Quick Reference Guide
Quick Reference Guide
Completion requirements
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Quick Reference Guide
Chest drain essentials on one page
The numbers, landmarks and red flags to know before the day.
| Topic | Key facts | Source |
|---|---|---|
| Triangle of safety | Lateral border of pectoralis major; anterior border of latissimus dorsi; fifth intercostal space; apex below the axilla | BTS 2023 |
| Needle path | Just above the upper border of the rib below. Avoid medial and posterior sites | BTS 2023 |
| Ultrasound | By the operator, at the bedside, in the procedure position, immediately before the procedure. No safe pocket, no drain | BTS 2023 |
| Lidocaine | Maximum 3 mg/kg (plain). 1% = 10 mg/mL. Follow your trust's total cap (often 200 mg) | BTS 2023; local policy |
| Checklist | LocSSIP: sign in, time out, sign out. Count the wire out intact | NatSSIPs 2 (2023) |
| Securing | Do not use a purse-string suture | BTS |
| Controlled drainage | No more than 1,500 mL in the first hour (1,000 mL may suit smaller adults), close the tap for 1 hour, then up to 500 mL per hour | ARNS 2020; NatPSA 2020 |
| Observations | Continuous direct observation for 15 minutes, every 15 minutes for the first hour, hourly for 3 hours, then 4-hourly | ARNS 2020 |
| Never | Never clamp a bubbling drain. Never let go of the wire. Never force a dilator | BTS; ARNS |
| After insertion | Chest X-ray, documentation, clear written and verbal handover | ARNS 2020 |
Red flags during drainage: stop and escalate
- Chest pain or discomfort
- Persistent cough, worsening breathlessness or vagal symptoms
- A deteriorating NEWS2 score
- 1,500 mL removed
Local anaesthetic toxicity
Stop injecting, call for help and the lipid rescue pack, 100% oxygen, IV access, 20% lipid emulsion 1.5 mL/kg over 2–3 minutes then 15 mL/kg/h (Association of Anaesthetists QRH 3-10).
Sources
- Asciak R, et al. British Thoracic Society Clinical Statement on pleural procedures. Thorax 2023;78(Suppl 3). doi:10.1136/thorax-2022-219371
- Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society Guideline for pleural disease. Thorax 2023;78(Suppl 3). doi:10.1136/thorax-2022-219784
- Association of Respiratory Nurses (ARNS). Good Practice Standards for Controlled Removal of Fluid from Chest Drains (Adults) (2020)
- NHS England. National Patient Safety Alert NatPSA/2020/008/NHSPS: Deterioration due to rapid offload of pleural effusion fluid from chest drains (1 December 2020)
- Centre for Perioperative Care. National Safety Standards for Invasive Procedures 2 (NatSSIPs 2), 2023. See NHS England: NatSSIPs
- Association of Anaesthetists. Quick Reference Handbook 3-10: Local anaesthetic toxicity, version 2 (2023)
These notes support a simulation course. They do not replace your trust's pleural procedure policy, the manufacturer's instructions for your kit, or supervised workplace training and sign-off.
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