Changes

#1. Ask for any allergic reaction to local anesthetics#2. Check proper puncture location with ultrasonography. ::*Strive to puncture close to the inferior rib border rather than the superior one, to avoid damage to intercostal nerves and vessels. The direction of the catheter should usually be toward the basal-dorsal parts. :*If the fluid space is wide enough, the thickness of the thoracic wall can be measured in order to subsequently perform anesthesia and catheter insertion without ultrasound guidance.:*The puncture location can be marked by a skin impression (such as a pen with withdrawn nib), or with a skin marker (which may, however, disappear during washing).#3. The skin area is washed with an antiseptic#4. Wear at least sterile gloves, and use sterile coverage on the ultrasound probe#5. Preferably use a pigtail catheter, generally of French gauge around 7 - 10, and fixate a cannula inside it#6. Have a scalpel ready for skin incision#7. Infuse local anesthetic, such as 10 - 20 ml of 1% carbocaine, both superficially, at the rib above and below, and by the pleura#8. Make a skin incision large enough for the catheter to pass#Under ultrasound guidance, insert 9. Insert the catheter with the cannula until reaching within the pleural space.#10. Loosen the cannula from the catheter, and advance the catheter only, generally in dorsal-basal direction.#11. Withdraw the cannula#12. Check for return. Attach plug or syringe to the external tip.#13. Twist the pigtail of the catheter#14. Fixate the external part to the skin