Pleural drainage ( thoracostomy )

Definition: pleural drainage = maneuver aseptic care ( surgery ) aimed intrapleural introduction of one or more sterile drainage tubing , connected to a suction evacuation for content pleural disease .

   indications:
Evacuation of a spontaneous pneumothorax / accidental / significant iatrogenic
Evacuation of spontaneous hemothorax / accidental / iatrogenic
Evacuation of purulent pleural effusion pleural empyema set { )
  Contraindications :
Uncertainty medical diagnosis
 responsibility:
  The maneuver will be carried out under aseptic correct , the doctor ( surgeon , pulmonologist , ATI -st ) , with care
  Headquarters toracostomiei :
   It depends on the nature of pleural effusion to be evacuated from the pleural cavity sea :
– Pneumothorax – II intercostal space . the line medioclaviculară
– Water / hemothorax – fourth or fifth intercostal space , mid- axillary line
– Pleural empyema – adequate space means collection
  For collections accumulated above the symphysis pleura toracostomiei election headquarters will be made by the physician after sighting radiological ± encysted pleural ultrasound
Materials needed:
Table sterile instruments
sterile fields
sterile gloves
Porttampon , wipes , disinfectant (alcohol iodine , betadine ) anesthetic ( 1% lidocaine 20 ml )
10-20 ml sterile syringes and needles for intramuscular two Kocher forceps fine scalpel blade
Sterile packs , sterile dressings , adhesive
sterile scissors
Needle and thread portac thread / nylon no. 8 sterile
 Pleural drainage tubes (type MONALDI or Nelaton , no. 14-20 )
 Jar sterile gradually with saline / sterile water and sterile connector for attaching the drain pleural drainage jar
Tubes for any laboratory samples .

patient Preparation
 Informing the patient about the need for intervention and its performance and patient consent
 Check radiographic (front and profile) and the identification of pleural effusion by clinical examination , with the election office thoracotomy
 Check BP, pulse and laboratory tests ( hemoglobin , hematocrit , blood type , Rh , TS, TC , platelets , fibrinogen )
 Managing premedication 30 min before intervention : Codeine 1-3 HP, atropine 1 mg . SC or i.m. and Diazepam 5-10 mg im. (if no contraindications )
 Preparation and verification tools required for the proper functioning suction drainage system
 Placing the patient in the supine position ( for thoracotomy performed about earlier ) or lateral decubitus on the healthy side ( if approached mid- axillary line )
    
Technical toracostomiei the tube through pleurotomie Minimum :
– Verification of the presence of clinical and radiological pleural effusion
– Careful selection of office toracostomiei
– Proper positioning of the patient
– Thorough sanitizing skin with betadine
– Establish local anesthesia with 1% lidocaine (5 mg / kg ) by infiltrating intercostal space plan awaiting installation plan and the effect of anesthesia (minimum 3 minutes)
– Placing the sterile field operators
– Skin incision with a scalpel , parallel to the top edge of the coast that separates lower fixed space thoracostomy on a 1-2 cm length represented
– Dissociation with Pean forceps inserted perpendicular to the thoracic soft Plans ( intercostal muscles ) to the parietal pleura
– Verification digital freedom produced pleural cavity through the opening instrumental
– Introduction thoracostomy tube with a curved forceps with atraumatic advancement of higher drain before, up to 15 cm
– Clamping the drainage tube with a Kocher clamp
– Fixing the skin of the drainage tube by sewing with thread or nylon
– Connection pleural drainage tube suction system
– Depensarea pleural drainage tube
– Check the drain intraplurale radiological position and expansionării lungs ( x-ray front and profile)

Postoperative surveillance of the patient :
 Placing the patient in antalgic position (high on three pillows at 45 ° )
 Placing drainage jar least 50 cm below the thoracostomy
 Checking the drainage tube suction jars ( 2 inches below the sterile liquid from the jar )
 Checking sistemului_de etanşietăţii and drainage
 Check permeability tubes
 Lack cudurilor drainage tube
 observation appearance and amount drained
 clamping drain to drain the jar fiecare_evacuare content
 patient handling and movement to be made only after clamping drain .

SUPPRESSION drain pleural
 Suppression drain will be at 24 hours after air has not disposed or when the amount of fluid drained decreased to < 50 ml/24 hours
 If pneumothorax drain maintenance lasts seven days , aimed Pleurodeza direct irritant effect on the drain and drain instillation of 1-2 ml of sterile irritant solutions 3-4 days
 Before suppression drain , it will be plucked 24 hours, checking after 24 hours to pluck reexpansionării lung and absence of waste collections
 Suppression pleural drain will be made by the physician
 Placing the patient in the lateral decubitus or supine healthy aseptic removal of the dressing , iodization skin around the drainage tube
 Cutting the wires that secure the drain to the skin with a sterile scissors
 tangent tube pinching the skin with forceps Kocher
 The patient will breathe with closed glottis
 Attach skin on pleurotomiei between index and thumb
 They go first centimeters of the drain slowly , then rapidly
 Bird sterile wound dressing of thoracotomy and fixing

Complications during pleural drainage :
> Complications any puneţii pleural
> Complications specific pleural drainage :
> Ex vacuo pulmonary edema
> Malposition subpleurală to drain
> Local pain by injuring an intercostal nerve
> Subcutaneous emphysema
> Infection pleural fluid from the outside
> Suppuration in the line drain
> Filling drain
> The output drain
> Bleeding outside on drainage (flow > 100 ml / h requires surgical haemostasis )

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