Chest Tube Insertion

  1. [FONT=Verdana, arial, serif][COLOR=#000000]I'm currently in a new job and saw a chest tube inserted in the ED. All that was used for this patient was Ativan &a Lidocaine (pre-procedure). About halfway through this patient was in excruciating pain so a nurse pushed for an order and was able to get 2 mg of morphine.

    so my question is... what is the norm medication-wise for chest tube insertions at your facility? Another place I was at used fentanyl and propofol which seemed much more appropriate. Especially after hearing this patient scream in excruciating pain tonight .[/COLOR]
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  2. 10 Comments

  3. by   Pixie.RN
    Depends on the situation. In trauma we can usually get the patient some meds prior to insertion (I think we did some Versed and fentanyl with the last one if memory serves), but if a patient is hemodynamically unstable, then it varies. Sometimes the chest tube is lifesaving, like with a tension pneumo or if they have a big hemothorax and are bleeding out into the chest and need autotransfusion. In those cases, time is a factor.
  4. by   BeeU_RN
    Thanks for your input! This was definitely a very stable patient who presented to our ED with chest congestion which ended up being a pneumo. There was definitely time to get some meds on board.
  5. by   KindaBack
    I've seen it run the gamut from conscious sedation to nothing but a local. Generally, for a patient such as yours, fentanyl titrated to effect, along with the local.

    No meds, or even just 2 of MS, seems positively barbaric in a stable patient.
  6. by   AJJKRN
    Yep, my place would have done the moderate sedation route with some versed and some fentanyl. Our facility requires all ED, ICU, and float RN's to be competent (aside from all the other RN's that do moderate sedation as their mainstay).
  7. by   BedsideNurse
    In ICU we usually give Fentanyl and Versed + local and that seems to do the trick just fine....Years ago I had a tension pneumo and they placed a chest tube with just local. For me it wasn't painful; basically just tolerable pressure (vs. the *completely* intolerable chest pressure of a tension pneumo).
  8. by   AnnieOaklyRN
    Hi,

    as others have said it depends on the physician and their comfort level with sedation. I find when the general surgeons do it, they often do not sedate well enough. Our ED docs which often times use Fentanyl and Versed or just order Propofol, which my opinion is the best option.

    Chest tubes are VERY painful and I think it's kind of inhumane when they do not sedate well enough, unless there are good reasons not to like BP etc.

    Annie
  9. by   Pixie.RN
    Have any of you seen the UreSil Thora-Vent used for simple pneumos? They are awesome! Much less traumatic for the patient, too.
  10. by   CCU BSN RN
    I have literally seen a PA place a chest tube on a stable patient with nothing but a local. He had a huge effusion, but stable on NRB and could've waited for IR to be called in. But alas, no. And I don't mean a little heimlich or a pigtail, I mean a 32 french pleural tube involving some pretty gnarly blunt dissection. This was on a tele floor where we weren't moderate sedation trained, and it was a surgical service that wouldn't have ordered anything anyway.

    It was scarring, and one of those defining moments as a new grad where you realize, 4 years later, that you should've done more than hold the patient's hand and distract him. That you should've demanded SOMETHING.
  11. by   Lev <3
    At my old ED, some morphine + local was standard. At my new ED, have not seen a chest tube a month in. This is what I signed up for I guess...Sighs...
  12. by   akulahawkRN
    Lidocaine works pretty well but it has to be well infiltrated into the tissues for it to work like it should. This means using a LOT of it. A couple mL of 1% or 2% isn't going to do the trick. I've had a local done for a procedure (cyst removal) and that went fine, the PA used around 5 mL total of 1% Lidocaine. That being said, tissues below the dermis weren't infiltrated. Most of the procedure was quite pain-free. Those few places that the Lido wasn't infiltrated, I experienced quite a bit of pain. I suspect providers are probably concerned about Lidocaine toxicity OR they're only used to doing a "topical" local so the deeper tissues aren't well infiltrated, so while the incision may be painless, the blunt dissection through the pleural space is horribly painful.

    The only time I would consider it OK to place a chest tube in an non-anesthetized patient is when the patient is so unstable that waiting for the lido to take effect could be lethal.

    For the record, no I don't place them in my practice as a Paramedic or an RN. I'm familiar with the procedure, but I am only authorized to do needle thoracostomies in my Paramedic Practice.

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