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

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.

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

Assistant: Opens dressing pack on to clean trolley and then when 1^st 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 1^st nurse ready, prepares ends of wound suture ready for tying to seal wound once drain is removed.

1^st nurse: Cleans chest drain insertion site.

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

After checking assistant nurse and child ready, 1^st 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 1^st 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 1^st 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.

1^st 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.