If losses >10 ml/kg/hr in a postoperative patient, notify surgeon immediately.
In the first two hours, losses may be up to 5 ml/kg/hr, thereafter it should be less than 2 ml/kg/hr. If losses exceeds these levels, check ACT, aPTT, PT, fibrinogen, platelets and TEG, and transfuse accordingly.
If significant losses continue, notify surgeons.
Insertion of chest drains:
Preparation and equipment:
1. Chest tube set and tray.
2. Choose appropriate size.
3. CXR before procedure.
4. Identify insertion site via ultrasound (ensure distance from liver, kidneys, spleen or heart).
5. Prepare chest tube insertion site with antiseptic solution and sterile drapes in standard fashion (sterile gown, gloves, head and face mask).
6. Consider local anaesthetic (i.e. lignocaine; remember: 1% = 10mg/ml, maximum lignocaine dose 5 mg/kg without adrenaline).
7. Attach introducer needle to syringe and advance slowly and carefully needle over the superior border of the rib into the pleural space. Fluid or air should be aspirated to verify intrapleural position.
8. When the appropriate drainage site and depth has been identified, de-attach syringe and slowly introduce the J-tip of the guidewire:Â the guidewire should pass through and into the pleural space without any resistance!
9. Remove the needle, but leave wire in situ.
10. While maintaining the wire position, dilate the tract by supplied dilator (hold dilator always at the tip, next to the skin, rotate it carefully to prevent the wire from kinking)
11. Remove dilator, keep the guidewire in situ, advance the chest tube slowly into the pleural space (if any resistance, ensure the guidewire is still in situ, re-dilate skin/pleural opening, if necessary).
12. Remove guidewire, leaving the chest tube in situ.
13. Use sutures or steri-strips to secure the chest tube.
14. Attach 3-way tap and connect the tip of the chest tube via connector to a chest tube (use minimal suction – 10 cmH2O)
15. CXR to confirm position and success!
16. Observe ventilation pressures and FiO2 always before, during and after the procedure.
Removal of chest drains:
Preparation and equipment:
1. Keep patient fastened. Food/formula 6 hours, breast milk 4 hours, clear fluids 2 hours.
2. Continue monitoring: ECG, SpO2, BP.
3. All emergency equipment available.
4. Appropriate analgesia.
| Age | < 6 month | > 6 month |
| Morphine | 20 mcg/kg | |
| Ketamine | 0.5 mg/kg | |
| if dysphoric response with Ketamine, consider midazolam 0.1 mg/kg, can be repeated once |
||
5. Remove drain in aseptic technique during expiration.
6. Repeat CXR 30 mins after drain removal to exclude pneumothorax.
 All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or Android. A list of contributors can be seen here.
