270 Section VII ■ Tube Replacement

Diagnostic Tap of Pleural Fluid

Follow the procedure for the insertion of a posterior chest

tube, with the following differences.

A. Differences

1. Use a 20-gauge angiocatheter.

2. Position patient without elevating the hemothorax on

the side of fluid collection. It will be necessary to lower

the affected side only if the quantity of fluid is small.

3. Select insertion site in anterior or midaxillary lines

below breast tissue for diffuse pleural collections.

Direct catheter tip posteriorly, after penetrating into

pleural space.

4. Keep system closed to prevent leakage of air into pleural

space.

Anterior Mediastinal Drainage

Most mediastinal air collections cause only mild symptoms and are not under sufficient tension to require drainage. Their presence often precedes tension pneumothorax

in the presence of lung disease and positive-pressure

ventilation. Posterior mediastinal tube insertion is rarely

required (37).

A. Indications

1. Significant air accumulation with physiologic compromise (38)

a. Increased intracranial pressure (39)

b. Poor cardiac output because of impeded venous

return

c. Critical interference with artificial ventilation

(1) Competition with lungs for thoracic volume

(2) Negative effect on pulmonary compliance

2. Drainage of fluid

a. Mediastinitis after esophageal perforation

b. Postoperative

B. Contraindications

No absolute contraindications

C. Equipment

Sterile

1. Antiseptic for skin preparation

2. Gauze pads

3. Aperture drapes

4. Surgical gloves

5. No. 11 surgical blade

6. Local anesthetic, as required

7. Curved mosquito hemostat

8. Drainage tube (see equipment for emergency evacuation of air leaks)

a. 10-Fr soft thoracostomy tube

b. IV cannula system

(1) 14- to 16-gauge angiocatheter

(2) IV extension tubing

(3) Three-way stopcock

9. 10- to 20-mL syringe

10. Connecting tubing and underwater suction device for

indwelling tube

11. 4-0 nonabsorbable suture on small cutting needle with

needle holder

12. Transparent bag to cover tip of transillumination

device.

Nonsterile

1. 0.5-inch adhesive tape

2. Transillumination device

D. Precautions and Complications

The problems encountered in evacuating material from the

mediastinum are similar to those encountered in placement

of chest tubes. In contrast to tension pneumothorax, mediastinal collections tend to accumulate more gradually. For

this reason, careful preparation of the patient and use of

sterile technique are possible and essential. For precautions

and complications, refer to E and G under Thoracostomy

Tubes at the beginning of this chapter.

E. Technique

Drainage for longer than 12 hours normally dictates placing

a 10- to 12-Fr tube by direct dissection because smaller

tubes occlude readily. Select indwelling tubes only in the

presence of significant lung disease or mediastinitis, where

continued accumulations are anticipated. Remove the

tubes as soon as possible to reduce the risk for infection.

Soft Mediastinal Tube Insertion

1. Follow sterile technique throughout.

2. Monitor infant’s vital signs and oxygenation.

3. Determine, by transillumination or radiograph, the

region of maximal mediastinal air accumulation

(Fig. 38.24).

4. Cover tip of transillumination light with sterile, clear

plastic bag for use after skin preparation.

5. Cleanse skin with antiseptic.

6. Drape patient with aperture drape, without obscuring

infant.

7. Infiltrate insertion site with 0.25 mL of local anesthetic.

8. With a no. 11 blade, make a small stab wound through

the skin at the subxiphoid.