Adult Medical Emergency Handbook - Scottish Intensive Care Society

4. Procedure for conventional (Argyle) drain
• Prepare the water seal bottle with sterile water.
• Infiltrate the skin down to parietal pleura with 1% lidocaine 10-
20ml, using a blue then subsequently a green needle aspirating
intermittently (look for air or fluid in syringe to confirm that the
pleural space has been entered). Maximum safe dose of lidocaine
is 200mg = 20ml of 1% in total.
• A small transverse incision into skin and subcutaneous fat is made
over the rib below the intercostal space selected for insertion of
the tube.
• Two 2/0 silk stitches should be placed across the incision with the
stitch ends left loose to close the wound after drain removal.
• Using blunt dissection (spreading forceps within the incision), form
a track for the tube through the intercostal muscles to the level of
the pleura. The size of the track is very important. Too small and
excessive force will be needed for drain insertion, too large invites
leakage of air and fluid around the drain. Work over the edge
of the rib below (remember the neurovascular bundle runs in a
groove on the inferior surface of the rib above). Finally, the parietal
pleura is gently penetrated (Fig 1a).
• Insert the clamped chest drainage tube (with the trocar removed)
through the prepared track using forceps to guide it in the desired
direction (Figs 1a / 1b).
• Secure and connect the drain as below.
5. Procedure for Seldinger (Cook) drain insertion
• Check pack contents before starting, and prepare the water seal
bottle with sterile water.
• Infiltrate the skin at the drain site with 2ml 1% lidocaine (orange
needle) waiting 2 mins for adequate effect, then make a skin
incision large enough for the chest drain using the scalpel
provided (Fig 2)
• Attach a green needle to a 10ml syringe filled with 1% lidocaine
and advance it through the tissues in the direction you wish the
tube to go, infiltrating as you go. Stay just above the superior
border of the rib below, and pause periodically to aspirate - air or
fluid, depending on situation, indicates pleural penetration (Fig 3).
Maximum safe dose of lidocaine is 200mg = 20ml of 1% in total.
Remove syringe and needle.
• After waiting at least 2 mins to ensure anaesthesia, change the
green needle for the blunt introducer needle from the Seldinger
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11
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