Manual of Common Bedside Surgical Procedure CHAPTER 4 - Thoracic Procedures

8/9/2019 Manual of Common Bedside Surgical Procedure CHAPTER 4 - Thoracic Procedures

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Authors/Editors: the Halsted Residents of The Johns Hopkins

Hospital; Chen, Herbert; Sonnenday, Christopher J.; ille!oe, "eith

#.

Title: Manual of Common Bedside Surgical Procedures, 2nd Edition

Copyright Â©2000 Lippincott Williams & Wilkins

> Table of Contents > CHAT!" # $ TH%"ACC "%C!'("!)

CHAT!" #

TH$RAC%C &R$CE#'RES

Herbert J. (eh %%% ).#.

"e*in +. Sta*eley$-Carroll ).#.

*e+si+e thoracic proce+,res may be +iagnostic- therape,tic- or in certainsit,ations- life$sa.ing/ All ho,se officers sho,l+ be familiar ith the +iagnosisan+ treatment of ple,ral eff,sion an+ pne,mothora1/ Also incl,+e+ in thissection are recommen+ations for chemical ple,ral s clerosis an+ emergencybe+si+e thoracotomy/

A. TH$RACETES%S

/ n+ icat ions3

a/ 'iagnostic thoracentesis is performe+ to +etermine the specific

ca,se of a ple,ral eff,sion/b/ Therape,tic thoracentesis is performe+ to relie.e +yspnea

2/ Contrain+icat ions3

There are no absol,te contrain+ications to thoracentesis4 relati.econtrain+ications incl,+e the folloing3

a/ Coag,lopathy 5T or TT 6 /7 ratio- platelets 6 80-0009

b/ )mall$.ol,me ple,ral f l,i+

c/ :echanical .enti lat ion

+/ (ncooperati.e patient

7/ Anesthesia3

; li+ocaine

#/ !


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silastic catheters an+ one$ay .al.es/ :an,fact,rers=

instr,ctions sho,l+ be cons,lte+ for information ,ni


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?/ Techn i


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breaths belo the tip of the scap,la/

e/ (sing a 22$ga,ge nee+le- infiltrate the skin- s,bc,taneo,s tiss,e-an+ perioste,m of the rib/ Caref,lly alk the nee+le

s,periorly o.er the e+ge of the rib hile infiltrating ith li+ocaine/

%nce o.er the top of the rib- sloly a+.ance the nee+le hileaspirating4 ,ntil ple,ral fl,i+ is enco,ntere+- a+minister ana++itional GI2 ml of li+ocaine an+ then ith+ra the nee+le 5seeig,re #/29/

f/ lace the $ga,ge nee+le on a 0$ml syringe- an+ insert it intothe ple,ral space as +escribe+ abo.e/ t is often helpf,l to ,se ato$han+e+ techni


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g/ (sing the )el+inger techni


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h/ With the scalpel- caref,lly make a small nick in the skin at the siteof the ire i nsertion to allo easy intro+,ction of the +ilator/

i/ ntro+,ce the +ilator o.er the ire to +ilate the skin an+

s,bc,taneo,s tiss,es/ The +ilator sho,l+ not be intro+,ce+ anyfarther than is necessary to +ilate the s,bc,taneo,s tiss,e an+allo smoother insertion of the catheter/

D/ nsert the ca theter in to the chest o.er the i re an+ then remo.ethe ire/ Jeep a finger o.er the en+ of the catheter to pre.ent airfrom entering the chest/

k/ Connect the e1tension t,bing an+ .ac,,m apparat,s 5see ig,re#/89/

+i. 0.0.

/K

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l/ %pen the stopcock an+ ith+ra fl,i+/ %nce the ret,rn of f l,i+ hassloe+- reposition the patient on the si+e an+ then the back toimpro.e flo/

m/ )loly ith+ra catheter to remo.e any pockets of f l,i+ locate+pro1imal to the tip/

n/ lace *eta+ine ointment an+ a +ry sterile +ressing on the p,nct,resite/ An occl,si.e +ressing is generally not necessary beca,se thenee+le tract ill seal/

o/ %btain a C" to r,le o,t pne,mothora1 an+ e.al,ate remainingfl,i+/

K/ Complications an+ :anagement3

+i. 0.4.

/

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a/ ntercostal .essel +amage

"isk of lacerating the intercostal .essels is minimiFe+ bypositioning nee+le closely to the s,perior e+ge of the rib 5seeig,re #/79/

f a laceration occ,rs- monitor hemo+ynamics closely an+

obtain serial C"s/ f the hemothora1 is significant- t,bethoracostomy may be necessary/

b/ oor flo

"otate the patient in all +irections to mobiliFe the thoracicfl,i+/

%ccasionally man,al aspiration of the fl,i+ ith a 70$ to ?0$ml syringe place+ on a three$ay stopcock may be ,sef,l/

Consi+er t,be thoracostomy if eff,sion is .isco,s an+ ,nableto be +raine+ a+e 8;9

)ymptomatic pne,mothora1 of any siFe

ersistent ple,ral eff,sion

/N

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!mpyema

b/ Anter ior chest t,be

ne,mothora1 5> 8;9


Bone

7/ Anesthesia3

; li+ocaine- se+ation optional

# / !


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lineGMthis is here the t,be ill enter the ple,ral space4 theincision is ma+e at the le.el of the si1th intercostal space lateralto the nipple b,t me+ial to the e+ge of the latissim,s +orsi 5seeig,re #/?9/

b/ )terile prep an+ +rape the hemothora1/

c/ "aise a skin heal ith the 28$ga,ge nee+le- an+ ith the 22$

ga,ge nee+le infiltrate the entire area ith ; li+ocaine/ t isimportant to infiltrate at the le.el of the ple,ra an+ posterior

perioste,m/ This le.el can be locate+ by +raing back slightlyafter entering the ple,ral space ith the 22$ga,ge fin+er nee+le/

+/ ntercostal blocks may be a+ministere+ for a++itional anesthesiaby inDecting 7GI8 ml of li+ocaine a+Dacent to the ne,ro.asc,lar

+i. 0.7.

/2




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b,n+le of the rib abo.e an+ belo the fifth intercostal space/ Caresho,l+ be taken to a.oi+ inD,ry to the intercostal artery an+ .ein/

e/ :ake an incision thro,gh the skin parallel to the a1is of the ribs/The length of the i ncision may .ary b,t sho,l+ be long eno,gh toallo insertion of a finger an+ chest t,be conc,rrently/

f/ :eas,re the chest t,be on the o,tsi+e of the patient=s bo+y an+i+entify ho far the t,be sho,l+ be a+.ance+ after placement/ Thetip of the t,be sho,l+ be at the ape1 of the l,ng- abo,t GI2 cmfrom the last hole in the chest t,be in a K0$kg a+,lt 5see ig,re#/K9/

g/ With the tonsillar clamp- create a tract from the incision site to theintercostal space abo.e 5see ig,re #/9/

+i. 0.8.

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h/ %nce the anterior intercostal fascia is i+entif ie+- the tonsillarclamp is a+.ance+ into the ple,ral space by rolling the clamp o.erthe s,perior e+ge of the rib to a.oi+ inD,ry to the ne,ro.asc,larb,n+le/

i/ %n entering the ple,ral space- a r,sh of air sho,l+ be hear+/ 'onot a+.ance the clamp any farther4 +ilate the tract ith the clampby sprea+ing it i+ely/ t is important to ens,re that the tract isa+e


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occ,r/

k/ lace one Jelly clamp on the +istal en+ of the chest t,be/

l/ Prasp the pro1imal en+ of the t,be in the Das of another Jellyclamp an+ insert both thro,gh the s,bc,taneo,s tract into theple,ral ca.ity/ 'irect the t,be posteriorly toar+ the ape1 5see

ig,re #/N9/

m/ %pen the Das an+ remo.e the pro1imal Jelly clamp hilea+.ancing the t,be to the pre+etermine+ position/

n/ Alternati.ely yo, may insert an+ +irect the t,be by ,sing a fingerplace+ into the incision thro,gh the tract/

o/ Attach the t,be to the le,r$e.ac an+ remo.e the +istal Jelly

+i. 0..

/2#




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clamp/

p/ To sec,re the chest t,be3 irst place to large .ertical mattresss,t,res on either si+e of the t,be/ Be1t reappro1imate the skinincision- lea.ing long tails on each s,t,re/ Then rap theremaining portion of each s,t,re aro,n+ the chest t,be to sec,re

it/ When the chest t,be is remo.e+- only the portion of the s,t,reattache+ to the chest t,be sho,l+ be c,t- lea.ing the .erticalmattress s,t,res in place to close the o,n+/


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h/ %n entering the ple,ral space- a r,sh of air sho,l+ be hear+/ 'onot a+.ance the clamp any farther4 +ilate the s,bc,taneo,s tractith the clamp by sprea+ing it open/

i/ lace a finger thro,gh the tract into the ple,ral space/ alpate thel,ng to confirm location in the ple,ral space an+ to ens,re that noa+hesions are present/ A chest t,be sho,l+ ne.er be inserte+blin+ly beca,se inD,ry to the .essels or l,ng parenchyma mayocc,r/

D/ lace one Jelly clamp on the +i sta l en+ of the chest t,be/

k/ Prasp the pro1imal en+ of the t,be in the Das of another Jellyclamp- an+ insert both thro,gh the s,bc,taneo,s tract into theple,ral ca.ity/ 'irect the t,be anteriorly toar+ the ape1/

l/ %pen the Das an+ remo.e the pro1imal Jelly clamp hile

+i. 0.1.

/28




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a+.ancing the t,be to the pre+etermine+ position/

m/ Attach the t,be to the le,r$e.ac an+ remo.e the +istal Jellyclamp/

n/ To sec,re the chest t,be3 irst place to large .ertical mattresss,t,res on either si+e of the t,be/ Be1t reappro1imate the skin

incision- lea.ing long tails on each s,t,re/ Then rap theremaining portion of each s,t,re aro,n+ the chest t,be to sec,reit/ When the chest t,be is remo.e+- only the portion of the s,t,reattache+ to the chest t,be sho,l+ be

c,t- lea.ing the .ertical mattress s,t,res in place to close theo,n+/

o/ lace a piece of eroform ga,Fe aro,n+ the entrance site an+ asterile +ressing on top/ asten sec,rely ith *enFoin an+ clothtape/

p/ Confirm placement ith a C"/

/ Techni


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b/ ersistent pne,mothora1

:ake s,re all clamps are off the t,bes an+ connection lines-an+ that there is not an obstr,ction in the system/

Check for an air leak in the system by clamping the t,be atthe chest all/ Air b,bbling i n the ater seal chamber hile

on s,ction in+icates a leak/ Change the le,r$e.ac system/

"epeat C" in # ho,rs/ f still present- higher s,ction ,p to $#0 cm can be achie.e+ ith an !merson p,mp/ f still nos,ccess- then a secon+ t,be sho,l+ be place+ .ia the anteriorapproach/

c/ Hemorrhage or l,ng inD,ry

:onitor hemo+ynamics an+ chest t,be o,tp,t- an+ obtainserial C"/

f o,tp,t is > 200 mlEhr or /8 L total or patient is ,nstable-then emergent thoracotomy is in+icate+/

+/ Car+iac +ysrhythmias

With+ra chest t,be GI7 cm if a+Dacent to heart/ f it stillpersists- ith+ra an+ re$insert .ia a ne incision/

:e+ical management if necessary

C. TR$CAR CATHETER ?&%@ST%C"ER=>TH$RAC$ST$)6

/ n+ icat ions3

These catheters re


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!mpyema

7/ Anesthesia3


# / !


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b/ )terile prep an+ +rape the hemothora1/

c/ "aise a skin heal ith the 28$ga,ge nee+le- an+ ith the 22$ga,ge nee+le infiltrate the entire area ith ; li+ocaine/ t ismost important to infiltrate at the le.el of the ple,ral an+posterior perioste,m/ This le.el can be locate+ by +raing backslightly after entering the ple,ral space an+ obtaining air ret,rnith the 22$ga,ge fin+er nee+le/

+/ :eas,re the chest t,be on the o,tsi+e of the patient=s bo+y an+i+entify ho far the t,be sho,l+ be a+.ance+ after placement/

e/ :ake a horiFontal incision appro1imately 0/8GI/0 cm/

f/ Prasp the base of the trocar portion of trocar catheter in the palmof the right han+ 5see ig,re #/29/ This han+ ill s,pply the+ri.ing force for the insertion/ The trocar sho,l+ be f,lly a+.ance+ithin the catheter/

+i. 0.11.

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g/ Prasp the tip of the trocar catheter ith the left han+ an+ insertthe ,nit thro,gh the incision/

h/ (sing the left han+ as a g,i+e an+ apply gentle force ith the righthan+ onto the trocar to t,nnel the trocar catheter ,n+er the skino.er the s,perior e+ge of the thir+ rib- a.oi+ing inD,ry to thene,ro.asc,lar b,n+le/

i/ Pently a+.ance the entire ,nit not more than 2GI7 cm into theple,ral ca.ity- aiming for the ape1/ Too m,ch force or e1cessi.ea+.ancement can res,lt in l,ng inD,ry/

D/ A+.ance the ca the te r only o.er the trocar 5ho l+ the trocar

stationary ith the right han+9 into the ple,ral space posteriorly

toar+ the ape1 to the +esire+ length 5see ig,re #/79/

+i. 0.12.

/2N




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k/ With+ra the trocar an+ clamp the en+ ith a Jelly clamp/

l/ Attach the t,be to the le,r$e.ac an+ remo.e the Jelly clamp/

m/ To sec,re the chest t,be3 irst place to large .ertical mattresss,t,res on either si+e of the t,be/ Be1t reappro1imate the skinincision- lea.ing long tails on each s,t,re/ Then rap theremaining portion of each s,t,re aro,n+ the chest t,be to sec,reit/ When the chest t,be is remo.e+- only the

portion of the s,t,re attache+ to the chest t,be sho,l+ be c,t-lea.ing the .ertical mattress s,t,res in place to close the o,n+/

n/ lace a piece of eroform ga,Fe aro,n+ the entrance site an+ asterile +ressing on top/ asten sec,rely ith *enFoin an+ clothtape/

+i. 0.13.

/70




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o/ Confirm placement ith a C"/


a/ oor position ing

The t,be sho,l+ be at the ape1 of the ple,ral ca.ity/ t

occasionally gets trappe+ in the maDor fiss,re of the l,ng/ f this occ,rs- the t,be sho,l+ be remo.e+ an+ re$inserte+/re


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This can be .ery ,sef,l in treating smaller pne,mothoracies- here therisk of air leak is minimal/


A stan+ar+ chest t,be sho,l+ be place+ rather than a perc,taneo,scatheter in the folloing sit,ations3

Hemothora1

)ignificant pne,mothora1 5> 8;9


!mpyema

7/ Anesthesia3


# / !


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after entering the ple,ral space ith the 22$ga,ge fin+er nee+le/

+/ :ake a small incision slightly larger than the +iameter of the chestt,be/

e/ lace the $ga,ge intro+,cer nee+le on the syringe an+ insertinto the incision/ 'irect the nee+le s,periorly ith the be.el

+irecte+ ,p- an+ a+.ance o.er the s,perior bor+er of the rib hileaspirating/ l,i+ or air sho,l+ be aspirate+ to .erify intraple,ralposition 5see ig,re #/#9/

f/ "emo.e the syringe an+ a+.ance the soft @ en+ of the ire

thro,gh the nee+le an+ into the ple,ral space/ The ire sho,l+a+.ance itho,t resistance 5see ig,re #/89/

+i. 0.10.

/7#




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g/ "emo.e nee+le an+ lea.e ire in place/

h/ While maintaining ire in position- se


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D/ "emo.e the ire an+ chest t,be inserter tr ocar - lea. ing the ches t

t,be in place/

k/ Attach the t,be to the le,r$e.ac/

l/ To sec,re the chest t,be3 irst place to large .ertical mattresss,t,res on either si+e of the t,be/ Be1t reappro1imate the skinincision- lea.ing long tails on each s,t,re/ Then rap theremaining portion of each s,t,re aro,n+ the chest t,be to sec,reit/ When the chest t,be is remo.e+- only the portion of the s,t,reattache+ to the chest t,be sho,l+ be c,t- lea.ing the .ertical

mattress s,t,res in place to close the o,n+/m/ lace a piece of eroform ga,Fe aro,n+ the entrance site an+ a

sterile +ressing on top/ asten sec,rely ith *enFoin an+ clothtape/

n/ Confirm placement ith a C"/


+i. 0.17.

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a/ oor position ing

The t,be sho,l+ be at the ape1 of the ple,ral ca.ity/ t

occasionally gets trappe+ in the maDor fiss,re of the l,ng/ f this occ,rs- the t,be sho,l+ be remo.e+ an+ re$inserte+/

re


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e1pan+e+9

b/ "ec,rrent malignant ple,ral eff,sions

c/ "ec,rrent spontaneo,s pne,mothoracies 5relati.e9

+/ rimary spontaneo,s pne,mothora1 5contro.ersial9


Allergies to tetracycline- +o1ycycline- or talc

7 / Anesthesia3

; li+ocaine 580 ml9

#/ !


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min,tes to +istrib,te the li+ocaine for anesthesia/

g/ il l the other ?0$ml syringe ith the +o1ycycline sol,tion/

h/ Attach the +o1ycycline syringe to the chest t,be- remo.e the Jellyclamp- an+ instill the sol,tion into the ple,ral ca.ity/ Clamp thechest t,be/

i/ "epeat )teps g an+ h ,ntil 700GI#00 ml of +o1ycycline ha.e beena+ministere+/

D/ "ota te the pat ient to each of the fol loing fo,r posi tions e.ery 70min,tes3

Left lateral +ec,bit,s

"ight lateral +ec,bit,s

Tren+elenb,rg

"e.erse Tren+elenb,rg

k/ After # ho,rs- replace the chest t,be back to le,r$e.ac s,ction forat least the ne1t 2# ho,rs- ,ntil the l,ng has f,lly e1pan+e+ an+no air leak is present/

K/ Techni


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a+ministere+/

D/ "ota te the pat ient to each of the fol loing fo,r posi tions e.ery 70min,tes3

Left lateral +ec,bit,s

"ight lateral +ec,bit,s Tren+elenb,rg

"e.erse Tren+elenb,rg

k/ After # ho,rs- replace the chest t,be back to le,r$e.ac s,ction forat least the ne1t 2# ho,rs- ,ntil the l,ng has f,lly e1pan+e+ an+no air leak is present/

+. E)ER@EC6 5E#S%#E TH$RAC$T$)6

/ n+ icat ions3

Car+iac arrest in .ictims of penetrating tra,ma to the thora1 ho ha+.ital signs in the fiel+ or on arri.al to the emergency

+epartment/ n certain sit,ations emergency thoracotomy may bein+icate+ in other penetrating tra,ma inD,ries/


!mergency thoracotomy has not been shon to be effecti.e in tra,matic

car+iac arrest secon+ary to bl,nt tra,ma/7/ Anesthesia3

Bone

#/ !


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i / Aor ti c c lamp

D/ ),ct ion appa ra t,s

8/ os it ioning3

),pine

?/ Techn i


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e/ *l,ntly +issect the mi+$+escen+ing thoracic aorta circ,mferentiallyfree from the posterior me+iastin,m an+ place an aortic clamp onit- being caref,l not to inD,re the esophag,s anteriorly/ Anasogastric t,be 5Chapter 89 can be place+ to

help +isting,ish the esophag,s from the aorta on palpation 5seeig,re #/N9/

+i. 0.19.

/#0

/#

/#2




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f/ lace aortic clamp across the aorta after it is mobiliFe+/

g/ "etract the left l,ng inferiorly an+ i+entify the pericar+ial sac/

h/ %pen the pericar+ial sac its entire length longit,+inally 5a

longit,+inal incision ill pre.ent inD,ry to the phrenic ner.e9/

i/ !.ac,ate any clot in the pericar+i,m- an+ +eli.er the heart intothe left hemithora1 for e1amination 5see ig,re #/209/

+i. 0.1.




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D/ nD,ries to the hear t may be

Documents

Manual of Common Bedside Surgical Procedure CHAPTER 4 - Thoracic Procedures