Underwater seal chest drainage in the highly dependent or critically ill infant or child: nurse role: chest drain removal

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Objectives

Chest drains and chest drainage systems are used frequently in the paediatric critical care unit. There are many reasons for chest drain insertion but primarily they are used whenever there are specific conditions that interfere with the normal mechanism of lung expansion and altered intrathoracic pressures.

Pleural chest tubes are inserted to evacuate blood, pus, air and fluid, from the thoracic cavity, to re-establish negative pressure in the intra pleural space and thereby expand the lungs following collapse resulting from surgery or trauma. 

Mediastinal chest tubes are placed in the mediastinum following open heart surgery, via a medial sternotomy in order to prevent accumulation of blood and clots around the heart, which could cause cardiac tamponade – a life threatening situation. 

There are many different types of chest drains available including one-way flutter valve drains such as the Heimlich device or portable drains. However, for the majority of patients in the paediatric critical care unit an underwater seal chest drainage system will be used. These systems provide an underwater seal, fluid collection chamber and suction chamber. 

In paediatric intensive care it is normally the physician or Advanced Nurse Practitioner who inserts chest drains. However, the bed side nurses’ role is pivotal in ensuring the patient is cared for safely throughout the insertion procedure.

This guideline is intended as a resource for staff involved in caring for children in Paediatric Critical Care 1D (PICU) that require chest drain insertion. The guideline has been constructed after literature search and review of sourced textbooks, national guidelines & recommendations British Thoracic Society, Medline and CINHAL, and external nurse expert peer review and opinion.

Further information on chest drainage in: ‘Tutorial Notes-Chest Drainage’ Maxwell

(2015) and additional chest drain system resource at: www.atriummed.com/ See also recommendations and precautions.

Scope

This nursing procedural guideline is intended to be followed by nurses involved in caring for the highly dependent or critically ill infant or child requiring underwater seal chest drainage within the Paediatric Critical Care Unit 1D (PICU) at the Royal Hospital for Children, Glasgow. 

Audience

All nursing staff involved in caring for infants or children requiring underwater seal chest drainage in Paediatric Critical Care (PICU) should be familiar with this nursing procedural guideline.

Equipment

Equipment (Fig.1 & 2):

  • Clean trolley                                
  • Gloves – sterile & non-sterile
  • Disposable apron                          
  • Disposable visor mask/goggles
  • Sterile Dressing pack: inc. drape, gallipot, gauze.
  • Chest drain site & wound site cleaning solution: 0.9% sodium chloride (Prontosan may also be used)
  • Stitch cutter          
  • Steristrips  
  • Occlusive dressing for chest drain wound site: E.g. Duoderm®        
  • Chest drain clamps (x2)                            
  • Clinical waste bags (x2) & large sharps bin (Fig.2)

*Dressing for mediastinal wound site and chest drain site if removing mediastinal drains post-cardiac surgery (Duoderm® & UrogoClean)

Fig. 1 Equipment for removal chest drain(s)

 

Fig. 2 Large sharps waste bin (‘Griff bin’)

Procedure

PROCEDURE Chest drain removal

RATIONALE

Before removing any chest drain ascertain the following with medical staff or Advanced Nurse Practitioner (ANP):

  • The child fulfils any necessary criteria for chest drain removal (see Precautions below and Flowchart in Appendix)
  • If more than one drain in situ then check which drain or drains are designated for removal

To ensure initial reason for chest drain insertion has been resolved.

Depending upon the reason(s) for chest drain insertion, it may be necessary to only remove one drain and leave the other(s) in situ. 

Prior to commencing procedure the nurse should note the child’s vital signs, colour, air entries, oxygen saturation, respiratory rate and effort.

To provide a baseline measure of infant/child’s observations, by which postdrain removal recordings may be compared.

Provide  age appropriate explanation of procedure.

To help alleviate any anxiety and ensure the child (and parent) understand and consent to procedure.

Assess child’s pain and sedation level and administer prescribed analgesia an appropriate time prior to the procedure

Removing a chest drain can be a painful and upsetting procedure and as such the child requires appropriate medication to ensure their comfort and to minimise pain and distress.

Assemble equipment (Fig. 1 & 2) and take to bed side once analgesia effective.

Depending upon type of analgesia prescribed it may be up to 30 minutes before effective.

1st nurse and assistant: Wash hands thoroughly with appropriate antimicrobial skin cleanser

To minimise the risk of infection

Don disposible apron, visor mask or goggles and non-sterile gloves.

To minimise risk of infection and to provide nurse with suitable protection from blood/chest drain fluid.

If suction connected then discontinue suction.

 

Clamp chest drain(s) being removed and all other drains connected to or sharing the same chest drainage unit.

If only one drain is removed and others on same connection/drainage unit are still in situ, the drainage tubing to the removed drain must remain clamped following removal. (Fig. 3)

Failure to clamp all chest drains connected to the drain being removed or those on the same drainage unit, will result in air being drawn into the system via the unclamped removed drain, resulting in air entering the child’s pleural/mediastinal space.

1st nurse: Gently loosen dressing around chest drain site and examine site. Identify drain anchor sutures and also wound site suture and expose the ends of these. Remove and dispose of non-sterile gloves.

Assistant: Stay beside child and be prepared to comfort and reassure child if required

To help prepare for drain removal, to check type of sutures in place and identify which is to be cut and which is to seal wound when drain removed.

 

Despite analgesia (and perhaps sedation) the child may become restless with handling of the drain and wound site.

1st nurse: Wash hands thoroughly again with appropriate antimicrobial skin cleanser.  

Assistant: Opens dressing pack on to clean trolley and then when 1st nurse ready, opens all other sterile equipment (see above) onto opened dressing pack.

1st nurse: Don sterile gloves and opens out sterile dressing pack once placed on trolley by assistant. (prepares all equipment & wet swabs with Prontosan - to apply on drain site once drain(s) removed).

To minimize risk of infection to the child.

 

To ensure all necessary equipment and dressings are available to the nurse to carry out the procedure

Assistant: When 1st nurse ready, prepares ends of wound suture ready for tying to seal wound once drain is removed.

1st nurse: Cleans chest drain insertion site.

1st nurse: Identifies and cuts drain anchor suture and ensures drain mobile and ready for removal.

After checking assistant nurse and child ready, 1st nurse using one hand to ‘brace’ either side of the chest drain site, should start to remove chest drain smoothly and briskly with other hand.

If the child is old enough to understand (and not on mechanical ventilation) they may be asked at this stage to take a breath and hold it as the drain is removed (a few practice breaths may be tried first). Once the drain is out they should be encouraged to breathe normally.

If the child is receiving inhalational anaesthetic for chest drain removal, please communicate with doctor administering anaesthetic when chest drain about to be removed.

Note: If at any point the drain does not come out easily or if there is an excess of tissue/omentum, then stop procedure, apply occlusive dressing and inform medical staff immediately.

To prepare for drain removal and ensure closure of drain site immediately as drain is removed. 

To ensure drain site clean and help prevent infection.

To ensure drain is not still secured to the child’s skin and is able to be removed easily.

Co-ordination between the two nurses is important whilst the drain is being removed. The drain site must be closed as soon as the drain is removed in case air enters the pleural/mediastinal space.

 

This type of respiratory manoeuvre is thought to help prevent the child breathing in and drawing air into the pleural space via the chest drain insertion site.

 

 

 

This is so that the doctor can administer peak end-expiratory pressure (PEEP) as the drain is removed.

Assistant nurse: As drain is removed the assistant should tie the wound suture firmly and securely to close drain site.

The assistant nurse should check that they do not pull the suture too tightly.

 

Tying the wound suture securely will ensure an airtight seal, prevent air entry through the drain site and formation of a pneumothorax. The drain site suture should be tied to ensure linear wound closure and an airtight seal. If the suture is pulled too tightly it will be difficult to achieve a smooth wound edge and good wound site closure.

1st nurse: As soon as drain is removed and wound site closed by assistant tying the suture, the 1st nurse should apply Prontosan swab over site briefly, then remove and quickly inspect the site. If closure of site does not look complete, then steri-strips* may be applied by the 1st nurse

If removing two drains (E.g. mediastinal) then repeat the above procedure (remember to keep clamps on until all drains to come out have been removed).

Once drain(s) removed, the site(s) should then be checked, cleaned again, steristrips applied (if required) and covered with a suitable occlusive dressing (E.g. Duoderml® +/- Urgoclean).

To close the wound, form an airtight seal and prevent air entry.

*Be aware that site closure may not be complete due to lack of C/D wound site stitch. E.g. drain inserted as emergency prior to transfer in to PICU.

In this situation apply sufficient steri-strips to close wound site. Document & report.

To keep wound site clean and reduce risk of contamination of site.

Note: In certain circumstances children with more than one drain on the same drainage system may require removal of only one of these drains.

In these cases follow above procedure, keep chest drain clamps on all drains, change connectors (if applicable) and do not remove clamps until remaining drains are connected back to the underwater seal unit.

Once underwater seal established on remaining drains, remove clamps and recommence suction (if required).

Failure to clamp all chest drains connected to the drain being removed or those on the same drainage unit, will result in air being drawn into the system via the unclamped removed drain, resulting in air entering the child’s pleural/mediastinal space.

1st nurse:

Ensure child comfortable and positioned upright after procedure. 

Note and document child’s vital signs, colour, air entries, oxygen saturation, respiratory rate and effort post drain removal. 

Arrange for chest x-ray post drain removal.

 

To ensure the child is comfortable and aid lung expansion post procedure.

To help indicate if there is re-accumulation of air or fluid in the pleural space or mediastinum.

To help identify if there is a re-accumulation of air or fluid post drain removal

Assistant nurse: 

Remove chest drain clamps and keep for resterilisation. Dispose of removed chest drains, drainage system, dressing pack and aprons and gloves into clinical waste bags (orange) x2, then place in large clinical waste bin (Fig. 16).

 

To reduce risk of contamination from hazardous clinical waste.


Fig. 3 Clamped chest drain tubes 

Further information and precautions

The decision to electively remove any chest drain(s) is a clinical one.

However, the following points should be considered prior to removal:

It should be ascertained that the chest drain is no longer required. That is, the original need for chest drain insertion has been resolved, such as evidence of lung re-expansion or diminished blood/serous loss.

If the chest drain is no longer functioning, that is, it is permanently blocked and unable to drain correctly, then medical staff will advise that it is to be removed. If there is still a need for chest drainage then a new one should be inserted.

The nurse should check the child’s vital signs, particularly their respiratory status. These should be stable before considering removal of chest drains.

The child’s blood results should be checked, in particular haematology and coagulation status should be available, before chest drain removal, as a low platelet count would result in excessive bleeding.

Other clinical evidence of bleeding in the child, such as oozing at invasive line or wound sites, should be noted as this may indicate clotting problems and result in excessive bleeding if drain removed.

If the child is receiving any anticoagulant or thrombolytic therapy then they are at greater risk of bleeding if the chest drain(s) is removed. Protocols for pausing therapy briefly for procedures such as chest drain removal, should be adhered to.

If any of these are evident it should documented and reported to the nurse-in-charge and medical staff so that they may make an informed decision about whether to remove any drains.

Sometimes omentum may come out with the chest drain being removed. If this does happen, pause procedures, clean site and apply dressing and inform medical staff immediately (see Note above)

Occasionally the chest drain wound site may not have a wound closing suture (E.g. drain insrted as emergency by transport team prior to admission). In this instance, when removing drain ensure application of sufficient steristrips, occlusive dressing and document (See *above)

APPENDIX: Quick guide flowchart: chest drainage - chest drain removal

References
  1. Balfour-Lynn, IM Abrahamson, E Cohen, G Hartley, J King, S Parikh, D Spencer, D Thomson, AH Urquhart, D (2005) BTS guidelines for the management of pleural infection in children. Thorax, Vol. 60, Suppl. I, pp. i1-i21
  2. Bar-El, Y Ross, A Kablawi, A Egenburg, S (2001) Potentially dangerous negative pressures generated by ordinary pleural drainage systems. Chest, Vol. 119 (2), pp 511-514.
  3. Bell, RL Oviada, P Abdullah, F Spector, S Rabinovici, R (2001) Chest tube removal: end-inspiration or end-expiration? Journal of Trauma, Injury, Infection and Critical Care, Vol. 50, pp. 674-677.
  4. Bruce, E Franck, L Howard, RF (2006) The efficacy of morphine and Entonox analgesia during chest drain removal in children. Pediatric anaesthesia, Vol. 16, pp. 302-308.
  5. Crawford, D (2011) Care and management of a child with a chest drain. Nursing Children and Young People, Vol.23 (10), pp.27-33.
  6. GOSH (2016) Chest drain management. Great Ormond Street Hospital: Clinical Guidelines, London. 
  7. Havelock, T Teoh, R Laws, D Gleeson, F (2010) British Thoracic Society Pleural Disease Guideline: Pleural procedures and thoracic ultrasound. Thorax, Vol. 65, (Suppl. 2): ii.61–76.
  8. Hunter, J (2008) Chest drain removal. Nursing Standard, Vol 22 (45), pp. 35-38
  9. Puntillo, K Ley, SJ (2004) Appropriately timed analgesics control pain due to chest tube removal. American Journal of Critical Care, Vol. 13 (4), pp. 292-302.
  10. Rosen, DA Morris, JL Rosen, KR Valnezuela, RC Vidulich, M Steelman, RJ Gustafson, RA (2000) Analgesia for pediatric thoracostomy tube removal. Anesthesia and Analgesia, Vol. 90 (5), pp. 1025-1028.
Editorial Information

Last reviewed: 30 November 2018

Next review: 30 November 2021

Author(s): Jeanette Grady, Claire Cairney - Clinical Nurse Educators, Paediatric Critical care

Approved By: PICU Clinical Guideline Group