0071643192.pdf

TECHNIQUE

■ Head of bed is elevated 30–60°.

■ Arm should be secured over patient’s head.

■ Local anesthesia and procedural sedation should be used.

■ 2- to 4-cm incision is made at fourth or fifth intercostal space, midaxillary

line (see Figure 19.2A).

■ Blunt dissection is performed with long closed Kelly clamp above rib to

avoid nerve/vessel damage (see Figure 19.2B).

■ Place finger through hole and feel for lung to confirm you’ve entered the

pleural space. This key step increases the likelihood that the tube will

enter the pleural space. (See Figure 19.2C.)

■ Use finger to guide tip of Kelly-clamped chest tube into pleural space.

■ Insert chest tube posteriorly and toward lung apex (see Figure 19.2D).

■ Connect to regulated suction (typically beginning at 20 cm H 2 O).

■ Secure with sutures (0 or 1-0 silk), gauze, and tape.

■ Confirm placement with CXR.

COMPLICATIONS

■ Diaphragm, spleen, lung, cardiac, vascular, or liver injury

■ Subcutaneous placement of chest tube

PROCEDURES AND SKILLS

A

B C

D

FIGURE 19.2. (A) Site of thoracostomy tube insertion. (B) Blunt dissection with Kelly

clamp. (C) Finger confirmation of hole into pleura. (C) Insertion of thoracostomy tube.

(Reproduced, with permission, from Brunicardi FC, Andersen DK, Billiar TR, Dunn DL,

Hunter JG, Matthews JB, Pollock RE, Schwartz SI. Schwartz’s Principles of Surgery, 8th ed.

McGraw-Hill, 2005:131.)