Neonatal Chest Tube Placement, by Dr. Elizabeth Doherty and Neonatal Nurse Practitioner Patricia
Fleck.
We will review indications, contraindications, equipment, procedure-- including preparation
and placement, complications, assessment and monitoring, and documentation.
Indications and Contraindications.
Indications. Tension pneumothorax not resolved with needle thoracentesis. Pleural effusion.
Hemothorax. Chylothorax. Epyema.
Contraindications. There are no true contraindications to neonatal chest tube placement when indicated.
Correction of preexisting severe thrombocytopenia, or coagulopathy, should occur prior to or
concurrently with chest tube insertion.
Equipment. Surgical chest tube, antimicrobial scrub, scalpel, sterile gauze, Kelly clamp,
sutures, needle driver, suction source, chest tube collection device, male-to-male connector,
shoulder roll, systemic and local pain medications, dressing materials, monitoring equipment.
Pre-Procedure and Positioning.
Obtain parental consent if non-emergent.
Ensure secure airway. Pre-medicate for pain control.
Position the infant supine with the affected side elevated with
shoulder roll and arm on the affected side restrained superiorly over the head.
Procedure.
Perform time out per institution-specific protocol. Perform sterile dress procedure,
physician and assistant. Prepare surgical area with chlorhexidine if the infant is greater
than 28 weeks gestation or if greater than 14 days old. Use alcohol if the infant is
less than 28 weeks gestation or if less than 14 days old.
Drape surgical area. Identify landmarks-- fourth, fifth, and sixth ribs midaxillary
line. Infiltrate the skin, muscle, and the rib periosteum with 1% lidocaine. Aspirate
during insertion to be sure not in a blood vessel.
Make a small transverse incision 0.5 centimeters over the superior aspect of the fifth rib.
Dissect the tissue with the Kelly clamp, tunneling to the fourth intercostal space. Close the
Kelly clamp and apply pressure over the superior aspect of the fifth rib until the clamp punctures
through the muscle, and parietal pleura. Appreciate sudden loss of resistance.
Enlarge the pleural opening by spreading the Kelly clamp open. Remove the Kelly clamp.
Attach the Kelly clamp to the distal end of the chest tube, allowing the chest tube to
extend just beyond the tip of the clamp. Trocar should not be used.
Enter the previously made track and enter the pleural space. Once inside the space,
turn the Kelly clamp 180 degrees. Unclamp the chest tube. To ensure the chest tube is
directed anteriorly, be sure to drop your wrist while advancing the chest tube into
the patient.
Direct the tube anteriorly to the apex of the thorax to the pre-determined length, assuring
all side holes are inside the chest. This distance is approximately 2 to 3 centimeters
for infants less than 1,500 grams, and approximately 3 to 4 centimeters for infants greater or
equal to 1,500 grams. Remove the clamp, being sure not to dislodge the chest tube. Connect
the chest tube to suction.
Suture one side of the incision. Wrap and tie the free end of the suture around the
chest tube. Apply occlusive petroleum dressing at the level of the skin. Cover with small
amount of dry gauze. Secure with Tegaderm.
Obtain chest X-ray to verify position.
Complications. More common: persistent pneumothorax, bleeding, and infection.
Less common: organ perforation, phrenic nerve injury.
Assessment and Monitoring.
Monitor cardiorespiratory and neurologic status before, during, and after the procedure. Monitor
insertion site for any bleeding. Evaluate chest tube drainage. Monitor pain management.
Documentation. Document detailed procedure note. Please help us improve the content by
providing us with some feedback.