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

PRE-PROCEDURE:
Carry out pre-procedure safety checks and alert pratitioner to results. E.g. patient assessed for risks, patient I.D., consent (where applicable), coagulopathies, allergies, medicines, bloods.

The nurse must be present to reassure the child throughout the insertion procedure and in case of any deterioration in the child’s condition during or after the chest drain has been inserted.

Therefore, it is advisable to have all necessary equipment at the bedside to avoid the nurse having to leave the patient.

PROCEDURE: The doctor/ANP should scrub and prepare for chest drain insertion as an operation using sterile gloves and gown.

The assisting nurse should open all equipment needed for the procedure onto the sterile drapes.

The nurse should open the under water seal chest drain system onto sterile drapes on trolley.

To minimise the risk of infection.

To ensure the doctor/ANP has all necessary sterile equipment readily available for chest drain insertion

Before use, the water seal chamber (B) should be filled as below* (Fig. 3):

• keep tap closed
• using attached 20ml funnel, fill funnel completely with sterile water
• open tap
• fill chamber to 2cm line

Once filled, water becomes tinted blue for improved visibility of air leaks and convenient monitoring of patient pressures.

Once chamber (B) (Fig. 3) filled, disconnect funnel ensuring suction tubing stopcock switched off. This end of the tubing is the suction tubing connection for wall suction if required.

Note: Whether or not suction is required it is better to fill the suction chamber (A) (Fig. 3) at this point also. Usually fill to level -20cmH2O.

If the doctor/ANP wishes to do this then they will follow the above steps*, keeping the entire system on the sterile drape. The, assisting nurse will only need to pour the water in. (Fig 4 & 5)   

OR

If the assistant nurse is to fill the chambers, the chest drainage system should be handed to the nurse by the doctor/ANP *Note: the sterile end of the tubing will be kept on the sterile drape by the doctor/ANP.

The assistant nurse should follow the steps above* (Fig. 6) ensuring sterile end of drainage system connection,  remains on sterile drapes until connection to chest required.

Water Seal Chamber (B) (Fig. 3) must be filled first and maintained at 2cm level to create a seal for closed drainage and keeping air from entering the cavity. This is filled regardless of whether suction is applied from the wall (Atrium 2016). 

After set-up, routinely monitor the water level for evaporation and fill with sterile water as necessary. NOTE: It is the water level that determines the amount of negative pressure (Atrium 2016). 

Seldinger insertion technique will beused to insert chest drain. Details in: ‘Tutorial Notes-Chest Drainage’ Maxwell (2018)  

Once drain in correct position it is sutured into place to secure it.

Once drain secured, hand physician or ANP the sterile distal end of drainage connecting tubing so it can be attached to the tapered sterile connector when tube is in.

Two sutures will be used – one solely to secure the drain and the other, a ‘mattress’ or similar suture for closing the wound post drain removal. The suture & type chosen must be suitable for a linear incision.

To ensure entire system remains sterile and intact.

When hemothorax is suspected, blood exposure can be reduced by connecting drainage tubing to Atrium® drainage system prior to insertion.

If suction required, connect chest drain system to suction source using clear hospital suction connecting tubing.  The suction used must be a high volume/low pressure system. Never connect a chest drain on its own to wall suction.

It is recommended that each separate chest drainage system has a separate suction source 

Ensure the chest drain, connectors (single or Y) and suction tubing are all connected to each other securely. 

Ensure suction tubing stopcock is switched ON. Adjust wall suction gauge (after connecting to patient's chest tube), until there is constant gentle bubbling in the suction control chamber (A) (Fig. 3). Negative pressure of -20cmH2O are most common. 

Continuous suction may be applied through the suction port in the drainage system to enhance drainage and help manage a non-resolving pneumothorax.

There is loss of suction if more than one chest drainage system is connected to one suction source

 Poor tube connections can lead to air leaks in the system.

 Vigorous bubbling is not only noisy but unnecessary as it can lead to faster evaporation of water in the suction control chamber (A) (Fig.3)  but will not increase suction. High levels of negative pressure can cause damage to lung tissue and perpetuate any existing air leaks.

Use multi-position hangers to hang unit from bedside or place on floor using swing-out floor stand incorporated into base. (To further avoid tipping - base of unit may be secured to floor using tape provided tape is clearly seen E.g. Sleek) 

Post insertion the nurse should ensure that the patient & family are updated the following are documented:

• Vital signs – pre & post insertion
• Chest drain size, site & date/time inserted
• Type of drainage & amount-chamber (D)(fig3)
• How your patient coped with the procedure
• Any medications required
• Chest x-ray results