Chest Drain Insertion in Neonate - Step by step guide

The following video explains the procedure of Chest drains insertion in neonates. This was made during my residency in NICU quite a long time back, and there will be few mistakes ( or many maybe). 

Even though it's crude, it should give a fair idea of the steps we must follow during the procedure. This can be a short revision for observed OSCE stations or Viva on procedures or equipment.

What are the Prerequisites?

Confirm the indication and necessity of invasive procedures. Rule out contraindication to perform chest drain insertion. Assist Initially to gain experience under supervision and follow proper steps.

Consent

Admission to NICU carries implicit consent for such an emergency procedure however it does carry risk and parents or carers must be fully informed about the procedure at the first suitable opportunity and written consent should be obtained.

What Equipment do we need to place the intercostal drain in Neonate?

We will need

1. A pigtail catheter or chest drain with trochar (use chart to choose the size appropriately) 
2. You need to choose from 8, 10 or 12 sizes, Even though traditionally it is said to use the biggest possible size, I didn't find this in litterature. 
3. We need a sterile dressing pack preferably something like an exchange transfusion tray. 
4. 75% isopropyl alchohol+ 2% chlorhexidine to prepare the area. 
5.  Underwater seal.

How to manage pain and Sedation during the procedure

Ketamine alone or Ketamine with midazolam can be used for sedation. Local anesthesia help reduces the need for systemic sedation and analgesia and should be used.

Let us see the video first before discussing the step by step procedure.

video of chest drain placement in neonates

The steps we followed during insertion of chest drain

1. Confirm the correct side of the chest, Choose which space you want to place the catheter, discuss beforehand. Use USG wherever possible. 
2. Position the baby chest with slight elevation from horizontal to create a space to operate. Use a roll under back for this. 
3. Prepare the site by sterilizing. 
4. Ask your assistant to hold the ipsilateral arm above the head so as to get more space. 
5. Mark, your Puncture site. 
6. In the video, we used an Anterior axillary line between the fourth and sixth intercostal space. Infiltrate local anesthetist Make a small incision just above and parallel to the rib to avoid damage to the neurovascular bundle. 
7. Dissect gently down further to reach pleura using a blunt curved hemostat in bigger babies as shown. Insert the tube while using the trocar to stabilize the tube. 
8. Once inside the pleural space, you will have a give away feel to the resistance. 
9. Keep the drain tube blocked until you connect it with the under-water seal or else the negative intrathoracic pressure will pull atmospheric air and result in pneumothorax. 
10. Secure the chest drain with purse-string suture and plaster. Avoid multiple connections for infection prevention. 
11. Continue analgesia to reduce post-procedure pain. 
12. Seggragate biomedical waste using the appropriate containers. (more on biomedical waste management)
13. Monitor frequently. 
14. Document the events in procedure notes including the site of puncture, size of drain, and length of insertion along with other data.
15. Inform carer.

Related articles

1. Procedure • Nasal Bubble CPAP Video. 
2. Procedure • T Piece Resuscitation Steps and • Video 
3. Ventilator Graphics • PV loops made easy. 
4. OSCE Observed stations • Procedures (lumbar puncture, abdominal paracentesis, liver biopsy, etc). 
5. OSCE • Tips on dealing with observed station in OSCE exam.
6. Procedure • PICC line insertion video.