Chapter 38 ■ Thoracostomy 271

9. Using a curved mosquito hemostat, dissect in the

midline at 30-degree angle to chest wall in cephalad

direction until entering mediastinal space. The mediastinum under tension should bulge downward.

10. Insert soft chest tube into dissected tunnel, and direct

tube cephalad and toward area of maximal transillumination.

11. Observe tube for air rush or condensation while completing insertion. If loculations are evident, break them

up using blunt dissection.

12. Connect to closed drainage system at vacuum of 5 cm

H2O, and increase to 10 cm H2O if necessary.

Accumulation in mediastinum is usually relatively

slow; therefore, lower suction pressures are effective.

a. Use low pressure to keep tube side holes patent

while clearing air collection.

b. Monitor efficacy by radiograph and transillumination (Fig. 38.24).

13. Secure tube with suture, and tape as for thoracostomy

tubes.

14. If drainage stops with significant accumulation still evident on transillumination or radiograph

a. Verify that accumulation is in mediastinum by lateral decubitus and lateral radiographs.

b. Verify tube position on radiographs.

c. Rotate tube.

d. Aspirate, but do not irrigate, tube; reattach to continuous drainage.

e. Change position of infant to move air toward tube.

Temporary Mediastinal Drainage

with IV Cannula

1. Assemble equipment and prepare patient as for insertion by mediastinal dissection.

2. Make a small stab wound in subxiphoid notch.

Mediastinal air under tension should be located in this

area, pushing the liver and heart away from needle tip.

3. Insert cannula with stylet at 45-degree angle to chest

wall in cephalad direction.

C

B

A

Fig. 38.24. Sequential radiographs. A: Tension pneumomediastinum (arrows). A mediastinal collection this massive is unusual.

B: Successful drainage tube (arrow). C: The apparent slipping of the

mediastinal cannula (arrow) is an artifact of patient rotation on this

lateral view. There is residual mediastinal air superiorly, but there

was no patient compromise at this time.

272 Section VII ■ Tube Replacement

4. As soon as cannula passes through skin, lower cannula

to a 30-degree angle with skin.

5. Remove stylet, and attach connecting tubing, stopcock,

and syringe.

6. Advance cannula into mediastinal space cephalad and

medially, but toward area of maximal transillumination. Aspirate while advancing, and monitor cardiac

tracing. Stop insertion if there is resistance, blood, or

arrhythmia.