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Pleural Procedures and Thoracic Ultrasound: British Thorax: First Published As 10.1136/Thx.2010.137026 on 9 August 2010

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Pleural Procedures and Thoracic Ultrasound: British Thorax: First Published As 10.1136/Thx.2010.137026 on 9 August 2010 BTS guidelines Pleural procedures and thoracic ultrasound: British Thorax: first published as 10.1136/thx.2010.137026 on 9 August 2010. Downloaded from Thoracic Society pleural disease guideline 2010 Tom Havelock,1 Richard Teoh,2 Diane Laws,3 Fergus Gleeson,4 on behalf of the BTS Pleural Disease Guideline Group < Supplementary appendices BACKGROUND curriculum for core medical training and trainees 1-4 are published online only. In hospital practice, pleural aspiration (thor- should be expected to describe the procedure and To view these files please visit acocentesis) and chest drain insertion may be complications in an examination. The trainee should the journal online (http://thorax. bmj.com). required in many different clinical settings for ensure each procedure is documented in their log a variety of indications. Doctors in most specialities book and signed by the trainer. A Directly Observed 1Wellcome Trust Clinical Research Facility, Southampton will be exposed to patients requiring pleural Practice (DOP) assessment should be completed in General Hospital, Southampton, drainage and need to be aware of safe techniques. support of this. UK There have been many reports of the dangers of Studies of training involving didactic lectures, 2Department of Respiratory large-bore chest drains and it had been anticipated manikin practice and following protocols, including Medicine, Castle Hill Hospital, that, with the previous guidelines, better training use of sedation and anaesthesia, have shown the Cottingham, East Yorkshire, UK 3Department of Thoracic and the advent of small-bore Seldinger technique risk of complications and patient pain and anxiety 4 Medicine, Royal Bournemouth chest drains, there would have been an improve- can be reduced and trainee knowledge and confi- Hospital, Bournemouth, UK ment. Unfortunately the descriptions of serious dence in the procedures may be increased.5 4 Radiology Department, complications continue, and in 2008 the National The use of simulators has been compared with Churchill Hospital, Oxford, UK Patient Safety Agency (NPSA) issued a report the use of animal models for blunt dissection as 1 Correspondence to making recommendations for safer practice. These part of ATLS training. Forty-one trainees and 21 Dr Tom Havelock, Wellcome updated guidelines take into consideration the experts were asked to evaluate a simulator Trust Clinical Research Facility, recommendations from this report and describe the compared with an animal model and they were Southampton General Hospital, technique of pleural aspiration and Seldinger chest found to be equivalent in most areas apart from Southampton SO16 6YD, UK; [email protected] drain insertion and ultrasound guidance. Much of anatomical landmarks where the simulator was this guideline consists of descriptions of how to do superior and the blunt dissection where the animal Received 12 February 2010 these procedures but, where possible, advice is model was superior.6 Accepted 4 March 2010 given when evidence is available. Training for thoracic ultrasound should follow the principles set out by the Royal College of http://thorax.bmj.com/ TRAINING Radiologists and is described in greater detail later < All doctors expected to be able to insert in this document. a chest drain should be trained using These guidelines will aid the training of junior a combination of didactic lecture, simulated doctors in these procedures and should be readily practice and supervised practice until available for consultation by all doctors likely to be considered competent. (U) required to carry out pleural aspiration or chest Before undertaking an invasive pleural procedure, tube insertion. An algorithm for the insertion of a chest drain is shown in figure 1. all operators should be appropriately trained and on September 29, 2021 by guest. Protected copyright. have been initially supervised by an experienced trainer. Many of the complications described in the PRE-PROCEDURE PREPARATION NPSA report were the result of inadequate training Timing of procedures or supervision. A recent survey of UK NHS Trusts < Pleural procedures should not take place out showed that the majority did not have a formal of hours except in an emergency. (U) training policy for chest drain insertion in 2008.2 Complications of most surgical procedures are Studies of clinical practice have shown that there higher when performed after midnight. Most is a wide variation in the knowledge and skills of pleural procedures do not need to be performed as doctors inserting chest drains. In a published study3 an emergency and therefore should not be carried where doctors were asked to indicate where they out overnight except in the case of significant would insert a chest drain, 45% indicated they respiratory or cardiovascular compromise. It may would insert the drain outside of the safety be considered in certain circumstances that pleural triangle, with the majority of incorrect answers aspiration is safer than a chest drain. being too low. Knowledge of the correct position was higher in the group with cardiothoracic surgery Aseptic technique experience and higher in doctors with competence < Pleural aspirations and chest drains should to insert drains without supervision. be inserted in a clean area using full aseptic Training should include a theoretical component technique. (U) describing the risks and technique, as outlined in this Empyema and wound site infections are significant document, prior to assessed manikin practice and complications of pleural procedures. finally supervised procedure until considered A large area of skin cleansing should be under- competent. In the UK it is currently part of the taken using two applications of alcohol-based skin Thorax 2010;65(Suppl 2):ii61eii76. doi:10.1136/thx.2010.137026 ii61 BTS guidelines Figure 1 Algorithm for the insertion of Insertion of Chest Drain Thorax: first published as 10.1136/thx.2010.137026 on 9 August 2010. Downloaded from a chest drain. Pneumothorax or pleural fluid requiring drainage Does this need to be done YES Insert drain as an emergency? ( eg, tension) NO Consider pleural aspiration to relieve Does the patient have YES Is it outside of normal YES symptoms and delay a drain insertion significant respiratory working hours? until working hours and when appropriate compromise? expertise and or supervision is available NO NO Delay procedure until Requirements for Insertion Prepare patient for chest drainage. working hours. of Chest Drain Written consent Clean area to perform procedure Is the drain required for Insert drain Competent operator or supervisor fluid? NO Nursing staff familiar with drain management YES Equipment Required for chest drain insertion Is the operator Seek senior help experienced? 1% lignocaine NO Alcohol based skin cleanser x2 coats YES Sterile drapes, gown, gloves Needles, syringes, gauze swabs Insert drain. Ultrasound guidance Scalpel, suture (0 or 1-0 silk) strongly recommended Chest tube kit Closed system drain (including water) and tubing Dressing Clamp disinfectant (or other if recommended by the local infection Preparation and consent control team), allowing it to dry in between applications. The Before performing a pleural aspiration, operators should ensure procedure should be carried out in a clean area appropriate for documented consent is obtained and that they are either such procedures. competent or supervised to do the pleural aspiration. They should be aware of the indication for the procedure, whether it is http://thorax.bmj.com/ Clotting disorders and anticoagulation diagnostic or therapeutic and have all equipment ready. < Non-urgent pleural aspirations and chest drain inser- The consent procedure should encompass the indications for tions should be avoided in anticoagulated patients until the procedure, alternatives to the procedure and the common international normalised ratio (INR) <1.5. (C) and serious complications. Patients known to be receiving anticoagulants or in whom there is a suspected coagulopathy (eg, liver failure) should have their Complications prothrombin time (PT) or international normalised ratio (INR) < The commonest complications from pleural aspiration measured prior to a non-urgent pleural procedure. In the case of are pneumothorax, procedure failure, pain and haemor- on September 29, 2021 by guest. Protected copyright. a tension pneumothorax, it may be necessary to insert a drain rhage. The most serious complication is visceral injury. 7 first before correcting an abnormal INR. McVay et al retro- These complications should be included in any consent spectively reviewed 608 cases undergoing paracentesis or pleural process. (U) aspiration and found that mild coagulopathy, defined as an INR A number of factors have been reported to increase the 9 <1.5 or platelet counts 50e99 10 /l, did not adversely affect the frequency of complications following pleural aspiration. The risk of bleeding with a fall in haemoglobin of 2 g/dl occurring in broadest agreement across the studies examined was that only 3.1% and 0.2% requiring transfusion. If a patient has abnormal coagulation and requires an invasive pleural procedure, the advice of the local haematologist should be sought regarding the correct action needed to normalise the Box 1 Indications for pleural aspiration clotting. Pneumothorax* < PLEURAL ASPIRATION (THORACOCENTESIS) Spontaneous primary pneumothorax (any size) < Pleural aspiration describes a procedure whereby pleural fluid or Small secondary spontaneous pneumothorax in patients
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