slides - BVPV SBIP

Transcript slides - BVPV SBIP

Thoracic Drainage

Endoscopische eenheid UZ Gent – 3K12 IE Longziekten UZ Gent – 7K12IE

Pleural Procedures

Thoracocentesis

Chest drain insertion

BTS Pleural Disease Guideline 2010 - Pleural procedures and thoracic ultrasound Thorax 2010;65(Suppl2):ii61eii76.doi:10.1136/thx.2010.137026

Interactivity

I will return my controller

Yes No

I speak

French Dutch Other

Chest Drain Insertion

Goal

• • • •

Understand basic princples of thoracic drainage and apply them in real life Recognition of most widespread systems and apply basic pricples on these systems Not every detail will be discussed Not all drainage systems will be discussed © 2010 Universitair Ziekenhuis Gent

I work at

49% A.

Hospitalisation internal B.

Hospitalisation surgical C.

Policlinic D.

ICU E.

ER F.

I ‘m

Nurse B.

Medical doctor C.

Student D.

Thoracic drainage :

37% 34% Huh ???? As student but nothing more Low exposure and not confident Regular exposure but not confident Much exposure and confident 4% 0% 25% As st ud Hu en h ??

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ut Lo n w ot ex hi ng po ...

su re an Reg d ul no ar t c ex ...

po su Mu re ch bu e t n xp os o.

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Agenda

Pleural anatomy and pathofysiology

Pleural space = real space between parietal and visceral pleurae.

10 à 20 µm wide Around the entire lung

Pleural anatomy and pathofysiology

Electronmicroscopy pleural space

– – – PP : parietal pleura VP : visceral pleura PS : pleural space

Pleural anatomy and pathofysiology

Continuous negative pressure in the pleural space. - 2cmH 2 0 (=vacuum)

Sum of lung recoil, thoracic wall strengths, oncotic en hydrostatic pressures.

Visceral pleura sucks to the parietal pleura

When thoracic wall moves outside (

inspiration

) lung is opened and air is sucked into the lungs =

active process

. When thoracic wall relaxes (

expiration)

lung recoils and air is pushed outside =

Pleural anatomy and pathofysiology

http://people.eku.edu/ritchisong/301notes6.htm

Pleural anatomy and pathofysiology

Air in the pleural space =

pneumothorax

Fluid in the pleural space =

Pleural anatomy and pathofysiology

Pneumothorax

Every condition when air is in the pleural space Detachment between parietal and visceral pleurae. Less expansion of the lung

Tension pneumothorax :

Valve principle Whole unilateral thoracic cavity filled with air and extra air is pushed in – high pressure on mediastinum and shift of mediastinum hemodynamic instability Primary pneumothorax  Secondary pneumothorax. Underlying comorbidity

Pleural anatomy and pathofysiology

Transudative Pleural Effusions Congestive heart failure Pericardial disease Hepatic hydrothorax Nephrotic syndrome Peritoneal dialysis Urinothorax Myxedema Fontan procedure Central venous occlusion Subarachnoid-pleural fistula Veno-occlusive disease Bone marrow transplantation Iatrogenic

+/- 70

Pleural anatomy and pathofysiology

Exudative Pleural Effusions Neoplastic diseases

Metastatic disease, Mesothelioma, Primary effusion lymphoma, Pyothorax-associated lymphoma

Infectious diseases

Pyogenic bacterial infections, Tuberculosis,Actinomycosis and nocardiosis, Fungal infections, Viral infections, Parasitic infections

Pulmonary embolism Gastrointestinal disease

Esophageal perforation, Pancreatic disease, Intra-abdominal abscesses, Diaphragmatic hernia, Post-abdominal surgery

Collagen vascular diseases

Rheumatoid pleuritis, Systemic lupus erythematosus ,Drug-induced lupus, Immunoblastic lymphadenopathy, Sjögren's syndrome, Churg-Strauss syndrome, Wegener's granulomatosis

Post-cardiac injury syndrome Post-coronary artery bypass surgery Asbestos exposure Sarcoidosis Uremia Meigs' syndrome Ovarian hyperstimulation syndrome Yellow nail syndrome Drug-induced pleural disease

Nitrofurantoin Dantrolene Methysergide Bromocriptine Procarbazine Amiodarone

Agenda

Thoracic Drainage

Pre – Procedure Preparation Indications Complications Equipment Patient position and site of insertion Analgesia, sedation and local anaesthesia Insertion technique Chest drain management © 2010 Universitair Ziekenhuis Gent

Pre – Procedure Preparation

Pleural procedures should not take place out of hours except in an emergency Pleural procedures should be performed in a clean area using full aseptic technique Written consent should be obtained for chest drain insertions, except in emergency situations Non-urgent pleural procedures should be avoided in anticoagulated patients until INR < 1.5

Pre – Procedure Preparation

Healthy subjects : no need for lab testing Patients at risk : lab testing

Hematologic, oncologic Thrombocytes - clotting

Pre – Procedure Preparation

Pre-drainage risk assessment

Cave emphysema – cave adjacent lung Imaging available Marking side Equipment available and checked

Indications

• • • •

Pneumothorax*

In any ventilated patient Tension pneumothorax after needle relief Persistent or recurrent pneumothorax after simple aspiration Large secondary spontaneous pneumothorax in patients > 50 years

Malignant pleural effusions + pleurodesis* Empyema and complicated parapneumonic pleural effusion* Traumatic heamopneumothorax

•

Post-surgical

Thoracotomy, oesophagectomy, cardial surgery)

Complications

Equipment

Sterile gloves and gown Mask and hat Skin antiseptic solution

iodine chloorhexidine in alcohol

Sterile drapes Gauze swabs Syringes + needles (21-25 G) Local anaesthetic

eg lidocaïne 1% of 2%

Scalpel + blade Suture

Non - resolving : Silk 0 - 1

Large bore drain insertion

Guidewire and dilatators

Small bore – Seldinger technique

Chest tube Fitting connecting pieces Connecting tubing + clamp Closed drainage system

Underwater seal – sterile water Electronic seal - drainage

Dressing

Equipment : small bore drain - seldinger

Equipment : large bore drains

Site of insertion

Site of insertion (1) : triangle of safety

Lateral edge pectoralis major Axilla Base Latissimus dorsi 5th intercostal space

Site of insertion (2) : 2

IC - midclavicular

Can J Rural Med 2009; 14 (4)

Site of insertion

Analgesia, sedation, local anaesthesia

Inserting chest drain = painful !!! 50% pts : 9-10 VAS Analgesia + sedation :

No established evidence – cave operators unfamiliarity Cfr local SOP Local aneasthesia

Lidocaïne 1% - particular attention to the skin, periostium and pleura

Up to 3mg/kg Epinephrine aids hemostasis + localise anaesthesia Not been studied in this context

Inserting technique

Confirming site of insertion Control site ‘Drawing’ Prior to insertion expected pleural contents (air or fluid) should be aspirated

Usually while administering local anaesthesia If this not possible → stop procedure Further imaging (eg US) might be helpful

Inserting technique : Small bore

Needle into pleural space with aspiration (air / fluid) Guidewire is passed through the needle Needle is removed – small incision next to te wire Dilator over the wire – twisting action – gentle, no substantial force – no more then 1 cm into pleural cavity Series of enlarging dilators up to the size of the drain Drain over the wire - aiming :

Apical : pneumothorax Posterobasal : pleural fluid

1 3 2 4

http://elearning.scot.nhs.uk:8080/intralibrary/open_virtual_file_path/i287n2751048t/chestdrains_18.htm

Inserting technique : Large Bore

Needle into pleural space with aspiration (air / fluid) Local aneaesthesia Incision (Ø drain) – alignement with intercostal space Blunt dissection using Spencer – Wells clamp or similar

Gently spreading No substantial force

(No) trocars !!!

Air : aiming apical Fluid : aiming posterobasal

Inserting technique : Large Bore

1 3 2 4

http://elearning.scot.nhs.uk:8080/intralibrary/open_virtual_file_path/i287n2751048t/chestdrains_18.htm

Insertion technique : sutures and securing

Prevention of kinking at skin surface Dressing under drain Anchoring suture not to firm Mattress suture Prevention of traction Omental taping Commercially available dressings Patient comfort Anterior © 2010 Universitair Ziekenhuis Gent

Main concern – dressing :

Only white gauzes Connection to aspiration Pain Relief Kinking of the drain 1% 11% 9% 79% On ly w hi te Co ga nn uz ec es tio n to a sp ira tio n Pa in Reli Ki ef nk in g of th e dr ai n © 2010 Universitair Ziekenhuis Gent

Chest drain management

Connection to a drainage system that contains a valve mechanism to prevent air or fluid from entering the pleural cavity.

Underwater seal Heimlich Flutter valve Other recognised mechanism: Electronic system (Thopaz) Indwelling tunneled pleural catheters (PleurX - Aspira)

Chest drain management

Connection to a drainage system that contains a valve mechanism to prevent air or fluid from entering the pleural cavity. 1.

Underwater seal

Heimlich Flutter valve Other recognised mechanism: Electronic system Indwelling tunneled pleural catheters

Under water seal – thoracic drainage

Basic Principles

1- bottle system 2- bottle system 3- bottle system 4- bottle system

1 – bottle system Fluid drains spontaneously due to gravity Air drains spontaneously when there is postive pressure in the pleural cavity (e.g. tension pneumothorax) Thomas Malfait – schematische voorstelling thoraxdrain

1 – bottle system Fluid drains spontaneously due to gravity Air drains spontaneously when there is postive pressure in the pleural cavity (e.g. tension pneumothorax) !!! When there is negative pressure in the pleural space (normal condition / inspiration) air can flow inwards Thomas Malfait – schematische voorstelling thoraxdrain

the drain is sealed by water

• 2cm H 2 0 • Easy to overcome by slight + intrathoracic pressure • - pressure of inspiration cannot overcome the seal Thomas Malfait – schematische voorstelling thoraxdrain

2cm

1 – bottle system Expiration

2cm

Inspiration

Inspiration :

Intrapleural negative pressure – water is pulled up

Expiration :

Normalisation of intrapleural pressure and lowering of waterlevel. Water is going up and down with every breathing cycle

► ‘Pendelen’ ►‘Tidaling’ ►‘Oscillation’

Excessive air intrapleural wil escape by drain - exhaling

► ‘Air Leak’

Thomas Malfait – schematische voorstelling thoraxdrain

2-bottle system Blood en fluid drains from pleural cavity into drainage recipient. Waterseal > 2cm Air cannot be removed anymore Thomas Malfait – schematische voorstelling thoraxdrain

2-bottle system Blood en fluid drains from pleural cavity into drainage recipient. Waterseal > 2cm Air cannot be removed anymore An collector in between

►

2-bottle system Thomas Malfait – schematische voorstelling thoraxdrain

3- bottle - system 2 bottle system = passive system Extra negative pressure (= aspiration/suctie) more rapidly expansion of the lung – better adherens lung to thoracic wall Extra bottle attached after waterseal – this is connected to an aspiration manometer : - ‘

suctioncontrol

’ - the amount of water in this bottle regulates the suctionforce - mostly15 to 20 cm water

►3- bottle - system

Thomas Malfait – schematische voorstelling thoraxdrain

3-flessen - systeem

15cm 2cm Suctioncontrol Waterseal

Thomas Malfait – schematische voorstelling thoraxdrain

Collector

Chest. 2005;127(6):2211-2221. !

3-flessen - systeem

suctioncontrol

’ - the amount of water in this bottle regulates the suctionforce - mostly15 to 20 cm water

►3- bottle – system Sommige systemen hebben dry-suctioncontrol – geen water meer invoeren maar draaien aan knop die de suctie regelt – principe blijft hetzelfde

Thomas Malfait – schematische voorstelling thoraxdrain

3-flessen - systeem

Wat gebeurt als in dit systeem aspiratie / suctie stopt?

15cm 2cm Suctioncontrol Waterseal

Thomas Malfait – schematische voorstelling thoraxdrain

Collector

Wat gebeurt als in 3 flessen systeem suctie stopt ?

69% A.

Vocht en lucht blijven verder draineren B.

Borrelen van waterslot wordt heviger 20% C.

Luchtlek neemt toe 3% 8% D.

Bo rrelen ..

va n w at er slo t .

Lu ch tlek n Ka ee ns o mt p to sp e an ni ng sp neu ...

3- bottle - system

15cm 2cm Suctioncontrol Waterslot

Thomas Malfait – schematische voorstelling thoraxdrain

Collector

4-flessen - systeem 3-flessen systeem is een volledig afgesloten systeem De lucht kan enkel via het afzuigsysteem ontsnappen Indien probleem met afzuigsysteem gevaar voor pneumothorax Hiertoe nog een 4 de fles aankoppelen (vlak naast de opvangfles waar overtollige druk toch nog een uitweg vindt Een

extra veiligheidswaterslot

Reeds vaak vervangen door balletje – vlotter langswaar lucht kan ontsnappen Thomas Malfait – schematische voorstelling thoraxdrain

4-flessen - systeem

Suctioncontrol Waterslot Collector

Thomas Malfait – schematische voorstelling thoraxdrain

Veiligheidsslot / manometer

Chest drain management

Drain should be checked daily for

Drainage volumes – Swinging - Bubbling

Underwater seal

Beneath insertion site - Keep upright

A bubbling drain should never be clamped A maximum of 1.5 L should be drained in the first hour

After an hour of waiting the rest can be drained off slowly

Suction :

No evidence to recommend or discourage the use of suction in a medical scenario

Eens drain geplaatst

97% A.

Patiënt moet zo stil als mogelijk in bed liggen Patiënt mag opzitten maar niet stappen C.

Patient mag rondstappen maar 0% 3% drainage kit lager als D.

insteekplaats Patient mag rondlopen en zwieren en zwaaien met drainagebak Pa tiën t mo et zo st il als ..

Pa tiën t ma g o pz itt en ma ..

g r on ds ta pp e.

Pa tien t ma Pa tien t ma g r on dl op en e.

Chest drain management

Removal

Non functioning drain < 200ml / 24 fluid production

Brisk movement with assistent closing the mattress suture of holding skin firmly together

Valsalva? No evidence for difference in pneumothoraces

In case of chest drain for pneumothoraces

Clamping can be done – cave tension pneumothorax

Verschillende systemen van dichtbij bekeken

Welk systeem meest gebruikt

60% A.

Atrium / Océan Pleurevac Flutter Valve / Heimlich Electronisch drainagesysteem Getunnelde permanente systemen Andere 15% 1% 23% At riu m / O céa n Flu Pl tter eu V El rev al ec ac ve tro / H ni eiml sc h Get dr un ich ai na neld ges e y..

per .

ma nen te ...

Veiligheidswaterslot Suctioncontrol Waterslot Collector

Dry suction control

Verschillende systemen van dichtbij bekeken

Heimlich Valve

Unidirectionele klep Mebraan die open en dicht kan klappen

Verschillende systemen van dichtbij bekeken

©Medela

Het hart van het thoraxdrainagesysteem

• Geïntegreerde vacuümbron • Oplaadbare lithium-ionen accu • Compact design • Lichtgewicht • Geluidsarm

Technische gegevens

• Laag vacuüm: -100 cm H2O • Lage flow: 5 L/min • Gewicht: 1 kg • Veiligheidsklasse: IP33 • Looptijd accu: min. 4 uur

©Medela 86

Product

Overloopbeveiliging /bacteriefilter Veiligheidskamer Opvangkamer Gradatie

Product Slangenset

Materiaal: PVC (van medische kwaliteit) Lengte: 1.5 m / ø 5 mm

Slangenset enkel

©Medela Klem Afvoerslang Meetslang Connectie naar pomp Connectie naar opvangpot Enkele patiëntverbinding Overloopbeveiliging

Functies Iedere 5 minuten wordt er een kleine hoeveelheid lucht door beide slangen geblazen

©Medela

Functies De druk wordt dicht bij de patiënt gemeten en wordt constant gehouden.

©Medela

Functie Een terugslagklep zorgt voor de waterslotfunctie

©Medela

Thopaz thoraxdrainagesysteem = in essentie een 3-flessen systeem Waterslot Collector Suction control

Verschillende systemen van dichtbij bekeken

Getunnelde ‘permanente’ drainagesystemen PleurX® catheter

(Cardinal Health, McGaw Park, IL)

Aspira® catheter

(Bard Access Systems, Salt Lake City, UT)

FAQ

Welke diameter van thoraxdrain te gebruiken? Kunnen alle thoraxdrains worden afgeklemd? Wanneer worden thoraxdrains afgeklemd? Mag een patiënt met een thoraxdrain bewegen? Welke suctie wordt nagestreefd? Hoe lang moet een drain ter plaatse blijven? Bestaan er alternatieven voor thoraxdrain? © 2010 Universitair Ziekenhuis Gent

slides - BVPV SBIP

Transcript slides - BVPV SBIP

Thoracic Drainage

Pleural Procedures

Thoracocentesis

Chest drain insertion

Interactivity

I will return my controller

Yes No

I speak

French Dutch Other

Chest Drain Insertion

Goal

I work at

I ‘m

Thoracic drainage :

Agenda

Agenda

Pleural anatomy and pathofysiology

Pleural anatomy and pathofysiology

Pleural anatomy and pathofysiology

Pleural anatomy and pathofysiology

Pleural anatomy and pathofysiology

Pleural anatomy and pathofysiology

Pleural anatomy and pathofysiology

Pleural anatomy and pathofysiology

Pleural anatomy and pathofysiology

+/- 70

Pleural anatomy and pathofysiology

Agenda

Thoracic Drainage

Pre – Procedure Preparation

Pre – Procedure Preparation

Pre – Procedure Preparation

Pre – Procedure Preparation

Indications

Complications

Equipment

Equipment : small bore drain - seldinger

Equipment : large bore drains

Site of insertion

Site of insertion (1) : triangle of safety

Site of insertion (2) : 2

IC - midclavicular

Site of insertion

Site of insertion

Analgesia, sedation, local anaesthesia

Inserting technique

Inserting technique : Small bore

Inserting technique : Large Bore

Inserting technique : Large Bore

Insertion technique : sutures and securing

Main concern – dressing :

Chest drain management

Chest drain management

Under water seal – thoracic drainage

Wat gebeurt als in dit systeem aspiratie / suctie stopt?

Wat gebeurt als in 3 flessen systeem suctie stopt ?

Chest drain management

Eens drain geplaatst

Chest drain management

Verschillende systemen van dichtbij bekeken

Welk systeem meest gebruikt

Verschillende systemen van dichtbij bekeken

Verschillende systemen van dichtbij bekeken

Verschillende systemen van dichtbij bekeken

FAQ

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