Advanced practice organ procurement techniques: insertion of thoracic catheters
Powner, David J
Advanced practice coordinators who perform procedures that may be associated with complications must be proficient at treating those untoward events. This discussion reviews the diagnosis of a pneumothorax as a complication of insertion of a central venous catheter and mechanical ventilation. The method for inserting the Wayne Pneumothorax Set thoracic catheter is presented. This and similar commercially available catheters may also be used to evacuate a pleural effusion or nonclotted blood from the thorax for diagnostic purposes or when treating hypoxemia. It is essential for organ procurement organizations to provide appropriate training and quality assurance programs to ensure safe practice. (Progress in Transplantation. 2007;17:23-28)
Insertion of a central venous catheter, the occurrence of barotrauma during mechanical ventilation, or the delayed manifestation of lung injury after chest trauma may produce a pneumothorax.1 In addition, under unusual circumstances during donor care, removal of a pleural effusion or hemothorax may be indicated during treatment of hypoxemia or for diagnostic evaluation.
This discussion reviews the technique for percutaneous insertion of the thoracic catheter from the Wayne Pneumothorax Set (Cook Inc, Bloomington, Ind). This and similar catheters are effective for removal of gas or thin fluids from the pleural space.” A large hemothorax, especially when blood clots are present, and thicker fluids, such as present when a parapneumonic effusion becomes infected (empyema), are best evacuated by a larger caliber thoracostomy tube. Physician assistance is usually required for placement of such a “chest” tube, and those insertion methods are not discussed here.6
Appropriate didactic instruction, clinical practice, and in-hospital resources must, of course, be provided by the organ procurement organization (OPO) to ensure safe practices by procurement coordinators. Because procurement clinicians will only rarely need to insert a thoracic catheter, options for initial training and ongoing skill assessment may include mannequins, simulators, nondonor cadavers, or donors in the operating room after organ removal.
Thoracostomy tube drainage units normally used with larger chest tubes are also attached to the Wayne catheter. Use and monitoring of these units are discussed elsewhere.7
A pneumothorax may occur during mechanical ventilation, after penetrating or nonpenetrating injury of the chest/lung, or after subclavian/internal jugular venipuncture. Its signs, symptoms, and effects on donor ventilation, oxygenation, or cardiovascular function may be manifested immediately or delayed. The consequences of a pneumothorax may be minimal or catastrophic depending on its size and whether increased intrathoracic pressure (tension) develops. Clinically important consequences usually include hypoxemia and potentially hypercarbia. A tension pneumothorax may reduce venous blood return (preload) to the heart or shift mediastinal structures to further worsen hypotension or produce cardiac arrest. The size (volume) of a pneumothorax can only be estimated from a chest radiograph and is better quantified via computed tomography (CT) of the chest.8
A “simple” nontension pneumothorax is illustrated in Figure 1. The volume of the right lung is reduced, which may affect oxygenation or ventilation, but no signs of increased intrathoracic pressure are noted (the apparent “shift” of the mediastinum to the left is most likely due to chest rotation). No cardiovascular compromise occurred in this patient. The vertical edge of the right lung is easily seen, whereas beyond the lung margin, the normal pulmonary “lung markings” have been lost and only the black “air density”9 of gas within the pneumothorax can be seen.
Pneumothoracies can be located in any part of the lung; for example, apical, lateral, or subpulmonic (under the lung, but above the diaphragm, see Figure 5).10 An anterior pneumothorax may be especially difficult to identify. Because donors are usually supine, the pneumothorax may become localized over the anterior (front) part of the thorax. Because the chest radiograph produces a 2-dimensional image of the 3-dimensional thorax, the air accumulation may be difficult to appreciate because normal lung markings or other thoracic structures posterior to (“behind”) the pneumothorax remain visible. Figure 2 illustrates an anterior pneumothorax. This and other less common manifestations of a pneumothorax may become more apparent on a lateral decubitus chest radiograph. As the donor is placed on his or her side, gas within the pleural space will move into a nondependent gravitational position along the upper lateral rib cage. A decubitus radiograph is always ordered as the “down side,” but when a pneumothorax is being diagnosed, the hemithorax of interest is always the “up side.” For example, if an anterior pneumothorax is suspected in the left hemithorax as in Figure 2, a “right lateral decubitus” chest radiograph should be ordered. The upper hemithorax (the donor’s left) on that radiograph is then inspected for the characteristic lung edge and loss of peripheral lung markings, as seen in Figure 3.
A radiographic “deep sulcus sign” may also be a subtle indicator of a pneumothorax (Figure 4). Extraalveolar gas may accumulate within the costophrenic angle above the lateral edge of the hemidiaphragm and adjacent to the ribs. The gas pushes the diaphragm medially and deepens the space between the rib cage and lateral hemidiaphragm (the costophrenic angle or sulcus). Because other pulmonary changes may also cause this radiographic appearance, a decubitus radiograph is indicated to clearly identify a pneumothorax; that also would appear as in Figure 3.
A “tension” pneumothorax is illustrated in Figure 5 and often produces a cardiopulmonary emergency. The causes of “tension” and “simple” pneuomothoraces are the same, but it is postulated that a “one-way” valve effect may occur at the site of lung rupture, whereby gas leaving the lung cannot reenter the airway. Gas thereby accumulating in the pleural space between the lung and thoracic wall develops increased intrathoracic pressure. Radiographie signs of a tension pneumothorax include extensive lung collapse, shift of mediastinal structures toward/into the opposite hemithorax, and downward compression (flattening) of the diaphragm, often into a concave configuration. Decreased venous blood return into the thorax because of the increased intrathoracic pressure may produce severe hypotension. Physical signs of absent breath sounds within the affected hemithorax, increased inspiratory airway pressure during mechanical ventilation, elevated and then lower central venous pressure, and deviation of the trachea away from the pneuomothorax may be present to various degrees.
Emergent treatment of a tension pneumothorax may be required even before radiographie confirmation if extreme hypotension is present. Needle decompression of the hemithorax may be required/justified in the appropriate clinical circumstances, physical findings (eg, absent breath sounds and hypotension) and changes in ventilator parameters are present. This procedure requires percutaneous insertion of a large-bore (18-, 16-, or 14-gauge) needle or needle/angiocatheter into the thoracic space to relieve high intrathoracic pressure. Although clinicians are often taught that the needle should enter the chest anteriorly in the second intercostal (between ribs) space (Figure 6), insertion through any intercostal space in the upper thorax will most likely be effective when the intrathoracic pressure is high. Often the thoracic anatomy (eg, subcutaneous fat, breast size/configuration, muscle mass) will dictate a more appropriate place for needle/catheter placement. Insertion in the upper thorax at or above the usual “nipple line” (fourth intercostal space; Figure 6) is preferred so as to avoid entry into the abdominal cavity. Percutaneous insertion is always above a rib so as not to injure the intercostal artery, nerve, and/or vein under each rib. Elevating the supine donor’s arm above his or her head (Figure 6 ) will widen the intercostal spaces in the axilla and facilitate placement of the needle or catheter. Anesthesia is not required.
For emergent decompression of a tension pneumothorax, the needle or needle/angiocatheter assembly is inserted through the skin, subcutaneous tissue, muscle, and pleura perpendicularly to and above the rib. Often a “gush” of gas can be heard as the hemithorax is decompressed. The angiocatheter, if used, should quickly be passed over the needle once entry into the pleural space is made and should be held firmly in place. Once either the needle or angiocatheter is in position, it must be held firmly and cannot be removed until a thoracostomy tube or thoracic catheter is inserted. Premature removal of the needle or angiocatheter may allow reaccumulation of the pneumothorax.
Figure 7 illustrates the Wayne catheter properly positioned following the insertion technique described in the Table. The patient shown in Figure 7 is the same as in Figure 1. Note the complete evacuation of the pneumothorax and reexpansion of the lung.
Whether a large pleural effusion contributes significantly to hypoxemia is controversial.11,12 “Compressive atelectasis” of regional lung units by adjacent fluid may contribute to the “shunt effect” of ventilation/ perfusion mismatching to worsen oxygenation.13 Removal of an effusion, however, must be supplemented by other treatment to reexpand those lung units. Occasionally, it may also be desirable to remove or sample an effusion for diagnostic purposes, particularly to determine if bacteria or white blood cells are present or if the fluid is blood.14 The volume of pleural fluid may be estimated from a decubitus chest radiograph (this time with the side of the effusion placed down),9 ultrasound of the involved hemithorax with the donor in a sitting position,15 or by CT scan. The decision to radiographically evaluate, remove, or sample a pleural effusion should be guided by OPO protocols.
As noted previously, a small thoracic catheter may not be suitable for thick fluids as found during infection in the pleural space (empyema) or for blood. However, these catheters will generally remain patent long enough to evacuate enough fluid/blood for diagnostic purposes, to decide if the lungs or other organs are eligible for donation, or if additional treatment or drainage is needed.
The Wayne thoracic catheter will be used as an example of several similar commercially available catheter sets. Some use a traditional Seldinger needlewire-catheter method for insertion, also available from the Cook company. The Wayne system discussed here, however, uses a catheter-stylet-needle assembly. Short-term placement of a catheter to “aspirate” a pneumothorax in the emergency department has been reported,” but rapid removal of the catheter does not appear to be advantageous during donor care.
The donor is positioned supine or semirecumbent with the arm on the side of the pneumothorax or fluid positioned away from the torso as shown in Figure 6. Entry at the fourth intercostal space (approximate nipple line), as shown, is satisfactory to evacuate a pneumothroax. Because gravity distributes effusion or blood posteriorly in the supine donor or toward the base of the hemithorax if the donor is semirecumbent or upright, catheter entry through a lower intercostal space may be considered when drainage of fluid is the goal. However, a lower interspace may increase the possibility of entry into the abdominal cavity and/or injury of the liver or spleen. Placement above the selected rib within the anterior-middle part of the axilla (between the anterior and middle axillary lines) is satisfactory for removal of both gas and fluid.
Insertion of the thoracic catheter is an aseptic procedure whenever possible. The insertion site is prepped with the antiseptic solution recommended by the OPO’s or the hospital’s protocol. The coordinator should wear a hat and mask and sterile gloves and gown. A wide aseptic field is used to ensure sterility of the catheter assembly. Topical anesthesia is not necessary. Insertion proceeds as described in the Table.
After placement of the thoracic catheter, monitoring the amount of fluid or blood drained from the thorax is routine. Under rare circumstances, continuing loss of a large amount of blood may produce anemia or cardiovascular changes of importance and require a larger thoracostomy tube for full evacuation or physician assistance for evaluation. Similarly, continuing loss of gas from the lung may reduce the delivered tidal volume to other areas of the lung and may interfere with oxygenation or ventilation. These effects of such a “bronchopleural fistula” may also be significant and require consultation with a physician and additional therapy.17
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17. Powner DJ, Grenvik A. Ventilatory management of life-threatening bronchopleural fistulae. Crit Care Med. 1981; 9:54-58.
David J. Powner, MD
Departments of Neurosurgery and
Internal Medicine, University of Texas
Health Science Center at Houston
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