What are the contraindications to chest drain (thoracostomy tube) insertion?

Contraindications to Chest Drain Insertion

Chest drain insertion is contraindicated in patients with uncorrected coagulopathy, when there is no safe insertion site available due to overlying structures, or when the benefits do not outweigh the risks of the procedure. 1

Absolute Contraindications

• Uncorrected coagulopathy - Insertion of a chest drain in patients with bleeding disorders significantly increases the risk of hemorrhagic complications 2
• No safe insertion site - When vital structures (e.g., liver, spleen, heart) are directly beneath the potential insertion site 1
• Lung adhered to chest wall at the insertion site - Risk of parenchymal injury
• Mechanical small bowel obstruction (for abdominal procedures that might be confused with thoracostomy) 3

Relative Contraindications

• Anticoagulant therapy - Increased risk of bleeding complications; consider reversal before procedure when possible
• Severe pulmonary bullae - Risk of creating a large air leak
• Previous pleurodesis on the same side - Difficult insertion due to adhesions
• Positive pressure ventilation with high PEEP - Increased risk of tension pneumothorax during insertion
• Hemodynamic instability - May worsen with procedure; requires stabilization first 3
• Respiratory instability - May require additional support during the procedure 3

Special Considerations

Anatomical Considerations

• Avoid posterior insertion sites - Intercostal vessels run under the ribs posteriorly, increasing risk of vascular injury 3
• Avoid areas with overlying structures such as:
  • Large midline wounds
  • Abdominal mesh
  • Ostomies
  • Areas with surgical emphysema 3

Patient-Specific Factors

• Morbid obesity - Makes identification of landmarks difficult and increases technical complexity 3
• Severe ascites - May impair wound healing and proper tube function; consider drainage of ascitic fluid first 3
• Ventriculoperitoneal shunts - Increased risk of infectious complications; consider prophylactic antibiotics 3
• Peritoneal dialysis - Consider converting to hemodialysis for 6 weeks if possible to reduce peritonitis risk 3

Risk Mitigation Strategies

1. Use proper technique:

   • Never use substantial force during insertion
   • Never use trocars for insertion (high risk of damage to intrathoracic structures) 3
   • Use Seldinger technique for small-bore drains when appropriate 3
   • Employ strict aseptic technique to prevent infection 3

2. Select appropriate tube size:

   • Small tubes (10-14F) are generally adequate for pneumothoraces
   • Larger tubes may be needed for hemothorax or large air leaks 3, 1

3. Proper positioning:

   • Position in the "safe triangle" (anterior to mid-axillary line, above level of nipple)
   • Avoid insertion too low (risk of diaphragm/abdominal injury) 1

4. Post-procedure management:

   • Obtain chest radiograph after insertion to confirm position
   • Connect to underwater seal drainage system immediately
   • Never clamp a bubbling chest tube (risk of tension pneumothorax) 3, 1

Complications to Be Aware Of

• Immediate complications: Cardiac arrhythmia (23-25%), arterial puncture (0-15%), hemothorax (0.1-11%), pneumothorax (1-4%), air embolism (rare) 3
• Delayed complications: Infection (1-6%), tube blockage, tube displacement, subcutaneous emphysema 3, 2
• Catastrophic complications: Injury to heart, great vessels, liver, or spleen 4

By carefully assessing for contraindications and using proper technique, the risk of these complications can be minimized, improving patient outcomes when chest drain insertion is necessary.