What is the recommended protocol for intercostal drain (ICD) saline irrigation?

Intercostal Drain Saline Irrigation Protocol

Saline irrigation of intercostal drains is not routinely recommended and should be avoided in most clinical scenarios due to potential risks of infection and complications.

General Principles for Intercostal Drain Management

• Sterile technique is essential during insertion and manipulation of any chest drainage system to prevent pleural infection, which occurs in approximately 1-6% of cases 1.
• Intercostal tubes should be inserted at the optimum site suggested by chest ultrasound, with small bore drains preferred whenever possible to minimize patient discomfort 1.
• Small bore drains (8-12 FG) are as effective as larger bore tubes and are associated with better patient comfort and shorter hospital stays 1.

Specific Recommendations Regarding Saline Irrigation

• There is no evidence supporting routine saline irrigation of intercostal drains in the British Thoracic Society guidelines for management of pleural effusions, pneumothorax, or pleural infection 1.
• Manipulation of chest drainage systems, including irrigation, increases the risk of introducing infection and should be minimized 1.
• Blocked chest drains can lead to serious complications including tension pneumothorax, as documented in case reports 2.

Management of Blocked Intercostal Drains

• For non-functioning chest drains, troubleshooting should be performed by experienced personnel, preferably respiratory specialists 1, 2.
• If a chest drain is not functioning properly:
  • Check for kinking, which accounts for approximately 18% of chest drain complications 3.
  • Ensure proper positioning - shallow placement (13% of complications) and subcutaneous insertion (18% of complications) are common errors 3.
  • Verify adequate fixation to prevent dislodgement (7% of complications) 3.

Alternative Approaches for Loculated Collections

• For multiloculated pleural collections resistant to simple drainage, intrapleural fibrinolytic therapy may be considered rather than saline irrigation 1.
• Fibrinolytic agents such as streptokinase (250,000 IU) or urokinase have shown efficacy in breaking down loculations and improving drainage 4, 5.
• When administering intrapleural fibrinolytics:
  • The intercostal tube should be clamped for 1 hour after administration 1.
  • In the absence of excessive fluid drainage (>250 ml/day), the intercostal tube should be removed within 12-72 hours after instillation 1.

Important Precautions

• A bubbling chest tube should never be clamped as this could potentially convert a simple pneumothorax into a life-threatening tension pneumothorax 1.
• If a chest tube must be clamped (e.g., after sclerosant administration), this should be done under the supervision of a respiratory physician or thoracic surgeon, with the patient managed in a specialist ward with experienced nursing staff 1.
• Patients with chest drains requiring complex management (including persistent air leaks exceeding 48 hours) should be referred to a respiratory physician 1.

Pain Management for Intercostal Drains

• For pain management, intrapleural local anesthetic (20-25 ml of 1% lignocaine) can be given as a bolus and at eight-hourly intervals after insertion 1, 6.
• Intercostal nerve blocks provide effective analgesia for chest tube-associated pain when pharmacological management is inadequate 6.

Complications to Monitor

• Monitor for complications including pleural infection, visceral injury (2% of cases), vascular injury, subcutaneous emphysema, and re-expansion pulmonary edema 3.
• Junior doctors have significantly higher complication rates (24%) compared to senior doctors (5%), highlighting the importance of proper training and supervision 3.