Risk Factors
As with any invasive procedure, there are risks to the patient and practitioner. Practitioners need to be able to assess the risk and decide if the benefits outweigh the risks, to reduce risks where possible and to be able to troubleshoot when things do not go to plan. The table below is not exhaustive, but highlights some of the risks and problems associated with the procedure.
Risks Associated with Chest Drain Insertion
| Risk | Cause | Practitioner's Action |
|---|---|---|
| Trauma to underlying structures |
Use of metal trochar Poor anatomical placement (liver, spleen) or poor patient positioning Dilator damage in Seldinger technique Needle or dilator damage in Seldinger technique Damage to neurovascular bundle Damage to long thoracic nerve |
Metal trochars should NEVER be used Make sure the drain is inserted in the safe triangle, or use USS if available Do not insert dilator deeper than needed to dilate chest wall Aspirate as you gently insert the Seldinger needle Insert drain along top of a rib Chose site just anterior to mid-axillary line Explore pleural space before inserting drain |
| Pain |
Inadequate analgesia Inadequate local anaesthetic Failure to consider benzodiazepenes |
Consider morphine and midazolam, IV titrated to effect, make sure local anaesthetic inserted down to level of rib and pleura |
| Local Anaesthetic toxicity | Failure to consider safe local anaesthetic dosages of up to 3mg / kg |
In an average adult 10ml 1.0% Plain lignocaine is sufficient, (20ml maximum). Procedure should be carried out where full resuscitation equipment available |
| Re-expansion pulmonary oedema | Rapid evacuation of air or fluid from the thoracic cavity | No more than 1.5 L should be actively aspirated from a pnuemothorax, empyema or effusion in one go |
| Haemorrhage |
Coagulopathy or thrombocytopaenia Damage to underlying organs |
In routine drain insertion correct coagulation problems if possible Avoid trochar use Careful use of needle and dilator in Seldinger technique |
