Surgical Chest Tube

• Coagulopathies, on home anticoagulants.
• Infection overlying insertion site.
  •  Note: If there is an overlying infection should make attempt to insert at alternative site. 
• Scarring, and pleural adhesions.
• Emphysematous blebs.

1. Perform timeout to ensure correct patient, procedure, and location. 
2. Insertion site is prepped with chlorhexidine swab x3. Let skin dry.
3. Open up chest tube tray + set up sterile field.
   1. Empty lidocaine 20mL of 1% without epi into basin on sterile field (max dose 4.5mg/kg).
4. Put on sterile gown + gloves + cap + mask. 
5. Apply one clamp to distal end of chest tube (sealing it), and one Kelly clamp to tip of tube. 
6. Apply full body gown to patient, centered around chest tube insertion site. 
7. Draw up 20mL of lidocaine into syringe. Inject lidocaine into subcutaneous space.
   1. Then inject deeper along the tract of eventual needle insertion. 
   2. As advance needle, aspirate back to ensure not in a vessel. 
   3. Anesthetize rib periosteum + continue until at pleural space. 
      1. Note: This step is critical. You need to make sure you are freezing the parietal pleura (this is where the most pain occurs). To do that, you advance the needle while pulling back the syringe, and stop when you see bubbles. Once you see bubbles, you know you’re intrathoracic, and you pull your needle back until the bubbles stop. This positions you right above the parietal pleura, then inject at that level to freeze the parietal pleura. 
8. Wait 1-2 minutes for lidocaine to take effect.

1. Make a scalpel incision at the skin surface at site of insertion + dissect subcutaneous tissue.
2. Insert closed Kelly clamp over superior border of rib and advance towards pleura. 
   1. The closed clamp is then advanced into pleural space + pop is felt. 
      1. Note: Make sure not to create multiple false tracts. Instead, stick to ONE track and go deeper in that tract. Deviating from the tract can create multiple false tracks and risks the tube not being able to enter the chest and being placed extra thoracic. 
   2. Spread clamp open, then remove clamp out of chest. 
3. Non dominant hand finger is then inserted along the created tract into pleural space.
   1. Finger performs full sweep around site of insertion to confirm in the pleural space. 
   2. Note: if there are dense adhesions do not disrupt them as this can cause lung injury. Only easily disrupted adhesions can be cleared.
4. Keep finger in place. 
5. 2nd Kelly clamp is used to grasp end of chest tube and tube is guided into pleural space adjacent to the inserted finger.
   1. Once the tip of the tube is in the pleural space, remove the clamp.
6. Advance the tube into the desired position (aim the tube towards the opposite shoulder if aiming for the apical space). Ensure all holes are in the pleural space.
   1. Apical direction = for pneumothorax drainage. Once in place should see condensation in the tube.
   2. Dependent direction = for fluid drainage. Once in place, should see fluid in the tube.
   3. Note: gentle tube rotation during advancement can help prevent tube kinking. 
7. Once in desired location. Remove cap from pleur-evac tubing, exposing the connector.
8. Attach connector to the inserted chest tube. Secure tightly. 
   1. Ensure tubing is clamped until properly connected to underwater seal. 

1. Take 1 large bite through skin on one side of chest tube less than 1cm away from the insertion site. 
   1. Perform hand ties x 3, creating air knot underneath chest tube. 
   2. Wrap the sutures in opposite directions around the tube (ensure sutures are close together) then hand tie the suture down to the chest tube + indent tube. Do 3 loops + tie down. 
2. Take 1 large bite through skin on other side of chest tube less than 1cm away from the insertion site. 
   1. Perform hand ties x 3, creating air knot underneath chest tube. 
   2. Wrap the sutures in opposite directions around the tube (ensure sutures are close together) then hand tie the suture down to the chest tube + indent tube. Do 3 loops + tie down. 
3. Gather loose ends of suture together + orange tape over the sutures/catheter.  
4. Orange Tape over the connector + catheter. 
   1. Although preferably zip ties are used if available. 
5. Add chest drain gauze x2 over the chest tube insertion site.  
6. Then roll a piece of single gauze and place over the chest drain gauze. Lay the tube over this roll. Apply another piece of gauze over top the tube (now tube is facing down towards patients’ feet). 
7. Secure tube/gauze with hypafix tape to chest wall. 
8. Distal to tube insertion site, tape down the tube with hypafix to patient skin (creating a loop/tent, so there is a gap between tube + patient skin). 
9. Connect pleur-evac to suction if needed. 
10. Document procedure. Document chest tube insertion depth. 
11. Obtain x-ray to confirm position. 

1. Assess chest tube for drainage fluid type and amount.
   1. For fluid removal target < 1-1.5L immediate removal to avoid re-expansion pulmonary edema. 
   2. Note: If the chest tube is inserted for traumatic hemothorax and > 1.5L of fresh blood is immediately removed, this is an indication for thoracotomy. 
      1. Note: Fresh blood is bright red. Old blood is dark red like Merlot. Also, ongoing bleeding that’s 200cc or more for 2 to 4 consecutive hours is also an indication for thoracotomy. 
2. Assess chest tube for tidaling. 
3. Assess for air leak, bubbling, subcutaneous emphysema. 
4. Assess vital signs and for respiratory distress. 
5. Confirm position on x-ray:
   1. Pneumothorax removal = tube ideally is more apical + anterior. 
   2. Fluid drainage = tube ideally more posterior + inferior. 
   3. Observe that the last sentinel drainage hole is within the thoracic cavity. 
   4. Ensure tube is not in the interlobar fissure, mediastinum, or lung parenchyma.

Document written by: Muralie Vignarajah MD

Staff Reviewed by: Dr. Wiley Chung (General Surgery, Thoracic Surgery)