Transillumination and Chest Drain Management …€¦ · Web viewIn general for an infant with a pneumothorax on respiratory support, a chest drain should be inserted if a needle

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Canberra Hospital and Health ServicesClinical ProcedureTransillumination and Chest Drain Management (Neonates)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Transillumination of the neonatal chest.................................................................2

Section 2 – Needle aspiration...................................................................................................3

Section 3 – Chest drain insertion, maintenance and removal...................................................4

Definition of Terms...................................................................................................................8

References................................................................................................................................ 8

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.........................................................9

Search Terms............................................................................................................................ 9

Doc Number Version Issued Review Date Area Responsible PageCHHS15/100 1 01/05/2015 01/04/2020 WY&C –

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

To describe the diagnosis of a pneumothorax by high intensity light and the safe drainage of a pneumothorax by needle aspiration of the chest.

Scope

This document pertains to infants and babies care for by staff in the Neonatal Intensive Care unit.

This document applies to: Medical Officers Nurses and Midwives who are working within their scope of practice (Refer to Scope of

Practice for Nurses and Midwives Policy) Student Nurses under direct supervision.

Section 1 – Transillumination of the neonatal chest

In an emergency, a pneumothorax can be diagnosed by using high intensity light.

Equipment High intensity fibre-optic cold light source (Transilluminator)

Procedure 1. Lower lights in the room to enable hyperlucent areas to be seen if present2. Clean the part of the transilluminator touching the patient with alcohol wipes3. Place the transilluminator along the posterior axillary line of the baby’s chest wall on the

side where air collection is suspected4. The transilluminator may be moved up and down along the posterior axillary line to the

frontal area to detect any areas of increased light transmission 5. Compare with the other side of the chest6. For a suspected pneumopericardium place the transilluminator in line with the 3rd and

4th intercostal space on the left mid clavicular line and angle the light towards the xiphoid process

7. If an abnormal air collection is detected notify the Medical Officer immediately8. Document findings in the patients clinical record9. If a pneumothorax is suspected a Chest X-ray will be ordered if time allows10. A Medical Officer may perform a Needle Aspiration to remove the collection of air if

there is a pneumothorax present and there are any signs of acute compromise.


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ALERT: Severe subcutaneous chest wall oedema or pulmonary interstitial emphysema may give a false positive sign.In general for an infant with a pneumothorax on respiratory support, a chest drain should be inserted if a needle aspiration has been performed.If there is a significant deterioration in a non-ventilated patient, the pneumothorax should be drained before a decision is made to intubate the patient.

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Section 2 – Needle aspiration

In case of emergency, if a tension pneumothorax is suspected, the pneumothorax should be drained as soon as possible by needle aspiration.

Equipment Pre warmed isolette or open care centre. Dressing pack Skin antiseptic preparation. 3 way tap. 10ml syringe Sterile gloves

Procedures Monitor oxygen saturation, heart rate, respiratory rate continuously throughout the

procedure Attach 3-way tap to 10ml syringe and turn all the 3-way tap ports to the on position Remove all the caps from the 3-way tap ports Add the butterfly needle extension or cannula to one of the 3-way tap ports

Place infant into position with the arm of the affected side restrained at a 90-degree angle

The involved side should be exposed and slightly elevated to ensure evacuation of air Doc Number Version Issued Review Date Area Responsible PageCHHS15/100 1 01/05/2015 01/04/2020 WY&C –

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Swab the infants’ skin in the area of the 2nd-3rd rib along the mid clavicular line Place a finger on the infant’s 3rd rib and guide the needle along the finger and insert into

the 2nd intercostal space at an angle of 90degrees an should AVOID THE NIPPLE.

Once in position turn the 3 way tap to aspirate air from the infants chest into the syringe Turn the 3 way tap, closing it off to the chest, to expel the air– operator to measure

amount Continue to aspirate until resistance is met and remove needle Arrange for an X-ray to confirm drainage of pneumothorax Record heart rate, oxygen saturation, respiratory rate during the procedure and after.


Section 3 – Chest drain insertion, maintenance and removal

Equipment Chest drain with trochar Underwater seal drain Sterile water Sterile dressing Heimlich valve for transport Howard Kelly clamps


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ProcedureRN/Registrar/Medical Officer1. Ensure the infant is continually monitored 2. Consider use of sedation / analgesia /local anaesthesia before commencing procedure3. Assemble drainage unit4. Position the infant supine on open care centre or in incubator

AlertThe second Intercostal space should be avoided as puncture of the subclavian vein may occur

The Registrar/Medical Officer will insert the chest drain as follows1. Medical officer to scrub and don gloves and gown2. Appropriate placement of the chest drain will be in the fourth intercostal space just

anterior to the mid axillary line3. Infiltrate the area with local anaesthetic before making an incision4. The infant should be placed with the effected side slightly elevated and the arm raised

above the infants’ head5. The drain should be inserted following an incision made into the ntercostals space –

being aware that the intercostal artery, vein and nerve run beneath the ribs surface6. A track through to the pleura is then made with blunt dissection using artery forceps.

The trocar should not be used to pierce the pleura7. The trocar may be bent 30-450 about 1.5-2cm from the tip to facilitate anterior

placement of ICC for a pneumothorax. The trocar is NOT to be more than 2cm from the tip to avoid excessive force with perforation of nearby organs. The chest tube should be aimed anteriorly to facilitate drainage of pneumothoraces

8. The drain is then inserted 2-3cms into the chest in preterm infants and 3-4cms in term infants ensuring that the side holes are within the pleural space

9. The trocar is withdrawn and the tube is clamped until connected to underwater seal drainage system or to Heimlich valve


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10. In preterm infants tape the chest tube in place with steri strips in term infants it is preferable to tape with steri-strips, alternatively suture the chest tube in place with 4.0 vicryl, do NOT use silk

The RN/Registrar/Medical Officer1. Check whether the fluid in the underwater drainage bottle is swinging or bubbling2. Cover ICC insertion site with transparent dressing to allow for site observation3. Apply low wall suction if requested at 5-10kPa 4. Tape all connection sites on tubing to help prevent disconnection5. Arrange chest x-ray to confirm placement of the ICC and evaluate the effectiveness of

the procedure and reduction in size of pneumothorax, chylothorax or pleural effusion

ManagementTo check the chest drain is correctly positioned and working effectively1. Ensure continuous monitoring of the infant with frequent assessment of vital signs and

hourly documentation of same2. Assess blood gases as requested3. Assess and document breath sounds and chest symmetry with cares4. Complete a pain score hourly and administer analgesia/sedation as ordered and when

required5. Evaluate serial chest x-rays to monitor the chest tube placement and visualise the

effectiveness of the evacuation6. Check dressing is intact and airtight at the insertion site; observe for any drainage or

leaking from same. Do not change if dry and intact


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7. Observe for signs of infection-erythema and purulent discharge around drain site and/or purulent discharge in drainage

8. Check the system is connected to low wall suction at between 5-10kpa if requested9. Ensure there is no pulling on the tube by securing the tubing to the bed – encircle the

tube with adhesive tape and pin the tape to the bed10. When moving the infant stabilise the tube by holding it close to the baby’s chest11. The underwater seal drainage system must be positioned below the level of the infant’s

chest to prevent water from being drawn into the pleural space12. The length of the drain below the level of the fluid should not be greater than 2-3cm as

this will increase resistance to the drainage of air13. Check clamps are available at the bedside to clamp tube if disconnected and during

changing of the drainage system when necessary14. If disconnection occurs immediately reconnect and inform the Medical Officer15. Frequently reposition the infant to provide maximum drainage and lung expansion16. Mark the water level in the chamber each shift to assess amount of fluid loss17. Monitor and record the amount, colour and consistency of the drainage hourly18. Check and document hourly for bubble and swing in the chamber, the water level rising

with inhalation and falling with exhalation reflecting respirations and tube patency (ventilated infants may have dampened oscillations)

19. Ensure the ICC remains patent at all times

RemovalChest drains are removed on medical orders when air and fluid accumulation has resolved

Equipment Basic dressing pack Gauze squares Sterile gloves Op-site 3000 Stitch cutter if required Steri- strips Aqueous Antiseptic solution 0.1% Sucrose

Procedure1. Ensure patient has adequate analgesia2. Position patient in lateral position to ensure easy access with affected side uppermost3. Remove dressing over chest tube and clean the drain site(s) and area with antiseptic

solution4. Wash hands and don non-sterile gloves 5. Remove sutures if present 6. To reduce the chance of introducing air into the pleural space, cover the chest wound

with a small occlusive dressing (gauze) while removing the ICC


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7. During expiration in spontaneously breathing infants and during inspiration in mechanically ventilated infants, rapidly remove the tube while applying pressure with the gauze over the site to produce an airtight seal

8. Close the wound with steri-strips 9. Cover site with transparent Op-site dressing to allow for site observation 10. Monitor the infant’s vital signs hourly and continue observation of patient for signs of

respiratory distress11. Document procedure


Definition of Terms

Pneumomediastinum – an air or gas travelled from alveoli and penetrated into the mediastinal tissue.

Transillumination – The passing of a light through the walls of an organ to facilitate medical inspection.

Pneumopericardium – a medical condition where air enters the pericardial cavity.

Pulmonary interstitial emphysema – is a collection of gases outside of the normal air passages and inside the connective tissue of the lung.


References

Cifuentes, J., Segars, A.H., & Carlo, W.A. (2007). Respiratory System Management and Complications. In C. Kenner & J. Lott (Eds.), Comprehensive Neonatal Nursing, a Physiological Approach. Philadelphia, W.A.: Saunders.

Cloherty, J., Eichenwald, E., & Stark, A. (2008). Manual of Neonatal Care. Philadelphia: Lippincott.

Cunningham, M., & Gomella, T. (2004). Neonatology: Management, Procedures, On-call Problems, Diseases, and Drugs. St Louis: McGraw-Hill

Gomella, P. (2009). Neonatology Management, Procedures, On Call Problems, Diseases and Drugs. New York: McGraw Hill.

Harris,P., Nagy, S., & Vardaxi, N. (2010). Mosby’s Dictionary of Medicine, Nursing & Health Professions (2nd Australian & New Zealand ed.). New South Wales: Elsevier Australia.

Henry, M., Arnold, T., & Harvey, J. (2003). British Thoracic Society Guidelines for the Management of Spontaneous Pneumothorax. Thorax, 58, (Suppl ll), ii39-ii52.


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Kattwinkel, J. E. (2005). Textbook of Neonatal Resuscitation (5th ed.). USA: American Academy of Pediatrics and Heart Association.

5 Moments of Hand Washing- Hand Hygiene Australia.

Taeusch H.W. et al. (2005). Avery’s Diseases of the Newborn (8th ed.). Philadelphia: Elsevier Saunders.

Truog, W., & Golomeb, S. (2005). Principles of Management of Respiratory Problems In M. MacDonald, M. Mullett, & M. Seshia (Eds.), Avery’s Neonatology Pathophysiology & Management of the Newborn (6th ed.). Philadelphia: Lippincott.

Verklan, M.T. (2004). Adaptation to Extrauterine Life. In M.T. Verklan & M. Walden, Core Curriculum for Neonatal Intensive Care Nursing. St Louis: Elsevier.

‘World Health Organisation (WHO) Guidelines on Hand Hygiene in Healthcare.


Implementation

This clinical procedure will be communicated at orientation.


Related Policies, Procedures, Guidelines and Legislation

PoliciesHealthcare Associated Infection (CHHS15/072) Section 2.2


Search Terms

NeonatalChest drainTransillumination

AspirationPneumothoraxUnder water seal drain



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Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair


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Documents

Transillumination and Chest Drain Management …€¦ · Web viewIn general for an infant with a pneumothorax on respiratory support, a chest drain should be inserted if a needle