TUBE THORACOSTOMY COURSE - cont'd info

Indications for Tube Thoracostomy

Hemothorax

Pneumothorax

– Symptomatic or clinical instability
– Large asymptomatic pneumothorax

Empyema or complicated parapneumonic effusions

Use for chemical pleurodesis in malignant effusions

Prevention of hydrothorax after cardiothoracic
surgery

Drainage of recurrent pleural effusions

Chylothorax

Esophageal rupture with leak into pleural space

Contraindications for Tube Thoracostomy

Relative contraindications to semi-elective chest tube
placement

– Coagulopathy (PTT> 1.5x ULN or INR>2 on warfarin)
– Thrombocytopenia (Platelets <30-40,000)
– Pleural effusion secondary to pleural tuberculosis
– Overlying skin infection
– Known multiple pleural adhesions
– Known or suspected mesothelioma
– Hepatic hydrothorax
– Caution if pleural effusion is loculated

Complications of Tube Thoracostomy

Major Complications

– Injury to liver, spleen, diaphragm, intestines, aorta, heart, or
intercostal artery
– Lung parenchyma perforation
– Empyema (2-25% after chest trauma)
– Laceration of long thoracic nerve

Minor Complications

– Subcutaneous emphysema or subcutaneous placement of tube
– Cardiac dysrhythmias (from adjacent chest tube)
• Persistent air leak
– Localized infection at insertion site
• Re-expansion pulmonary edema
– Malposition

Equipment for Tube Thoracostomy

PSP = primary spontaneous pneumothorax
SSP = secondary spontaneous pneumothorax
MV = mechanical ventilation

Sterile gown and gloves

Cap and mask

Sterile towels

Prep: Betadine or Chloraprep

10 mL syringe with needles

1% lidocaine + /- epinephrine

2 long Kelly clamps

No. 10 blade on scalpel

Chest tube

– 12-14F for PSP
– 14F for SSP
– 20F for large air leaks or MV
– 14-20F for infection
-20-28F for trauma

Needle driver

1-0 silk suture (2 packs)

Xeroform gauze

Sterile pack of 4 x 4 gauze pads

Suture scissors and Foam tape

Wire-directed Pigtail catheter placement Equipment

• Have patient in semi-upright position
• Prep skin with chlorhexidine swabs
• Sterile drape

• Aspirate as anesthesia needle is advanced until you see a steady stream of bubbles and grasp needle at skin to determine the depth of insertion
• Advance the introducer needle perpendicular to the skin above the rib until you aspirate a steady stream of bubbles
• Grasp the needle hub and remove the syringe
• Advance the wire through the needle about 15 cm
• Remove the needle leaving the wire in place
• Make stab incision over the wire
• Dilate the skin and soft tissue over the wire
• Introduce the pigtail catheter with wire guide over the wire to the last black line
• Remove the wire leaving the catheter in place
• Suture pigtail catheter in place

• Apply Opsite around Pigtail catheter

Coding for Tube Thoracostomy

• 32551 Tube thoracostomy with or without water seal
• 32005 Pleurodesis

Procedural Sedation for Tube Thoracostomy

Options for Moderate-Deep Procedural Sedation for Non-emergent Chest Tube Placement

• Opioid (e.g., fentanyl 1 mcg/kg IVP) + benzodiazepine (e.g., midazolam 2-4 mg IVP)
• Ketamine 1.5 mg/kg IVP
• Ketofol (0.75 mg/kg ketamine IVP + 0.75 mg/kg propofol IVP)

Anesthetize the skin,
periosteum, and pleura

Max dose is 4.5 mg/kg
lidocaine

Max dose 7 mg/kg
lidocaine with
epinephrine

– 1% lidocaine
= 10 mg/mL
– 70 kg man
– 30 mL lidocaine or 49
mL lidocaine with
epinephrine