Caboolture Hospital Intensive Care Unit
Effective from: January 2020
Review date: January 2023
Intercostal Catheter (ICC) – Insertion, Management and Removal – 005333
Intercostal catheters (ICC’s) are inserted into the pleural space and connected to an underwater seal drainage system to remove air or fluid to re-establish negative intra-pleural pressure. The pleural space normally contains a thin film of lubricating fluid that allows the lungs to move without friction during breathing, and to maintain the two pleural surfaces in close opposition.
The presence of excess fluid (pleural effusion), blood (haemothorax) or air (pneumothorax) in this space alters intra-pleural pressure and causes partial or complete lung collapse. Intercostal catheters are an invasive device and all management processes must follow the principles of Aseptic Non-Touch Technique.
Purpose and intent
This guideline outlines the process and requirements to prepare for and assist with the insertion, management, and removal of an intercostal catheter/ chest drain.
Scope and target audience
This guideline applies to all Caboolture Hospital medical and nursing clinical staff (permanent, temporary and casual) and all organisations and individuals acting as its agents (including Visiting Medical Officers and other partners), involved in providing care and management of patients requiring ICC/chest drains whilst admitted to the Intensive Care Unit.
Competency and education
All clinicians involved in the insertion, maintenance and removal of ICC’s must ensure that this is within their scope of clinical practice, determined by the individual’s credentials, education, training, competence and maintenance of performance at an expected level of safety and quality. Education is provided to nursing and medical staff through their unit induction process and formal education programs such as in-service and ICU Transition to Nursing Practice program, this includes supervised practice and/or simulation.
Procedure / process
The core principles of management of ICC follow (ANTT) and Personal Protective equipment (PPE) including eye-protection must be worn for all procedures with risk of exposure to bodily fluids. Observe the throughout all clinical patient contact.
Risks and precautions
- The air vent of the under water sealage drain (UWSD) must always be open to the atmosphere unless on suction.
- Failure to do this may result in a tension pneumothorax
Insertion of chest tube
Obtain patient consent and assess risk:
- In the event that the insertion of the ICC is deemed an emergent procedure then there is implied consent
- The Next of Kin may consent for the ICC if the patient is deemed not competent to make an informed decision
Medical officer responsibilities
It is the responsibility of the Medical Officer (MO) to ensure that the patient:
- has had the procedure explained to them
- has been provided with the ‘patient information’ sheet (see Appendix 2).
- has been informed of the risks associated with this procedure
- has given written consent
- has had a risk assessment completed, particularly in relation to the risk of haemorrhage
- Check identity of the patient and ensure patient consent has been obtained in writing.
- Ensure the MO has reviewed the most recent chest x-ray available.
- Confirm site and side for insertion of chest tube with the MO – provide patient privacy and clip hair around the insertion site (if required).
- Ensure adequate IV access is available.
Equipment required for ICC insertion
- Clarify which chest drain kit is required:
- Cook-Wayne Pneumothorax set – 14 Fr
- Cook Pig-Tail – 8 Fr; Lock Pericardiocentesis set 8.3 Fr
- Trocar Catheter – 24 Fr
- CareFusion – Safe -T-Centesis Pig Tail Catheter Drainage Kit 8 Fr
- Rocket – Seldinger Chest Drain Kit – 12 Fr
- Use the appropriately sized chest tube, without a trocar unless specifically requested by the MO:
- Pneumothorax 20 – 24 Fr (6.7- 8 mm)
- Effusion/Pus 24 – 28 Fr (8 – 9.3 mm)
- Blood /Pus – 32 Fr (10.7 mm)
- Some doctors prefer to use small bore catheters (14 Fr or less)
Set up sterile equipment for intercostal catheter insertion
Additives required on Hospital-specific Procedure tray
Specific Procedure tray for ICC insertion
Set up and prime the sterile chest tube drain collection device:
To fill water seal:
Assistant role during ICC insertion
- Wear appropriate personal protective equipment (PPE).
- Assess the patient’s pain and anxiety levels – premedication may be considered.
- Place the patient in the MO’s preferred position for the chest tube insertion.
- Usual position is to recline the patient on the bed at 30º, slightly rotated, with the arm on the affected side abducted and the hand behind the head to expose the axillary area.
- Assist the patient to stay in the same position and ensure they maintain the correct arm position during the insertion procedure; it may be necesssary to hold their abducted arm behind their head.
- Observe and reassure the patient – encourage the patient to breathe normally.
- Continuously monitor:
- Respiratory rate, oxygen saturation and blood pressure
- Level of comfort, pain and distress
- Assist MO throughout the insertion procedure – pass equipment as requested.
- After the chest tube is inserted, the correct placement of the chest tube can be confirmed by:
- ‘Fogging’ of the chest tube with expiration.
- Movement of air (bubbling) in the underwater seal chamber of the drainage system after tube placement for pneumothorax.
- Fluid drainage after chest tube placement for pleural fluid.
- ‘Swinging’, ‘tidalling’ or ‘oscillating’ of the fluid level in the water seal chamber (this is less prominent with small bore catheters).
Connect the inserted ICC tube to chest drain
Once the chest tube is in position and secured, immediately connect the chest drain tubing to the chest tube.
- If the chest tube has been clamped, remove clamp immediately after connection to the drainage system.
- Tape the junction of the chest tube and drainage tube with Hypafix™ to prevent separation.
- This is best done with a strip of Hypafix™ tape lengthways across the connection point.
- The connection may be additionally secured at either end of the lengthways tape by taping around the individual tubes.
- Ensure the drain system is positioned at least 80 cm below the patient’s chest level at all times.
- Encourage the patient to fully exhale to assist drainage of the pleural space and lung re-expansion.
- Assess the patient and patency of chest drain.
Securing the chest tube
The tube will be sutured in by the medical officer, and the tube must be supported to prevent it falling out while the anchoring suture is completed.
- Secure the tubing to the skin to facilitate drainage and reduce tube dislodgment.
- Use a mesenteric tag of Hypafix ™tape applied to the chest tube about 15 – 20 cm distal to the insertion site.
Atrium Oasis™ Drains:
Three-chamber systems currently used in ICU are the Atrium Oasis™ Dry Suction Chest Drain (used for patients above 15 kg).
- The system is suitable for all applications from small pneumothorax to moderate or large haemopneumothorax and enables ‘suction control’.
- The addition of suction improves the rate of and flow of drainage.
- Additional suction helps overcome an air leak by improving the rate of airflow out of the patient.
Application of suction
Not all chest drains are connected to suction.
Low-pressure suction therapy may be used in some patients with a chest drain to facilitate the removal of air or fluid from the pleural space, to assist with lung re-expansion. Application of suction to a chest drain is dependent on the clinical condition and doctor’s preference.
- An order for suction to be applied, and the amount of suction, must be prescribed by a Medical Officer and recorded in the patient clinical record
- The Oasis™ suction is measured in cm H2O and is represented as a negative number (ie -10 to -40 cm H2O).
- check the amount of suction (if ordered) against the Atrium Oasis™ suction gauge setting.
- When suction is not being used, disconnect the tubing from suction port and leave the air vent open to create the ‘underwater seal’
Increase external suction source to -80 mm Hg or higher, and connect tubing to the chest drain as per manufacturer’s instructions
The Orange Suction Bellows will expand and become visible in the assessment window (Label E) when the external suction is applied
Suction control is regulated by adjusting the control dial setting to the prescribed level (Label A) on the three-chamber Atrium Chest Drain System
Record the level or amount of drainage as indicated by the patient’s clinical condition on the chest drain unit (Atrium Oasis™) and on the fluid balance chart.
- Document drainage 8 hourly if minimal drainage and more frequently as indicated by volume.
- Record colour, consistency and turbidity of drainage fluid.
- If there is a sudden increase in the amount of drainage, monitor vital signs and measure drainage every 15-30 minutes to ensure that it is not continuous.
- Report large losses (> 5 mL/kg/hr) to the Medical Officer.
- Remember that a change in the patient’s position may lead to a sudden increase in drainage as the fluid moves from a previously dependent position to one which can be drained.
- If drainage stops suddenly, suspect that the tubing may be blocked and check the system.
Chest drain dressings
Assist the Medical Officer to initially dress the chest tube site following insertion:
- Dressings are done using ANTT principles
- Dress site using a drain dressing and secure with clear Opsite™ dressing or Hypafix™ tape
- Dressings should be changed daily and PRN if visibly soiled or dressing becomes wet
- observe the ICC insertion site for signs of infection and presence of surgical emphysema.
Confirmation of chest tube placement and documentation
- Ensure that a chest X-ray has been organised for confirmation of tube placement.
- Document the insertion procedure:
- completed by the MO in the patient’s chart
- document all nursing interventions, observations and the patient education that has been provided post procedure
- Monitor and record patient and chest drain observations
Chest drain observations
- Assess and record the patient’s clinical status hourly for four hours, and then every 4th hour.
- Observe and record (on a dedicated ICC observation form or on CIS) the following:
- basic vital signs
- oxygen saturation
- level of consciousness
- pain score and discomfort level at rest, and with deep breathing and coughing
- presence of dyspnoea or cyanosis
- Check drainage system to ensure patency and security of tubing.
- ensure all connections are tight and tubing is not kinked
- ensure the tubing is straight and that dependent loops do not form
- ensure the chest drain system is always at least 80 cm below the patient’s chest level
- ensure the water seal chamber is always upright and maintained according to manufacturer’s instructions
- milking or stripping of the drainage tubing is not recommended
- Observe the chest drain and record:
- tube position and security of connections
- drainage amount, type and colour
- fluctuating of the fluid level (swinging/tidalling) in the water seal chamber as the patient breathes (i.e. toward the patient on inspiration and away on expiration in accordance with normal changes in intrathoracic pressure)
- presence of air loss evidenced by intermittent bubbling in the underwater seal drain chamber
- if air loss is evident as continuous bubbling in the assessment chamber, check for leaks.
- Check with MO if suction may be intermittently turned off to assess bubbling, as some patients may be compromised if suctioning is discontinued even for a short period.
Clamping of the chest tube
If the chest tube is clamped for any period of time, ensure that the patient knows they have to report any symptoms of chest tightness, shortness of breath or chest pain
- These symptoms could indicate the recurrence of pneumothorax or development of a tension pneumothorax; a life-threatening emergency.
- Chest tubes should NOT be clamped overnight.
- Clamping to check whether a pneumothorax re-accumulates is generally unnecessary.
- Clamping may be necessary for a drain that has been placed for pleural tap.
- The Atrium Oasis™ drains have a blue slide clamp included however spare chest drain clamps should be readily available at the bedside.
- use Non-serrated clamps (so as not to damage the chest tube) if clamping is necessary
- in an emergency, a sterile 500mL bottle of water may be used as an underwater seal
- It is preferable to use the technique of clamping the tube with your hands when changing the chest drain system (i.e. when the drainage chamber is full).
- Use of a 3-way tap is an alternative if a pigtail drain is inserted.
Removal of the intercostal catheter and chest tube drain
Indications for removal
- Fluid drainage has been less than 200 mL over preceding 24 hours.
- Resolution of a pneumothorax:
- the air leak (bubbling) has ceased for 24 hours in the presence of tube patency
- the lung is fully inflated on x-ray
- If there is doubt whether the air-leak has ceased, a written order may indicate to clamp the chest tube or disconnect suction for a period prior to chest tube removal, to ensure a pneumothorax does not reoccur off suction
- Repeat x-ray in several hours to check for re-accumulation of air
Equipment required for chest drain removal:
- Antiseptic solution Chlorhexidine 2% and 70% alcohol
- Steri-Strips™ or suture (if wound closure suture not present)
- Sterile forceps, scissors and stitch cutter
- Steri-Strips™ or suture (if wound closure suture not present)
- Dressing tray and normal saline ampoules
- Drain sponge dressings and sterile gauze
- Non-serrated Clamps
- Sterile gloves and apron
- Face mask and protective eyewear
- Blue protective liner
- Waste disposal for contaminated materials
- Assess the patient’s level of understanding and adequately explain the procedure to the patient.
- Ascertain whether analgesia may be required and administer analgesia in a timely manner.
- The patient may experience moderate to severe pain during chest tube removal.
- Ensure that any analgesia is provided, optimally so that peak effect occurs at the time of tube removal.
- Review the breathing technique that the patient will use during the removal procedure. There are several possible breathing techniques used during the procedure to theoretically reduce the risk of air being sucked in through the wound during tube removal. It is essential to coach the patient in the technique to be used:
- Full inspiration – the chest tube is removed on full inspiration.
- Full expiration – the chest tube is removed on full expiration.
- Valsalva manoeuvre or breath hold – instruct the patient to take a deep breath, and either hold their breath (or blows out against a closed glottis) to create positive intra-pleural pressure.
- Position the patient comfortably so that access to the entry site of the chest tube is provided. Continuously reassure the patient during the procedure and encourage them to relax.
If suction is being used, disconnect the suction tubing from chest drain before turning suction off.
- Perform social hand-wash, don PPE and gloves.
- Remove the anchoring, mesenteric tag of tape and loosen the existing dressing surrounding the chest tube.
- Ensure the chest tube remains supported.
- Remove the dressing and discard appropriately.
- In ‘locking pigtail’ catheters, the curl of the tail is locked in place to prevent migration during use or dislodgement from the pleural space.
- The proximal end of this catheter is provided with a locking hub, and this locking mechanism must be released before drain removal is attempted
- The unlocking technique uncoils the distal end of the drain by cutting to release the catheter string that creates the pigtail coil
- Failure to uncoil a pigtail drain prior to removal can cause severe pain and internal tissuie damage to the patient.
- Confirm you can identify the presence, or not, of both the wound closure and anchoring sutures placed by the MO when the chest tube was inserted
- Anchoring suture secures and attaches the chest tube to the skin, and is usually wrapped around the base of the tube and tied along the tube
- Wound closure sutures (purse string/mattress suture) are placed insitu, ready to close the wound after chest tube removal
Image from https://www.sciencedirect.com/science/article/pii/S1357303908000960; viewed 26/09/2019
Set up sterile field for intercostal catheter removal:
- Perform clinical hand-wash and don sterile gloves.
- Set up equipment using a sterile field.
- Thoroughly clean drain insertion site using aseptic technique.
- Clean the skin and sutures around the tube site with antiseptic solution.
- Also cleanse the first 10 cm of the external drain.
- Dry the area with gauze to ensure the occlusive dressing will adhere to the skin.
- Untie wound closure suture and place one throw of a knot in the wound closure suture.
- Unwind the ties of the wound closure suture, usually wound around the base of the tube.
- The ends of the closure suture may be tied together and this knot should be cut.
- Confirm the position and viability of the suture to close the site effectively after the tube is removed.
- Cut the stay or anchoring suture and support drainage tubing with non-dominant hand.
- Gently withdraw the chest tube 0.5 to 1 cm, ensuring the chest tube is free of subcutaneous sutures and will be able to be withdrawn easily.
ICC removal procedure:
Place the sterile gauze square over the top of the tube (with the non-dominant hand) to reduce potential splash injury. Direct patient to perform the selected breathing technique.
- The non-dominant hand (or assistant) supports the insertion site and controls the wound opening by gently squeezing the sides of the wound/ chest tube together as the tube is removed.
- Remove the tube swiftly but gently, in one smooth continuous motion with the dominant hand while simultaneously pinching the skin around the insertion site.
- Little or no resistance should be felt when removing the drainage tube.
- The edges of the wound should be gently squeezed together as the tube is removed.
- Tighten the wound suture to close the wound (do not pucker the skin) and tie the suture strings securely.
- Steri-Strips™ may be applied if required to securely close the drain site.
- Instruct the patient to breathe normally; apply an occlusive dressing to cover the exit site.
- Request the patient to cough, to ensure that no air can be heard escaping from the wound.
- Check that the tip of the drain is intact.
- Perform clean-up post procedure, hand hygiene and document drain removal in patient record.
If the patient experiences undue pain, or resistance is felt when removing the chest tube, stop the procedure and check the following:
- Suction is disconnected from drainage system.
- No residual sutures present, including subcutaneous sutures.
- Locking mechanism on pigtail catheter has been released to uncoil the drain.
- If there is no obvious cause, stop the procedure and call for senior medical assistance.
- A nurse stays with the patient to safeguard and assess the patient’s condition.
Patient care and monitoring after chest drain removal
- Assist the patient into a comfortable position, provide nurse call bell at hand and advise patient to rest quietly but report:
- Any increase in pain at the site or chest tightness on inspiration.
- Shortness of breath or breathlessness.
- Air loss or discharge oozing from the insertion site.
- Regularly assess and document patient’s vital signs, pain level and specific respiratory status observations:
- SpO2 and respiratory rate
- depth and quality of respirations
- air entry to lung fields
- notify MO immediately of any change in the patient’s condition
- Arrange a post procedure chest X-ray to be performed within 1-3 hours after drain removal and ensure the result is documented in the patient’s clinical record.
- the follow up x-ray must be reviewed by MO in a timely manner to confirm that the lung has remained inflated.
- small residual air collections usually spontaneously resolve over 24-48 hours
- Check the dressing daily for signs of air or fluid leakage – reinforce dressing as required
- Take down the occlusive dressing after 48 hours to inspect the insertion site for signs of infection or continued drainage.
- Reapply occlusive dressing and change daily until the suture removed (at 72 hours or as ordered) and changed as required until the site has healed (generally 7 days).
- Provide the patient with education regarding activities to avoid following pleural drainage, until they have specialist medical clearance.
Potential complications during or after chest drain removal
- recurrence of the pneumothorax
- re-collection of pleural effusion
- empyema (infection in pleural space) or subcutaneous infection at the insertion site
- necrosis around tube site (if the suture is too tight, especially if a ‘purse string’ suture is used)
Partnering with consumers
Patients and family members are to be encouraged and given the opportunity to ask questions, clarify information and identify goals of treatment with intercostal catheter insertion and the placement of a chest drain. Staff are responsible for providing information in a way that is understandable and that meets their needs and are to check consumer’s understanding of discussions.
Aboriginal and Torres Strait Islander considerations
Specific cultural implications exist for the provision of healthcare for Aboriginal and Torres Strait Islander patients and their families.
- As a matter of best practice to provide culturally capable patient care, seek cultural guidance from the local Aboriginal and Torres Strait Islander Hospital Liaison Officer, the Aboriginal and Torres Strait Islander Cultural Practice Coordinator, Health Worker, the family group or the wider community.
- Refer to the Metro North Hospital and Health Service Intranet page on Cultural Resources and Queensland Health Publication: “Aboriginal and Torres Strait Islander: Patient Care Guidelines Published by the State of Queensland (Queensland Health), May 2014.
Legislation and other authority
- Health Act 1937
- Health Practitioner Regulation National Law Act 2009
- Atrium (2004) Dry Suction Chest Drain Product Information.
- Children’s Health Service District Nursing Standards (2010) Clinician Development Education Service Online Education Program (CDES) Retrieved on June 2011.
- Northside Health Service District, The Prince Charles Hospital Policy and Procedures (2010).
- Oasis Chest Drain – A personal guide to managing dry chest drain Retrieved on 24 July 2010 at www.atriummed.com/PDF.
- Tollefson J. (2010) Clinical psychomotor skills assessment tools for nursing students (4th ed), Cengage Learning Australia Limited. Australia.
Appendix 1 – Patient consent and information sheets
Intercostal Catheter Insertion
Clinical Nurse Consultant, Caboolture Hospital Intensive Care Unit
Clinical Nurse Consultant, Caboolture Hospital Intensive Care Unit
Adverse events relating to ICC will be documented in the patient’s medical record. All clinical incidents, near-miss events and procedural noncompliance of ICC management are to be recorded via RiskMan and addressed by the Caboolture ICU Safety and Quality Committee. This information will be used to review practice and identify areas for future quality improvement initiatives as per MNHHS Quality Improvement Procedure (PROC089). In the absence of clinical incidents, proactive annual audit from CIS data of ICC documentation will be conducted and presented within the schedule of Caboolture ICU Safety and Quality Committee.
CRICU V1_2016/WUG ICC (Intercostal catheter) Set up, Insertion, Management and Removal
Clinical Nurse Consultant, Caboolture Hospital ICU
Director, Caboolture Hospital ICU
Staff Specialists and Consultants, Caboolture ICU
Members of Caboolture ICU Safety and Quality Committee
CN ICU Portfolio Holder, Standard 3: Healthcare Associated Infections
Dissemination via email cascade to key staff groups and stakeholders; online publishing on QHEPS; ICU Staff notification as per clinical in-service/meetings
ICC; Chest Drain; Atrium Oasis Drainage System; 005333
Clinical Nurse Consultant, Caboolture Intensive Care Unit, Metro North Hospital and Health Service
Authorising Officer Signature
Director, Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Service
The original signed version is kept in file at Service Improvement Unit, Caboolture Hospital, Metro North.