Ultrasound-guided chest tube insertion

Author: Mikael Häggström

Planning

Choice of procedure

Pigtail catheter insertion is an effective and safe method of draining pleural fluid. It is encouraged for use in all cases of pleural effusion requiring chest drain except for empyema and other loculated pleural effusions, where it has low success rates.

Coagulation: Low risk of bleeding This procedure counts as conferring a relatively low risk of clinically significant bleeding. Required lab test Prothrombin time (PT or INR): Inpatients: within 24 hours Outpatients with a healthy liver: Within 2 weeks Outpatients with liver disease and no additional acute disease since then: Within 1 week Lab interpretation INR should be corrected if over 2.0 If partial thromboplastin time (aPTT or APTT) has been tested, it should be corrected if over 1.5 times its normal upper limit. If platelet count has been performed, transfusion is indicated if it is below 50 x 109/L (equals 50,000/µL). Anticoagulant medication Coumarin (warfarin): Normally stop 3-5 days before, in order to reach INR ≤ 2.0 Low-molecular-weight heparin (LMWH): Stop 1 preceding dose Dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa, Lixiana): Glomerular filtration rate over 30 ml/min: Stop 24 hours before Glomerular filtration rate less than 30 ml/min: Stop 48 hours before Clopidogrel (Plavix), prasugrel (Efient), ticagrelor (Brilinta, Brilique, and Possia): Stop 5 days before Dipyridamole (Persantine): Stop 48 hours before NSAIDs (including aspirin): No need to stop

Technique

This is an example used in Swedish practice, in this case without use of Seldinger technique:

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• The puncture location can be marked by a skin impression (such as a pen with withdrawn nib), or with a skin marker (which may, however, disappear during washing).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. Inject 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
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, and note the color of any fluid. Attach plug, syringe or bag to the external tip.
13. Twist any pigtail of the catheter
14. Fixate the external part to the skin

Report

• Type of anesthesia used.
• Type of catheter, including caliber and any internal locking mechanism such as pigtail.
• Color of the pleural fluid
• Optionally, whether a bag is attached to the external tip, and whether the attachment is clamped or open.

See also: General notes on reporting