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INTENSIVE CARE SERVICE

NURSING POLICY & PROCEDURES

NAME OF POLICY: INTERCOSTAL CATHETER GOAL: TO ENSURE DRAINAGE OF PLEURAL SPACE AND/OR REINFLATION OF AFFECTED LUNGS Introduction: There are two pleural membranes. The outer, or parietal, is adherent to the inside of the thoracic cavity. The inner, or visceral pleura, is adherent to the surface of the lung. There is a small negative pressure (-4-10 mmHg) between the two, which sucks the visceral pleura onto the parietal pleura. Therefore in everyday life, the pleural space is only a potential space. A serous fluid acts as a lubricant between the two membranes. As the visceral pleura is adherent to the lung surface, the lung is held on to the thoracic wall by virtue of this attachment. When a person’s ribs move up and out and the diaphragm moves down during inspiration, the lungs expand to occupy all the available space. This lowers the pressure in the lungs, which causes atmospheric air to be drawn in. Any injury or pathology that interferes with the integrity of the pleural membranes can lead to the lung collapsing There are two main indications for the insertion of an intercostal catheter. The first is to allow the lung to re-inflate and the second is to facilitate the removal of material from the pleural space such as fluid, blood, pus or air. The most common sites for the intercostal catheters are: anterior tube is place in the second intercostal space in the midclavicular line and an axially tube is place in an intercostal space from the fifth to eighth intercostal spaces between the anterior and posterior axillary lines.

The anterior tube position is chosen because air floats upwards in the chest cavity. The posterior tube is placed in a dependent position for drainage, a site is chosen so that the patient in the supine position will not compress the tube or be uncomfortable. Any lower than the eighth may compete with the bulge of the diaphragm into the thoracic cavity. For air and fluid evacuation a 24 French gauge tube will be usually inserted and 36 French gauge tube for the purpose of drainage of blood or pus

©ROYAL PRINCE ALFRED HOSPITAL INTENSIVE CARE SERVICE

Pneumothorax can be related to a surgery procedure (lobectomy, open-heart surgery) or from trauma (penetrating knife wound, blunt trauma from a fall, or from (baro-trauma) positive pressure ventilation). Blister and blebs on the lung parenchyma usually cause spontaneous pneumothorax. All these allow air to enter the pleural space. Air entering the pleural space brings about an increase in the intrapleural pressure from negative to positive pressure and terminates the suctioning or pulling effects of the pleural cavity on the elastic lung tissue. The lung immediately collapses to an unstretched condition, which is about one-third of its expanded size.

Haemothorax is a collection of blood in the pleural space. Haemopneumothorax is both air and blood in the pleural apace. Like pneumothorax, these conditions result in high intrapleural pressures and partially collapse the lung.

Haemothorax

Tension pneumothorax is a more serious complication that can develop when air continues to leak from hole in the lung into the pleural space and has no way to escape. As more and more air accumulates in the pleural space, pressure within this space rises significantly. If the pressure builds up enough, it causes “medialstinal shift” which mean that the entire mediastinal area including the heart and other structures pushed towards the unaffected or good side. This reduces the size of the unaffected lung. This is a critical life-threatening situation and requires immediate attention. Early signs of mediastinal shift may include an overextended chest, shallow gasping respiration, shift of the trachea in the suprasternal notch and changes in arterial pulse.


Pleural effusion is an excess of fluid in the pleural space. Normally the pleural space contains 10mls of fluid. However the volume can increase to more than 1500mls with an effusion. Effusions typically occur at the base of the pleural space (due to gravity) and can be unilateral or bilateral. It develops after an underlying condition disrupts the mechanisms that normally control the movement of fluids into and out of the pleural space. These mechanisms include: Hydrostatic pressure, which tends to push fluids out of compartment Colloid osmotic pressure, which tends to pull fluid into compartments Intact structures such as, capillaries, lymphatic vessels and pleurae

There are two types of pleural effusions They both cause the same signs and symptoms and require similar treatment. However each points to different underlying problems

Exudative effusion is generally associated with pleural disease, develops when capillaries

become more permeable and leak protein-rich fluids into the pleural space. Because of its high protein content, this type of effusion usually resembles plasma. Inflammation of tissue, lungs, and lymphatic vessels can bring this on; fungal, viral or bacterial lung infections, subphrenic abscess and cancer.

Transudative effusion occurs when protein-free fluids leak from intact capillaries and

pass through the pores of membranes. This type of effusion is generally associated with normal lung tissue. It can be found in conditions such as: congestive heart failure, pulmonary oedema, renal disease and hepatic disease. This type of effusion is also known as hydrothorax.

Chylothorax is lymphatic leakage into the pleural space with subsequent accumulation. It usually is milky-white in colour related to its high fat and fat-soluble vitamin content as well as it being high in protein. The fluid can accumulate at a rate of 1500mls a day causing haemodynamic compromise and metabolic sequelae due to this loss. The primary causes of a chylothorax are malignancy, congenital, subclavian vein obstruction, trauma including surgical; related to mobilization of aortic arch (eg. repair of aortic coarctation, patent ductus arteriosus or vascular rings) or esophageal resection. The treatment consists of not only the drainage of this fluid but also aggressive maintenance of fluid and nutritional status.


Assisting with the Insertion of a Pleural Drain

Equipment: Sterile pack, gown and gloves 24 or 36 size tube will be required Dressing pack Petroleum impregnated gauze (gelonet) Aseptic antibacterial solution One Key-hole gauze Intercostal set (sterile) Suture and blade Single plastic bottle or Thoraseal 111 50mls catheter syringe for usage in one bottle system Sterile water (500mls) Kocker clamps, two for each tube. Ensure teeth of the clamp are covered with plastic to

provide safety during clamping ICC adapters (small, medium large) Low suction port connected to outlet source (working order) if required Appropriate “Y” connectors (if multiple ICC are required) Rack or stand for 1 bottle system Sterile scissors or large stitch cutter if required Adhesive for dressing (white large width) Adhesive for occlusion over each connection site (brown)

UWSD Set-Up Using 1 Bottle System: Inform patient and significant others where possible Ensure patient has adequate analgesia (review with RMO) Reassure patient throughout procedure if conscious Sit bottle into holding basket Remove plastic cover from the “vent” side of the one bottle system Insert 50ml sterile syringe catheter into “vent” side Using sterile water fill to “0” marker inscribed on the bottle. Do not replace plastic cover

over this “vent” Ensure sterile drainage tubing is place on Dr.’s. sterile field Dr. will connect one end of the tubing to the intercostal catheter when ready, the other end

will be connected to the UWSD marked “patient” Ascertain the size of the ICC tube to that of the drainage tube, it usually is too big. anticipate using one of the selected connectors (S/M/L)

If suction required follow steps below

Connect suction tubing to suction outlet source and place to the “vent” side of the bottle

When ready for use turn on the suction at the required kPa as ordered (usually 3-5 ) If no suction is required ensure the “vent” side of the bottle is open to air


Ensure clamp is immediately released from ICC after connection Observe and monitor the system to ensure it’s working correctly (see nursing

responsibilities and trouble shooting below) Once the purse string has been inserted clean and dress the ICC site Secure tube to decrease traction Secure all connection site with adhesive tape Assess patient respiratory status, during and post insertion X-ray to clarify tube position and evaluate lung expansion

UWSD Set-Up Using Thoraseal 111 System: Use the picture below to assist with the set-up

See below for further instructions for Thoraseal setup


Fill suction outlet to desired level per RMO orders (usually 15-25cm H20)

Fill water seal to inscribed “marked” level

Connect suction to suction port After connection to patient, turn on the suction so that gentle bubbling is noted in the

suction chamber. (Vigorous bubbling will cause noise and evaporate the water) Use Thoraseal built-in hanging device for security

Nursing Responsibilities

At the start of each shift ensure patency the system (see trouble shooting for guidance) Respiratory assessment Palpate skin around tube insertion site for subcutaneous emphysema (notify Dr. if present,

see under air leak) If patient is on suction, turn off the suction for evaluation, at the same time check the

amount of kPa or cm H20 is correct with Dr. orders. If water has evaporated from the required amount, restore it.

Observe for oscillation/swing/tidelling in the tubing (reversed on PPV) Observe of air leak (bubbling, continuous or intermittent) If concerned about “air leak” see

under trouble shooting Amount of drainage, this is usually recorded every 6/24hr on the flow chart and marked on

the bottle accordingly Ensure there are no kinks in the tubing Ensure all connections site are secure and have insulate adhesive around each site Ensure the tubing is secure and that insertion dressing is intact Record and document finding of each UWSD hourly, report abnormal finding if trouble

shooting has not found and or solved the problem. Dressings are changed every 48hr or when necessary Ensure bottle is change if greater than 200mls of fluid is insitu (if using one bottle system

and it is not on suction) Daily X-ray to assess progress of the condition and to detect complications


Requiring Fluid Specimens: The Thoraseal tubing is made of self-sealing silicone, permitting a small needle to be inserted to withdraw fluid. Follow steps below: Thoraseal Ensure universal precaution are undertaken Anticipate specimen collection when there is drainage in the tubing Use a 25 gauge needle attached to 5-10mls syringe Insert needle into tubing with care and extract fluid required Syringe into yellow top jar and send to appropriate laboratory with forms Document when specimen was taken

One-bottle system Do not remove fluid from the drainage bottle as this has been laying insitu for a period of time and may be contaminated Ensure universal precautions and apply aseptic technique Anticipate specimen collection when there is drainage in the tubing Assess patient respiratory status prior, during and after this procedure Turn off suction if applicable Remove adhesive from connector site (closest to the patient) apply antibacterial solution

with gauze Clamp closest to the patient chest cavity Disconnect tubing and allow fluid to drain into the yellow top jar Re-connect tubing and unclamp Apply adhesive tape to connection site Re-evaluate drainage system

Trouble shooting Fluctuation (tidaling/oscillation/swinging) Tidaling is indicated by fluctuations in the water seal chamber that correlates with the respiratory cycle. This action reflects the changes in the pleural pressures that occur with respiration. Fluctuations will be the reverse when PPV in applied. A rise in the tubing will indicate inspiration and a fall will indicate expiration.


As suction diminishes tidaling One must evaluate with the suction off. Tidaling will not be noted if there is an obstruction or if the lung has fully expanded or if suction is on. Solution: Observe X-ray for re-expansion of lung, this will be the definitive answer. Even after the

chest tube has ceased to function and the lung has re-inflated sometime the ICC may be left in for another 24-48hr depending on the patient’s overall physical condition and the degree of potential recurrence

Auscultate lung field To clear obstruction check for Kinks (increases pressure) Dependent loops (lie tubing flat along the length of the bed) Clot formation (cough, take a deep breath, change patient position)

Bubbling: Turn the suction off to evaluate the system and the patient. Diminished bubbling should be a sign that the lung is re-expanding. Absence of bubbling indicates that evacuation is complete and the pressure of the expanded lung has sealed the chest tube opening or that the tube is blocked. If there is a patient air leak, bubbling will be noted on spontaneous expiration, if it is noted that bubbling is continuous both inspiration and expiration one should suspect an airleak. If PPV is applied continuous bubbling is present, but if vigorous bubbling occurs suspect an airleak in the system Solution: Check X-ray to confirm lung expansion Check all connection sites are secure and have appropriate adhesive tape around them If leak persists follow these steps Clamp starting at the chest wall and work at intervals moving down the tubing. (For

example you have clamped near the chest wall than bubbling has ceased, the leak must be in the patient and not in the system, due to dislodged tube or from around the insertion site. Inform Dr if tube is or has migrated out (one can often see the eyelets).

It may need replacing, no not push it back in. Apply Vaseline gauze (gelonet) Consider bronchopleural fistula

Milking and Striping: Striping is controversial and should not be done with out the Intensivist order. Stripping is known to create transient high levels of negative pressure (-400cmH20) within the pleural space and cause barotrauma. Milking a chest tube is less stressful on the pleura. It is performed by gently squeezing the chest tube between your fingers and performing this process down the length of the tube. Clots and fibrin can obstruct the drainage system, which may require milking. Ensure Dr. has given the permission

Metal stripping device


Clamping: Clamping the tube is only used in the event of tube disconnection or breakage of the bottle. In such cases the pleural tube can be quickly clamped off, preventing renewed pneumothorax and consequent collapse of the lung. The clamp should not be left on for long periods as a tension pneumothorax can develop, putting pressure on the heart, which in turn can lead to cardiac arrest. The patient should never be left unattended when the clamps are on.

When transporting a patient there is no need to clamp the tubes as long as the system remains below the patient’s chest cavity and is secure so that no fluid is sucked or poured into the pleural cavity. If this can not be achieve then clamp the tubes for the shortest possible time. Intercostal Catheter Falls Out: Ask Patient to cough (if applicable) Cover site with petroleum gauze and dry dressing Stay with patient and assess respiratory/haemodynamic Notify RMO X-ray required Anticipate re-insertion

When to Change the Tubing and Drainage System One-Bottle System: If no suction is applied, change drainage bottle if 200ml plus is present. As the drainage

increases the patient effort to expel the air on expiration is made more difficult due to the increasing pressure the patient has to overcome as the fluid submerges the straw. When suction is applied this negates the effort on the patient’s part to expel the air so the bottle does not require changing as often.

Tubing is changed every 48hr along with the dressing. It is usually undertaken at midnight as this coincides with the overall fluid balance of the patient. (See below for Thoraseal 111 change)


Procedure: Universal precautions and aseptic technique Chose an appropriate time (eg. not after pulmonary toileting) Monitor respiratory status during and post procedure Inform patient of procedure Prepare equipment (as above) Remove adhesive tape form all connection sites Ensure new drainage bottle is secure in rack Swab connection site, closest to the patient Clamp as close to the patient as possible (as above) Disconnect old tubing and reinsert new tubing Unclamp Apply adhesive tape to all connection sites Document change and drainage Assess drainage system

Thoraseal: The Thoraseal system should be changed every 7 days or if an air-leak is detected in the system. The same principles and steps are as for the one-bottle system (see above). The need to change the drainage bottle only may apply. Follow steps below:

Ensure universal precautions When full, remove adhesive tape around connectors Clamp closest to the patient and disconnect the tubing Twist drainage bottle as shown in picture below and replace it with a new one Connect to patient and unclamp Ensure adhesive tape around connection site Dispose of drainage container appropriately Document change and drainage Dispose of equipment appropriately


Removal of an ICC: (Two RNs required) Inform patient and significant others if applicable Ensure X-ray confirms re-expansion Assess for fluctuations in the tubing, there should be none Sit patient in high fowler position if possible Consider analgesia if applicable Remove dressing Demonstrate action of the Valsalva manoeuvre (increasing the intra-thoracic pressure by

holding ones’ breath and attempting to breath out against a closed glottis) Clamp tube Obtain purse string Evenly and gently pull the tube out while the other RN pulls on the purse string to draw

the wound margins together, preventing re-entry of air into the pleural space Dress with occlusive dressing

Post removal Monitor respiratory status Document time of removal Order an chest x-ray approx. 30min post removal


COLLECTION CHAMBERS

One-way mechanism: The simplest way to create a one-way valve is the use of an underwater seal. The distal end of the drainage tube is placed about 2cm beneath the surface of a solution, preferably sterile water or saline. This water seal creates a closed chest drainage system by closing off the open end of the tubing from the atmosphere. A slightly positive pressure in the pleural space during exhalation or coughing will force air out of the pleural space through the tubing. Once the small amount of water in the straw is pushed out of the way, the air will bubble out into the solution. But air can no longer be drawn back up through the solution into the chest. One-Bottle System: This is the simplest closed chest drainage system. The drainage tubing is connected to a rigid straw that extends into a single sterile plastic bottle that serves as both a collection chamber and a waterseal. Sterile water or saline is poured into the bottle so the straw is submerged about 2cm.

An exit “vent” lets incoming pleural air form the patient escape from the chamber into the atmosphere. Otherwise enough pressure could build up in the bottle to prevent any more pleural air from coming in (ensure the protective plastic cap is removed) Drawbacks of a One-Bottle System: The bottle is used not only as the waterseal but as a drainage bottle and at times suction chamber too. As drainage fills the bottle, more of the waterseal is submerged. More force is then needed (by the patient) to push the solution inside the straw out of the way allowing pleural air and liquid drainage into the bottle. Emptying the drainage bottle once it reaches 200mls or more can solve this problem. Alternatively separate collection bottle between the drainage tubing and the water-seal bottle can be used (see two-bottle system below).


Two-Bottle System: In the two-bottle system, drainage falls into the collection bottle and air flows beyond into the separate waterseal bottle. This setup keeps the waterseal at a fixed level and allows more accurate observation of the volume and type of drainage. As with the one-bottle system, the water seal bottle must have an exit vent to the atmosphere that allows incoming pleural air to escape. Bubbling from an air leak and fluctuations in the waterseal straw will occur in the same way as they do in the one-bottle system.

Drawbacks in the Two-Bottle System: The separate collection bottle adds dear-air space to the drainage system – a reservoir of air that can be drawn into the pleural space. The two-bottle system (and one-bottle system) limits gravity chest drainage. To drain air and liquid from the pleural space, pressure must be higher in the chest the in the bottles. Placing the bottles below the chest creates the pressure difference; additional pressure is created at the patient end of the tubing by expiration and coughing. The drainage system must be able to handle enough airflow to match the size of the patient’s air leak. Sometimes the pressure difference and airflow capacity of gravity drainage system aren’t enough and suction must be added. Three-Bottle System: The safest way to regulate the amount of suction is to add a third, or control bottle to the drainage system. The third bottle in the system is used to set a maximum limit on the negative suction pressure that is imposed on the pleural space. This maximum pressure is determined by the height of the water column in the air inlet tube. Negative pressure (from wall suction) draws the water down the air inlet tube, and when the negative pressure exceeds the height of the water column, air is entrained from the atmosphere. Water is added to the suction-control chamber to achieve a water level of 20cm. The wall suction is then activated and slowly increased until bubbles appear in the water. This bubbling indicates that atmospheric air is being entrained and the maximum negative pressure has been achieved.


Dry Suction system

The Heimlich valve, created by Dr. Henry Heimlich is best suited for an uncomplicated pneumothorax or haemothorax that requires little or no drainage collection or suction. This valve is not used in the general intensive care areas but may be seen on patients on intra hospital transfers due to its portability, lightweight and the ability of the valve to function in any position. It does not need to be below the chest cavity.

The Heimlich valve is made of clear plastic and attached to connecting tubing, which in turn attaches to the patient’s chest tube or small bore percutaneous catheter. The valve consists of rubber flutter leaflets that are compressed at the distal end. These leaflets allow one-way flow so that air, fluid or blood clots exiting through the valve can’t return to the pleural space. If drainage is excessive, Physician can withdraw air or fluid with a syringe by unscrewing the connecting tubing

form the stopcock. A bag can be attached to the valve if there is a persistent amount of small drainage. Small holes or a .5cm tear should be made towards the top of the bag to allow air to escape otherwise tension pneumothorax may result.

The drainage fluid can also cause the valve to stick so both nurse and the patient need to be aware of the signs of tension pneumothorax: increasing dyspnoea, +/- pain, reduced air entry to the affected side and a mediastinal shift / tracheal displacement to unaffected side.

Should you suspect a tension pneumothorax the valve should be changed immediately. In an emergency or in the absence of another valve, disconnecting the valve from the ICC will allow air to escape giving immediate relief to the patient. The tube can then be attached to a conventional UWSD bottle system.

Dressings to the ICC site should be done as required when wet or at least Daily to observe the site.

The valve should be changed weekly. The tube is clamped with Kocher clamps momentarily while the valve is changed and secured as per instructions earlier in this protocol.

The bag should be changed as frequently as required or weekly. It is important that fluid does not cause the tear in the bag to stick together preventing air escaping.

It can also be attached to suction if required. (See pictures below)


REFERENCES Butcher L & Melinda, S. (1999). Critical Care Nursing. W. B> Saunders Company, Philadelphia Marino, P. L. (1998). The ICU Book.Lippincott Williams & Wilkins, Philadelphia O’Hanlon-Nuchols, T (1996). Commonly Asked Question about Chest Tubes. American Journal of Nursing (AJN) May 1996. Vol.96, No5 Oh, T. E. (1997). Intensive Care Manual. Butterworth Heinemann, London. Pettinichhi, T. A. (1998) Trouble shooting chest Tubes. Nursing98, March pp58-60 Peek, J.G (2000) Clinical review: The Pleural Cavity. BMJ Vol.320 13 May 2000 Product Information Sherwood Davis & Gecko (1999). Understanding Underwater Chest Drainage. Occupational Health and Safety: Universal precautions taken in the preparation, administration of drug and disposal of equipment and sharps. Cross Referenced: RPAH Occ. Health & Safety Manual and Infection Control Manual NSW Infection Control Policy 98/99 Revised by: Frankie Hopkins (ACNC) January 2002 Reviewed by: Morgan Smith (Ed.Cardiothoracic) Authorised and assisted by: Dr. Richard Totaro (Intensivist ICU) January 2002 Revision January 2004 With the introduction of Powerchart online ordering, a clinical agreement has been set up with the Director of ICS and other Staff Specialists. Nursing Management, with the agreement of the hospital executive, have made arrangement that allows all permanently employed RPAH Nursing Staff to place orders for a variety of tests on their behalf. It is a Health Insurance Commission (HIC) directive that all orders placed by nursing staff are countersigned by the responsible MO within 14 days.


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