You are asked to see a 60-year-old male who has been trampled by a bull. He has a history of previous right sided pneumonia complicated by empyaema 10 years ago but is otherwise well
CT shows a significant right sided pneumothorax, but nil other injuries. He currently has a respiratory rate of 30, Saturations 94% 15L NRBM, HR 100, BP 140/90.
(This viva dealt with the insertion and complications of thoracostomy tubes.)
The original college viva had a haemopneumothorax, but I removed the haemo.
The trainee should be directed to discuss large bore ICCs
1. Small bore pleural catheters (8-14 Fr) inserted by Seldinger technique: spontaneous pneumothorax, free flowing (transudative) pleural effusions
2. Middle-size pleural catheters (14-20Fr), using Seldinger technique or blunt dissection: spontaneous pneumothorax, free flowing (transudative) pleural effusions, pyothorax or empyema
3. Large bore pleural catheters (20-24 Fr), using blunt dissection only: haemothorax, acute trauma, open thoracostomy, post cardiothoracic surgery oesophageal or spinal surgery, acute traumatic pneumothorax
The following features need to be arranged before ICC insertion:
Correct draping technique:
The marking of a site using thoracic ultrasound for subsequent remote aspiration or pleural drain insertion is not recommended.
Real time bedside ultrasound imaging, wherever available, should be used to select the appropriate site for pleural drain placement.
Typical site of insertion: mid-axillary line, between 4th and 5th ribs, usually on a line lateral to the nipple.
The "triangle of safety" is bordered by:
Insertion of a pleural drain should be made within the “triangle of safety” with the following potential exceptions:
The surface anatomy related to the liver:
The surface anatomy related to the spleen:
Lignocaine 1 % without adrenaline: maximum dose is 3mg/kg
Lignocaine 1 % with adrenaline (1:100 000): maximum dose is 7mg/kg
This should be a safe demonstration of using the Kelly clamp
A satisfactory drain position is:
A standard large-bore ICC has numbers on the surface which indicate depth of insertion from the most distal side-hole. Allowing a normal chest wall thickness of 3cm, the ICC would therefore need to be inserted to a depth marker of 5 or 6 cm to give a satisfactory margin of error.
Indications for multiple ICCs include:
How does it work?
"What are the safety features of this device?"
"What is the purpose of the underwater seal?"
The following regular observations should be made on every patient after ICC insertion:
The drained volume of fluid is an important parameter for draining pleural fluid:
In addition to drain obs, the appearance of the insertion site needs to be documented during every ICU round.
Additionally, the patient should have a minimum of 4-hourly observations recorded, consisting of:
When removing the chest drain, maintaining a positive intrathoracic pressure is important so that air is not entrained into the chest cavity while a breach in the chest wall exists.
The BTS guidelines had previously recommended removing the chest drain during expiration or Valsalva, but this is no longer the case. Instead, the patient should be asked to take a deep breath in, and to hold it. This maximises positive intrathoracic pressure, which prevents entrainment of air through the chest wall defect. The objective is to ensure that there is no negative intrathoracic pressure during the chest drain removal procedure, and to ensure the lung is closely apposed to the pleura.
Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.