THORACIC: PIGTAIL CHEST TUBE INSERTION

DOCUMENT TYPE: PROCEDURESite Applicability

This document is applicable in the Neonatal Program at BC Women’s Hospital

Practice Level/Competencies

Chest tube insertion is a painful and invasive procedure requiring attention to pain management and sterile technique.

An emergent thoracentesis (needle aspiration) may be necessary until a chest tube can be placed, if the neonate’s condition shows acute deterioration with cardiopulmonary compromise, or until adequate pharmacologic pain management can be employed.

This procedure is performed by Physician or Nurse Practitioner in the Neonatal Program This is a two person insertion procedure: a scrubbed assistant is required

Equipment & Supplies

1. Local Anesthetic2. Chest tube drain Pigtail (#6 or #8.5 F) 3. Chest tube insertion tray4. Dexidin 2 solution (2% chlorhexidine gluconate with 4% isopropyl alcohol)5. Sterile drapes, 2-36. Sterile ruler7. Needle, 25/28 gauge and 1 cc syringe8. 10mL prefilled saline syringe (sterile)9. 3-0 Curved suture set (if necessary)10.Tegaderm, 2-311.Steristrip or Episeal strip12.Disposable hat and masks13.Sterile gloves and gown 14.Requisition, Chest x-ray

ProcedureSteps Rationale1. Perform Hand Hygiene prior to entering patient

care space2. Introduce yourself to the family Discuss procedure with the family and assess their

desire to be present during the procedure Explain the procedure to the family to ensure

agreement to treatment3. Verify patient with two identifiers4. Perform physical assessment Vital signs

Auscultation of lung fields Skin integrity assessment at insertion site

5. Review chest x-ray findings6. Review available laboratory results CBC

Platelets Prothrombin time

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THORACIC: PIGTAIL CHEST TUBE INSERTION

DOCUMENT TYPE: PROCEDURE Partial thromboplastin time

7. Assess neonate’s history for bleeding disorders and/or anticoagulant therapy

8. Initiate orders for suction The recommended pressure for initial suction is -10 to -15cm H20; increase only as indicated. Avoid excessive pressure, which risks drawing tissue into side holes of chest tube

9. Request assistance to set up equipment from RN

RN will retrieve and utilize: “Thoracic: Assisting with Chest Tube Insertion Procedure”

Identify assistant who can scrub and assist with the procedure

10. Ensure cardio-respiratory status is adequately monitored

Ensure the volume of the monitor is increased during the procedure

Ensure a blood pressure cuff is placed on infant for duration of procedure

11. Order and administer analgesia as appropriate Either Morphine 100mcg/kg IV direct or Fentanyl 1-2mcg/kg IV direct

RN will administer IV analgesia Assess for effectiveness of analgesia to ensure

efficacy of medication12. Examine the neonate to determine the

insertion site

*two person procedure*

Position the infant supine with a blanket rolled behind their back; bundling of lower limbs may assist in settling of baby

Affected side should be elevated above the mattress Hold infant’s arm alongside the head

13. Landmark insertion site With a lateral approach the insertion site is the 4th, 5th or 6th intercostal space or lateral to the anterior axillary line avoiding breast tissueThe 4th intercostal space in the mid axillary line is the

preferable site for a pigtail catheter14. Perform a time-out Confirm correct neonate, correct site, correct

procedure15. Don head covering, mask, eye protection,

hand hygiene, don sterile gown and sterile gloves

All people involved in procedure should wear masks, hats and eye protection

16. On a sterile field prepare supplies and equipment

Attach a 10mL prefilled saline (sterile syringe) syringe to the insertion needleo For infants >1kg measure 4cm from the last

drainage hole in the Fuhrman Cathetero For infants ≤1kg measure 2cm from the last

drainage hole in the Fuhrman Catheter Place Steri-strips or episeal on the catheter and

needle to mark the locations noted aboveDepth of insertion of needle should be no more than 2cm (unless infant is extremely edematous)

17. Cleanse the insertion site 1. Scrub site with Dexidin solution using side-to-side motion for 30 seconds. Allow to air dry for 60 seconds

For infants less than or equal to 1000 grams:Remove residual Dexidin solution on skin using sterile normal saline or sterile water after the chest insertion procedure is complete

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THORACIC: PIGTAIL CHEST TUBE INSERTION

DOCUMENT TYPE: PROCEDURE18. Use sterile drapes on neonate to prepare a

sterile field for procedure19. Re-identify landmarks and select the skin

entrance site20. Draw up local anesthetic (1% lidocaine without

epinephrine or preservative) with assistance from RN and anesthetize the skin at the level of incision, subcutaneous tissue, periosteum of rib, chest wall muscles and pleura

Aspirate before administration of medication to ensure anesthetic is not instilled in to a blood vessel

Use a 1mL syringe and 25-G needle Do not repeat dose of anesthetic within 2 hours and

do not use more than 0.45ml/kg total dose

21. Insert the tip of the introducer needle with the 10mL prefilled saline syringe attached over the top of the ribcage (avoid breast tissue)

Stretch the skin cephalad and place negative pressure on the syringe; walk the introducer needle over the superior aspect of the rib, directed toward the opposite shoulder, advancing the introducer needle into the pleural space

22. Aspirate from the 10mL saline syringe: when air bubbles appear in the syringe this confirms the placement of the introducer needle in the pleural space

Stop aspirating when air bubbles are obtained

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THORACIC: PIGTAIL CHEST TUBE INSERTION

DOCUMENT TYPE: PROCEDURE23. Hold the introducer needle in place; remove

the syringe24. Straighten and introduce the J-tip of the

guidewire into the introducer needle hub Utilize assistant as required Advance the guidewire until the silver coloured line

on the wire is at the level of the introducer needle hub

The guidewire should advance without hindrance25. Hold the guidewire securely in place and

slowly remove the introducer needle Utilize assistant as required

26. Thread the dilator over the guidewire and use a gentle twisting motion to advance the dilator into the skin, subcutaneous tissue and pleura

Utilize assistant as required

27. Remove the dilator while maintaining the guidewire in place

Utilize assistant as required

28. Straighten the pigtail catheter tip and thread it over the guidewire, advancing until all of the catheter side holes are in the pleural cavity

Utilize assistant as required Advance to the suggested depths marked previously

(step 16)29. Carefully remove the guidewire while holding

the pigtail catheter in place. If the catheter cannot be advanced over the

guidewire thread the dilator over the guidewire again30. Attach the adaptor to the external end of the

catheter and connect the pleural tube to a water-seal drainage system with suction or to a one-way Heimlich chest drain, while holding the pigtail catheter securely to the chest.

The assisting RN will ensure all connections between the chest tube and the drainage system are secure

Use caution to not exert tension on chest tube at this stage to minimize dislodgment

31. Palpate the area around the insertion site, and observe for bubbling from the chest tube

32. Hold the chest tube in place and remove all disinfectant from the skin with sterile water

Dry skin thoroughly prior to securing the pigtail catheter

33. Apply a clear dressing to secure the catheter against the chest wall in a ‘bridging’ fashion

Ensure that the chest tube does not bend at a sharp angle, which may increase risk for occlusion.

Place a 2X2 gauze at base of chest tube and position chest tube on top of gauze.

Secure to chest wall using Tegaderm over the 2x2 gauze

Generally a suture is not required to secure a pigtail catheter

If the skin opening is large, place a suture at base of chest tube and loop suture threads around chest tube 3 times and tie

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THORACIC: PIGTAIL CHEST TUBE INSERTION

DOCUMENT TYPE: PROCEDURE34. Order a two-view (anterior/posterior and

lateral) chest radiograph35. Discard supplies and remove PPE: perform

hand hygiene36. Reassess infant’s status Pain

Respiratory status Breath sounds Hypotension Arrhythmias Drainage from insertion site Temperature

37. Document procedure Indications for procedure Equipment used (e.g. size of chest tube) Medications administered Sterile precautions Infant’s tolerance to procedure Site of insertion (intercostal level) Depth of insertion Any complications Post insertion chest x-ray findings Consideration of post-procedure analgesia Participants in the procedure Conversation with parents/caregivers

DocumentationDocument procedure in Progress notes

Related Documents Thoracic: Assisting with Chest Tube Insertion: Procedure Thoracic: Chest Tube Drainage System: Procedure

ReferencesElsevier Clinical Skills (2018). Chest Tube Insertion Pigtail Catheter: Advanced Practice (Neonatal) retrieved December 6,

2018 HYPERLINK "http://point-of-care.elsevierperformancemanager.com/" \l "/skills/1321/illustrations"http://point-of-care.elsevierperformancemanager.com/#/skills/1321/illustrations

Cates, L.A. (2009). Pigtail Catheters Used in the Treatment of Pneumothoraces in the Neonate. Advances in Neonatal Care, 9(1), 7-16

Weim Y.H., Lee, C.H., Cheng, H.N., Tsae, L.T & Hsiao, C.C. (2014). Pigtail Catheters Versus Traditional Chest Tubes for Pneumothoraces in Premature Infants Treated in a Neonatal Intensive Care Unit. Pediatrics and Neonatology, 55, 376-380

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN15-Jan-2019 C-06-12-60034 Thoracic: Pigtail Chest Tube Insertion Approved at: Neonatal Leadership Committee

DISCLAIMERThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health

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THORACIC: PIGTAIL CHEST TUBE INSERTION

DOCUMENT TYPE: PROCEDUREServices Authority (PHSA) assumes no liability arising from use or reliance on this document.  This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA. 

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