wear mask, sterile gown and sterile gloves. Nurse to wear mask.
2 Analgesia should be routine except under emergency circumstances. A Morphine Bolus of 100mcg/kg can be given IV or via an existing Morphine Infusion.
3 For insertion of a Pigtail Catheter, open a Dressing Pack and add:
• The Contents of A Fuhrman Pleural Drainage Set:
             One 8.5 French, 15cm long polyurethane catheter with 6 sideports
             One guide wire, 40ck long
             One 18 gauge needle, 7cm long
             One dilator
             One three-way-tap
             One 5-in-1 connector (pineapple)
•  Two extra guards
•  Skin disinfectant appropriate for the infant's gestation and postnatal age
•  1ml syringe
•  25g needle     
4 Insertion Procedure for NSANP/Registrar
• Position the baby with the affected side elevated to 30-40° by placing a towel under the back
   An assistant should rotate the arm towards the head.
• Prepare the skin with an antiseptic over the entire lateral portion of the chest to the mid-clavicular line. Blot excess antiseptic and allow to dry.
• Infiltrate 1% Lignocaine at the insertion site (between 4th and 5th intercostal space) in the anterior axillary line.
• Mark off 1 cm on the needle with a steristrip.
   Attach a 3-way tap and a 5ml or 10ml syringe to the needle and gently advance through the chest wall while aspirating the syringe.
• The guide wire is encased in a plastic sheath. The tip will fit neatly into the hub.
   Introduce it gently and advance about 2-4cm ( the tip of the guide wire is very soft and should advance without impedance).
•  Remove the needle while holding firmly onto the guide wire leaving this in place.
•  Mark off one cm on the dilator, advance it over the guide wire and insert through the skin using gentle twisting movements.
•  Withdraw the dilator and advance the pigtail catheter over the guidewire (all the side ports should be inside the chest wall).
•  Fix the pigtail catheter to the chestwall with a tegaderm dressing
•  Attach the pineapple connector and connect to underwater drainage system
•  A three way tap is provided in case of the need to drain fluid
•  Obtain Chest Xray
Open a chest drain pack only if a Trochar Drain is required and add:
            chest trochar cannula appropriate for baby
            3 way tap
            10ml syringe
            Skin disinfectant appropriate for the infant's gestation and postnatal age
            1ml syringe
            25g needle
5 Have filter needle and 1 amp of 1% lignocaine ready for Dr/NS-ANP to draw up. 
6 Wall suction unit. 
7 Position baby supine and flat with affected side slightly tilted up (by using a folded nappy) 
8 Set up Atrium chest drain. 

Preparation of the Atrium Chest Drain

  1. Fill water seal chamber: Twist top off water bottle supplied and insert tip into suction port located on the top left-hand corner. Squeeze contents into water seal chamber (B) until fluid reaches the 2cm fill line. Once filled, water becomes tinted blue.
    To remove excess water, aspirate with a syringe and needle via grey grommet situated on the back of the chamber.
  2. Dry suction regulator: The suction regulator (A) comes preset to -20cmH2O. Using the dial located on the left side of the drain, dial down to -10cmH2O.
  3. Connect chest drain to patient prior to initiating suction. Connect suction tubing from suction source to suction port.
  4. Turn wall suction unit on. Adjust suction pressure as required to move bellows into window (E). Bellows do not need to reach the Δ mark for pressures less than -20cmH2O.

Atrium water seal chest drainAtrium Water Seal Chest Drain

see diagram opposite

Connecting/Securing of Chest Drain

  1. Following chest drain insertion, connect to 3 way tap. Place Green Vygon connector on to the 3 way tap.
  2. Place small pineapple connector on to atrium chest drain tubing, then connect to Vygon connector.
  3. Chest drain is secured in place by either:
          small thin sleek gate dressing
          Tegaderm
          suture may be used
  4. Ensure that any surplus tubing is coiled on the bed so that tubing hangs straight to the atrium drain.
  5. The tubing from chest drain is secured to the bed by using tape and safety pin to ensure chest drain does not become dislodged.
  6. Document insertion of drain in multidisciplinary notes and on Level 3 nursing chart.
  7. Ensure parent/s informed.

Ensure Atrium Chest Drain Unit is Functioning Correctly

Follow the steps at the beginning of each shift to ensure the atrium chest drain is functioning correctly.

  1. Chest drain is taped securely.
  2. Tubing is taped and pinned to bed to prevent dragging and accidental disconnection.
  3. Check for any oozing from drain site. (Inform Dr/NS-ANP.)
  4. Ensure the wall suction source is adjusted as required to maintain a movement of the bellows (E).
  5. Check water seal is maintained at 2cm line.
    If < 2cm fill using syringe and needle via grey grommet situated on the back of the chamber.
    Check the air leak zone.
    When bubbles are observed going from right to left in the water seal chamber(C) this confirms a patient air leak. DO NOT TURN OFF WALL SUCTION OR THE STOPCOCK WHEN CHECKING)
          Continuous bubbling confirms a persistent air leak.
          Intermittent bubbling with float ball oscillating confirms the pressure of an intermittent air leak.
          No bubbling with minimal float ball oscillation at bottom of water seal will indicate no leak present.
  6. If drainage is present in the collection chamber (D) record the level on the chest drain chart (CR5586).

Nursing care of baby with a chest drain

  1. Padded artery forceps at bedside.
  2. If baby to be transported ensure the atrium chest drain unit is not lifted higher than baby's chest and is kept in upright position.
  3. Record air leak zone activity hourly on Level 3 chart, or the chest drain chart. Record as continuous bubbling (CB), intermittent bubbling (IB), or no movement (N).
  4. Level in collection chamber read and recorded on the chest drain chart. Graduated in 1ml increments (infant paediatric drain).
  5. Monitor continuously.
    Hourly recordings - cardio-respiratory and SpO2 status.
    Q4H BP.
  6. Baby is not usually nursed prone. Positioning is determined by area of air leak.
  7. Baby is not taken out of incubator/off heat table for cuddle with parents.
  8. Ensure parents are kept informed of baby's condition.
  9. Analgesia is given as prescribed.

Chest drain during transport

Underwater sealed drainage is inappropriate during transport so we use a Heimlech Flutter Valve to drain air from the chest. This valve will allow air to escape from the chest but will not allow air to return through the system, i.e passage of air is one-way only.

  • The underwater seal drainage system is disconnected at the 3 way tap (3 way tap turned off to patient during change over) and using the Vygon connection the Heimlech Flutter Valve is connected.
  • The 3 way tap is then opened to baby.

transport

Chylothorax drains

The nursing care is the same as for a baby with a pneumothorax except:

  1. Prepare atrium chest drain using an adult dry suction chest drain unit (holds 2.1 litres).
  2. Do not connect the chest drain to the wall suction: leave as a gravity-drainage system.
  3. A chest drain chart is used to record all losses and replacement fluids. 
  4. If there is fluid loss from the drain insertion site, ensure all losses are measured and recorded. 
  5. If baby is oedematous/hydropic, attention should be paid to pressure areas, e.g. nurse on gel mattress. 
  6. Check drain site frequently to ensure tube is secure. Reapply adhesives as necessary. 
  7. Occasionally these babies are stable enough to be held by their parents.
  8. Nursing prone may be advisable to facilitate drainage and comfort.

Connecting two or three chest drains to one suction source

Follow the steps below to set up 2 / 3 chest drains from 1 Low Pressure Suction gauge.

  1. Use appropriate packet marked "2 Atrium Chest Drain T piece and silastic tubing"  or "connecting T piece for 3rd Atrium Chest Drain" 
  2. Assemble as per diagrams opposite
  3. If you are unable to achieve constant gentle bubbling in both drains, use a G clamp (in drawer of pneumothorax trolleys) to suction tubing of individual atrium suction tube and tighten slowly to achieve correct bubbling.

Removal of chest drain

This is a delegated medical responsibility that may be undertaken by an experienced neonatal nurse. The chest drain will usually be clamped for 24 hours and an x-ray of chest taken to ensure no reaccumulation of air has occurred. This is a two person procedure with one sterile and one assisting.

  1. Assemble equipment for sterile procedure plus scalpel blade, steristrips, tegaderm, and gauze.
  2. Doctor/NS-ANP or nurse puts on sterile gloves.
  3. Position baby (chest drain side slightly tilted upwards). Remove tegaderm, sleek plaster and hold drain up slightly.
  4. Wound is held together as drain removed
  5. The wound should be sealed following removal of the drain. This may be by using steristrips applied to close drain site or by using a small gauze square placed over the thoracotomy incision. Apply tegaderm over the top of the steristrips or the gauze.
  6. A routine chest x-ray 4 hours after drain removal is not mandatory. Chest x-rays should be performed if the baby has any significant clinical change following the drain removal.
  7. Document removal of drain in:
    Multidisciplinary notes.
    Level 3 chart.

Troubleshooting

Blue water goes up the narrow water seal tube (e.g. to 10-15cm)

This is due to a rise in the intrathoracic pressure. These changes are usually due to mechanical means such as milking/ stripping the drainage tubes, or due to deep inspiration after all air leaks have resolved.

To correct: Depress the manual high negativity vent located on the top of the drain until the water seal column lowers to the desired level. Do not lower water seal column when suction is not operating, or when on gravity-drainage only. Temporarily connect to the wall suction first.

Changing the suction pressure

To alter suction pressure rotate the suction regulator (A) located on the top left hand side of the drain. Dial down to lower the pressure and up to increase the suction pressure.

Is it normal for the patient pressure float ball to fluctuate up and down (tidal) near the bottom of the water seal column?

Yes. Once baby's air leak is resolved you can see moderate tidalling in the water seal column.

Increases in intra-thoracic pressure will cause the water level to rise (the ball rises) during baby's inspiration and will lower during expiration.

Drain output recording

See also PDF of the form to record drain output 

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Document Control

  • Date last published: 10 October 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years