Chapter 39 ■ Pericardiocentesis 275

3. Swabs or gauze pads

4. Gloves

5. Local anesthetic

6. 16- to 20-gauge IV cannula over 1- to 2-inch needle

7. Indwelling drainage catheter (optional)

8. Three-way stopcock

9. Short IV extension tubing (optional)

10. 10- to 20-mL syringes

11. Preassembled closed drainage system as for emergency

evacuation of air leaks, thoracostomy tubes described in

Chapter 38 (optional)

12. Connecting tubing and underwater seal for indwelling

drain (optional)

13. Specimen containers for laboratory studies, if procedure is diagnostic

Nonsterile (See also I)

1. Transillumination device (optional, for pneumopericardium)

2. Echocardiogram/sonography imaging device (optional

in urgent situations)

I. Procedure

1. If ultrasound/echocardiographic imaging is available,

and if time permits, imaging can be performed to determine an optimal needle entry site and angle. In addition, the approximate distance required to reach the

pericardial space can be estimated (15). Even after a

sterile field is created, ultrasound imaging can be performed from a nonsterile area of the chest to monitor

the effusion during the procedure. If imaging is done

from a part of the sterile field, the transducer can

be placed in a sterile sheath (or a sterile glove). Care

should be taken to avoid moving a probe with sterile cover back and forth between sterile and nonsterile

areas.

2. Similarly, evaluation with transillumination can be performed in cases of pneumopericardium, if time permits.

3. Cleanse skin over xiphoid, precordium, and epigastric

area with antiseptic. Allow to dry.

4. Arrange sterile drapes, leaving the subxiphoid area

exposed.

5. Administer local anesthesia if the patient is conscious.

For example, 0.25 to 1 mL of subcutaneous 1% lidocaine instilled within 1 to 2 cm of the xiphoid process.

(See also Chapter 6.)

6. Form a closed system by assembling a syringe, threeway stopcock, and extension tubing so that the stopcock

is open to both the syringe and the extension tubing,

but closed to the remaining side-port .

7. Using the IV needle/cannula, enter the skin 0.5 to 1 cm

below the tip of the xiphoid process, in the midline or

slightly (0.5 cm) to the left of the midline. The needle

should be at a 30- to 40-degree angle to the skin, and

the tip should be directed toward the left shoulder

(Fig. 39.4). A different approach may be used in certain

cases, for example, if an echocardiogram suggests that

most of the fluid is right-sided or apical.

8. Advance the needle until air or fluid is obtained.

a. A rhythmic tug, corresponding to the heart rate, may

be felt as the needle enters the pericardium.

b. If ultrasound imaging is available, needle position

can be determined either by visualizing the tip of

the needle within the pericardial space or by demonstrating that the amount of pericardial fluid is

diminishing as fluid is aspirated (Fig. 39.5). Some

authors have described reinfusing a small amount of

the aspirated fluid while imaging to observe the

location of microcavitation echoes (15,20,21).

9. Fix the needle in position and advance the cannula

over the needle into the pericardial space. Remove the

needle, and connect the cannula to the closed system

syringe for aspiration.

10. Aspirate as much fluid/air as possible. If the syringe fills,

use the third port of the stopcock to empty the syringe,

or to attach a second syringe, and then aspirate more,

repeating as needed. If diagnostic studies are desired,

the fluid should be transferred to appropriate specimen

containers.

a. If bloody fluid is aspirated, there could be a serosanguineous or hemorrhagic effusion, or the needle

might have entered the heart (usually the right ventricle). There are a few clues that can be helpful in

determining whether the needle has entered the

heart (see J).

b. Note that small single-lumen catheters may easily

become blocked.

 

274 Section VII ■ Tube Replacement

3. Clinical signs of cardiac tamponade may evolve gradually or rapidly (1,3,18).

4. The primary therapy for cardiac tamponade is to evacuate the pericardial space. Volume expansion and pressor agents may be of transient benefit, but they usually

do not result in sustained clinical improvement

(1,8,12,16,19).

5. Cardiac tamponade may require urgent treatment with

pericardiocentesis in infants with severe hemodynamic

compromise (1,16,17).

D. Indications (1,12,15–17)

1. Cardiac tamponade due to pneumopericardium

2. Cardiac tamponade due to pericardial fluid

3. Aspiration of pericardial fluid for diagnostic studies

E. Contraindications

1. There are no absolute contraindications to performing

pericardiocentesis in the setting of cardiac tamponade.

2. Relative contraindication for diagnostic pericardiocentesis

a. Coagulopathy

b. Active infection. (However, infection may also be an

indication for diagnostic pericardiocentesis in some

clinical situations.)

F. Precautions

Draining a large volume from the pericardial space can

alter cardiac preloading conditions significantly, and some

infants may require a supplemental intravascular fluid

bolus after the pericardium is drained.

G. Limitations

1. Cannot readily evacuate thrombus

2. Cannot remove mass lesions

H. Equipment

Sterile

1. Antiseptic solution

2. Aperture drape or multiple drapes to be arranged

around access site

Fig. 39.2. Chest radiograph with pneumopericardium.

CVL, crossing into left atrium

Central venous catheter crossing atrial septum.

*-pericardial effusion, RA - right atrium, LA - left atrium,

 RV - right ventricle, LV - left ventricle.

RA LA

RV LV

Fig. 39.3. Echocardiogram image of preterm infant with pericardial effusion and central venous line in left atrium.

Blood pressure

Inspiration Expiration Inspiration Expiration Fig. 39.1. Pulsus paradoxus.

 

273

Alan Benheim

 John North

39 Pericardiocentesis

A. Definitions

1. Pericardium

a. A double layer of mesothelial lining surrounding the

heart, consisting of the visceral pericardium on the

epicardial surface and the parietal pericardium as an

outer layer

b. Between the two layers, there is normally a small

amount of pericardial fluid (typically <5 mL for a

neonate) that is thought to reduce friction.

2. Pneumopericardium

a. Collection of air in the pericardial space

3. Pericardial effusion

a. Accumulation of excess fluid in the pericardial

space

4. Pericardiocentesis

a. A procedure to remove air or excess fluid from the

pericardial space, usually through a needle, small

cannula, or drainage catheter

5. Pericardial drain

a. A catheter or other drainage device left in place to

allow intermittent or continuous evacuation of air or

fluid from the pericardial space

b. Placed in select situations with recurring accumulation of air or fluid in the pericardial space

6. Tamponade

a. Clinical condition with limited cardiac output

because of external restriction of expansion of the

heart, preventing normal cardiac filling, resulting in

a decreased stroke volume and impaired cardiac

output

b. May be caused by

(1) Fluid or air in the pericardial space

(2) Abnormalities of the pericardium (restrictive or

constrictive)

(3) Increased intrathoracic pressure associated with

obstructive airway lung disease or tension pneumothorax

7. Pulsus paradoxus (Fig. 39.1)

a. Respiratory variation in blood pressure, with a

decrease in systolic blood pressure during spontaneous inspiration. (During positive-pressure ventilation, this is reversed, with a rise in systolic pressure

during inspiration.)

b. This finding occurs during tamponade.

B. Purpose

1. To evacuate air to relieve cardiac tamponade

2. To evacuate fluid to relieve cardiac tamponade

3. To obtain fluid for diagnostic studies

C. Background (See also A)

1. The heart lies within a closed space, covered by the

pericardium. The pericardial space lies between

the two layers of the pericardium. If the pericardial

space fills with excess fluid or if air accumulates, the

heart has less space available, and the pressure within

the pericardium increases. Increased intrapericardial

pressure restricts venous return and impairs cardiac filling. The decrease in venous return and cardiac filling

results in a reduced cardiac output. This clinical situation is known as cardiac tamponade (1–5).

2. Neonates are at increased risk for cardiac tamponade

when there is

a. Accumulation of air dissecting into the pericardium

from the respiratory system (Fig. 39.2) (4–7)

b. Pericardial fluid accumulation due to perforation or

transudate from umbilical or central venous catheter (Figs. 32.15, 39.3) (1,8–12)

c. Cannulation for extracorporeal membrane oxygenation (13,14)

d. Cardiac catheterization, either diagnostic or therapeutic (15)

e. Postoperative pericardial hemorrhage following cardiac surgery (2,16)

f. Postpericardiotomy syndrome, typically 1 to 3 weeks

after cardiac surgery (2,16,17)

g. Pericardial effusion as part of generalized edema/

hydrops (3,16)

h. Pericardial effusions due to infectious or autoimmune causes. (These are less common in neonates

than in older children.)

 

26. Bowen A, Zarabi M. Radiographic clues to chest tube perforation

of neonatal lung. Am J Perinatol. 1985;2:43.

27. Perman MJ, Kauls LS. Transilluminator burns in the neonatal

intensive care unit: a mimicker of more serious disease. Pediatr

Dermatol. 2007;24:168.

28. Strife JL, Smith P, Dunbar JS, et al. Chest tube perforation of the lung

in premature infants: radiographic recognition. AJR Am J Roentgenol.

1983;141:73.

29. Kumar SP, Belik J. Chylothorax—a complication of chest tube

placement in a neonate. Crit Care Med. 1984;12:411.

30. Rosegger H, Fritsch G. Horner’s syndrome after treatment of tension pneumothorax with tube thoracostomy in a newborn infant.

Eur J Pediatr. 1980;133:67.

31. Nahum E, Ben-Ari J, Schonfeld T, et al. Acute diaphragmatic

paralysis caused by chest-tube trauma to phrenic nerve. Pediatr

Radiol. 2001;31:444.

32.Grosfeld JL, Lemons JL, Ballantine TVN, et al. Emergency thoracostomy for acquired bronchopleural fistula in the premature

infant with respiratory distress. J Pediatr Surg. 1980;15:416.

33. Faix RG, Naglie RA, Barr M. Intrapleural inoculation of Candida

in an infant with congenital cutaneous candidiasis. Am J Perinatol.

1986;3:119.

34. Gooding C, Kerlan R Jr, Brasch R. Partial aortic obstruction produced by a thoracostomy tube. J Pediatr. 1981;98:471.

35. Ragosta KG, Fuhrman BP, Howland DF. Flow characteristics of

thoracotomy tubes used in infants. Crit Care Med. 1990;18:662.

36. Arda IS, Gurakan B, Aliefendioglu D, et al. Treatment of pneumothorax in newborns: use of venous catheter versus chest tube.

Pediatr Int. 2002;44:78.

37. Purohit DM, Lorenzo RL, Smith CE, et al. Bronchial laceration

in a newborn with persistent posterior pneumomediastinum.

J Pediatr Surg. 1985;20:82.

38. Moore JT, Wayne ER, Hanson J. Malignant pneumomediastinum: successful tube mediastinotomy in the neonate. Am J Surg.

1987;154:687.

39. Tyler DC, Redding G, Hall D, et al. Increased intracranial pressure: an indication to decompress a tension pneumomediastinum.

Crit Care Med. 1984;12:467.

 

7. Secure cannula in effective position, and attach IV

extension tubing to underwater drainage system with

suction pressure of 10 cm H2O. The smaller cannula

will require higher suction pressures unless the air

accumulates slowly. Because air loculates within the

mediastinum and the side holes occlude easily, small

catheters are rarely effective for anything other than

acute relief of tension. Remove cannula as soon as

possible.

References

1. Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest

tubes for pneumothoraces in children treated in the emergency

department. Pediatr Emerg Care. 2002;18:265.

2. Lawless S, Orr R, Killian A, et al. New pigtail catheter for pleural

drainage in pediatric patients. Crit Care Med. 1989;17:173.

3. Wood B, Dubik M. A new device for pleural drainage in newborn

infants. Pediatrics. 1995;96:955.

4. Rothberg AD, Marks KH, Maisels MJ. Understanding the Pleurevac.

Pediatrics. 1981;67:482.

5. Gonzalez F, Harris T, Black P, et al. Decreased gas flow through

pneumothoraces in neonates receiving high-frequency jet versus

conventional ventilation. J Pediatr. 1987;110:464.

6. MacDonald MG. Thoracostomy in the neonate: a blunt discussion. NeoReviews. 2004;5:c301.

7. Chan L. Medial pneumothorax: a radiographic sign that should

not be overlooked on the supine view. Am J Emerg Med. 1999;

17:431.

8. Dennis J, Eigen H, Ballantine T, et al. The relationship between

peak inspiratory pressure and positive end expiratory pressure on

the volume of air lost through a bronchopleural fistula. J Pediatr

Surg. 1980;15:971.

9. Zidulka A. Position may reduce or stop pneumothorax formation

in dogs receiving mechanical ventilation. Clin Invest Med. 1987;

10:290.

10. Stevens TP, Harrington EW, Blennow M, et al. Early surfactant

administration with brief ventilation vs. selective surfactant and

continued mechanical ventilation for preterm infants with or at

risk for respiratory distress syndrome. Cochrane Database Syst

Rev. 2007;17:CD003063.

11. Ryan CA, Barrington KJ, Phillips HJ, et al. Contralateral pneumothoraces in the newborn: incidence and predisposing factors.

Pediatrics. 1987;79:417.

12. Kuhns LR, Bednarek FJ, Wyman ML. Diagnosis of pneumothorax or pneumomediastinum in the neonate by transillumination.

Pediatrics. 1975;56:355.

13. Wyman ML, Kuhns LR. Accuracy of transillumination in the recognition of pneumothorax and pneumomediastinum in the neonate. Clin Pediatr. 1977;16:323.

14. Albelda SM, Gefter WB, Kelley MA, et al. Ventilator-induced

subpleural air cysts: clinical, radiographic, and pathologic significance. Am Rev Respir Dis. 1983;127:360.

15. Allen RW, Jung AL, Lester PD. Effectiveness of chest tube

evacuation of pneumothorax in neonates. J Pediatr. 1981;99:

629.

16. Batton DG, Hellmann J, Nardis EE. Effect of pneumothoraxinduced systemic blood pressure alterations on the cerebral circulation in newborn dogs. Pediatrics. 1984;74:350.

17. Cartlidge PH, Fox PE, Rutter N. The scars of newborn intensive

care. Early Hum Dev. 1990;21:1.

18. Bhatia J, Mathew OP. Resolution of pneumothorax in neonates.

Crit Care Med. 1985;13:417.

19. Merenstein GB, Dougherty K, Lewis A. Early detection of pneumothorax by oscilloscope monitor in the newborn infant. J Pediatr.

1972;80:98.

20. Noack G, Freyschuss V. The early detection of pneumothorax

with transthoracic impedance in newborn infants. Acta Paediatr

Scand. 1977;66:677.

21. Grim P 3rd, Keenan WJ. Two uncommon radiographic signs of

an anterior neonatal pneumothorax. Correlated with clinical finding. Clin Pediatr. 1986;25:440.

22. Genc A, Ozcan C, Erdener A, et al. Management of pneumothorax in children. J Cardiovasc Surg. 1998;39:849.

23. Mehrabani D, Kopelman AE. Chest tube insertion: a simplified

technique. Pediatrics. 1989;83:784.

24. Mauer JR, Friedman PJ, Wing VW. Thoracostomy tube in an

interlobar fissure: radiologic recognition of a potential problem.

AJR. 1981;139:1155.

25. Strife JL, Smith P, Dunbar JS, et al. Chest tube perforation of the

lung in premature infants: radiographic recognition. AJR. 1983;

141:73.

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. 

 

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.

 

Chapter 38 ■ Thoracostomy 267

Fig. 38.17. Posterior view of thoracic organs. Traumatic

hemorrhage of the left upper lobe was due to perforation

by a thoracostomy tube.

A B

Fig. 38.18. Postmortem examination of an infant with bilateral pneumothorax, pneumomediastinum,

and pneumoperitoneum secondary to pulmonary air leaks. Attempted needle aspirations, as shown by

multiple skin puncture sites of the pneumomediastinum and pneumothorax (A), resulted in needle punctures of the liver (arrows, B) with peritoneal hemorrhage.

268 Section VII ■ Tube Replacement

Fig. 38.19. Scar from thoracostomy insertion, emphasizing the

importance of avoiding the breast area. Massaging the healed

wound with cocoa butter helps break down adhesions that lead to

dimpling at the scar.

Fig. 38.20. The thoracostomy tube is completely outside the

pleural space on this slightly oblique chest film. Note that the long

feeding tube is not in an appropriate position for transpyloric feeding. Indwelling tubes may dislodge when other emergency procedures are performed.

Fig. 38.21. The side holes of both thoracostomy tubes are outside the pleural space on this radiograph.

Fig. 38.22. The tip of the thoracostomy tube has been advanced

too far medially and is kinked against the mediastinum. Withdrawing

the tube 1 or 2 cm would improve drainage at the medial thorax.

Note the endotracheal tube tip in the right mainstem bronchus.

Chapter 38 ■ Thoracostomy 269

5. Misplacement of tube

a. Tube outside pleural cavity in subcutaneous placement (Fig. 38.20)

b. Side hole outside pleural space (Fig. 38.21)

c. Tip across anterior mediastinum (Fig. 38.22)

6. Equipment malfunction

a. Blockage of tube by proteinaceous or hemorrhagic

material

b. Leak in evacuation system, usually at connection sites

c. Inappropriate suction pressures (32) (Fig. 38.11)

(1) Excessive pressure

(a) Aggravation of leak across bronchopleural

fistula

(b) Interference with gas exchange

(c) Suction of lung parenchyma against holes

of tube

(2) Inadequate pressure with reaccumulation

7. Infection

a. Cellulitis

b. Inoculation of pleura with skin organisms, including Candida (33)

8. Subcutaneous emphysema secondary to leak of tension

pneumothorax through pleural opening

9. Aortic obstruction with posterior tube (34)

10. Loss of contents of pleural fluid

a. Water, electrolytes, and protein (effusion)

b. Lymphocytes and chylomicrons (chylothorax)

Emergency Evacuation of Air Leaks

Life-threatening air accumulations require emergency

evacuation. This provides temporary relief to the patient

while preparing for thoracostomy tube placement. The following techniques using modified equipment are less traumatic than using straight needles or scalp vein sets. We suggest using an anterior approach for emergency evacuation

because position will not interfere with the preparation of

the lateral chest site for an indwelling chest tube.

Tubes used for emergency evacuation require suction

pressures as high as 30 to 60 cm H2O to overcome the resistance of their small diameters (35). This requirement and

their tendency to occlude make these cannulas unreliable

for continuous drainage of a significant air leak.

A. Indications

Temporary evacuation of life-threatening air accumulations

while preparing for permanent tube placement

B. Contraindications

1. When patient’s vital signs are stable enough to allow

placement of permanent thoracostomy tube without

prior emergency evacuation

2. When air collection is likely to resolve spontaneously

without patient compromise (nontension pneumothorax)

A. Equipment

All sterile

1. Gloves

2. Antiseptic solution

3. 18- to 20-gauge angiocatheter (36)

4. IV extension tubing

5. Three-way stopcock

6. 10- and 20-mL syringes

B. Technique

1. Prepare skin of appropriate hemithorax with antiseptic.

2. Connect a three-way stopcock to an IV extension tubing. Connect syringe to three-way stopcock.

3. Insert angiocatheter at point that is

a. At a 45-degree angle to skin, directed cephalad

b. In second, fourth, or fifth intercostal space, just

over top of rib, well above or below the areola of the

breast

c. In midclavicular line (Fig. 38.23A)

4. As angiocatheter enters pleural space, decrease angle to

15 degrees with the chest wall and slide cannula in

while removing stylet (Fig. 38.23A).

5. Attach IV extension tubing to angiocatheter, open stopcock, and evacuate air with syringe (Fig. 38.23B).

6. Continue evacuation as patient’s condition warrants,

while preparing for permanent tube placement.

7. Cover insertion site with petroleum gauze and small

dressing after procedure.

B A

Fig. 38.23. Emergency evacuation with a vascular cannula. Puncture the skin and enter the pleura at a

45-degree angle, immediately above a rib.