Reinsertion of Chest Drain Through Same Tract
Do not reinsert a new chest drain through the same hole or tract after dislodgement—this significantly increases the risk of infection, empyema necessitans, and inadequate drainage positioning. 1, 2
Primary Recommendation
A dislodged chest drain requires removal and insertion of a new drain at a fresh site under sterile technique, ideally with ultrasound or CT guidance to ensure optimal positioning. 1, 3 The existing tract is contaminated and may not provide adequate pleural access, particularly if the original drain was partially extra-pleural or if tissue has begun to seal the tract. 4, 1
Key Clinical Reasoning
Why Not Use the Same Tract?
Infection risk is substantially elevated when reinserting through a previously used tract, as the tract is now colonized with skin flora and potentially contaminated with pleural fluid or pus. 2, 3 Empyema necessitans—where infection extends through the chest wall—has been documented as a complication of chest drain sites, particularly when tracts are manipulated or reused. 2
The original tract may be malpositioned or partially extra-pleural, which could have contributed to drain failure or dislodgement in the first place. 1 Reusing this tract perpetuates poor positioning and risks introducing air into subcutaneous tissues, causing surgical emphysema. 4, 1
Tissue response and tract closure begin immediately after drain removal or dislodgement, making the tract unreliable for adequate pleural access within hours. 5
Proper Management After Dislodgement
Step 1: Assess clinical status immediately 1
- Check for respiratory distress, chest pain, or subcutaneous emphysema
- If the patient has a pneumothorax with ongoing air leak, urgent intervention is required to prevent tension pneumothorax 4
- If managing empyema, assess for fever, sepsis, or clinical deterioration 6
Step 2: Obtain imaging before reinsertion 1, 5
- Ultrasound is highly sensitive (81-88%) for identifying residual fluid collections and septations 7
- Contrast-enhanced CT provides anatomical detail of locules and optimal positioning for new drain placement 7, 5
- Imaging confirms whether drainage is still needed or if the collection has resolved 1
Step 3: Insert new drain at a fresh site 3, 5
- Use ultrasound or CT guidance to identify the optimal insertion point 7, 6, 3
- Employ strict aseptic technique to minimize infection risk 4, 3
- Select appropriate drain size (small-bore 10-14F is adequate for most cases, including empyema) 4, 6
Step 4: Consider whether reinsertion is necessary 1
- If the patient is clinically improving with resolution of fever and symptoms, and imaging shows minimal residual fluid, drain reinsertion may not be required 1
- If significant loculated fluid persists despite previous drainage, consider intrapleural fibrinolytics (urokinase 40,000 units for children ≥10 kg, or streptokinase 250,000 IU for adults) with the new drain 7, 6
Critical Pitfalls to Avoid
- Never attempt to reinsert through the same tract "for convenience"—this compromises sterility and positioning 2, 3
- Do not clamp a bubbling drain if attempting to assess whether reinsertion is needed, as this risks tension pneumothorax 4
- Do not reposition or manipulate a functioning drain solely based on radiographic appearance; if the drain is producing output with respiratory swing and clinical improvement, leave it in place 1
- Avoid delay in surgical consultation if the patient has persistent sepsis at 5-8 days despite drainage, as organized empyema may require VATS or decortication 7, 6
When Surgical Escalation Is Required
Early discussion with thoracic surgery is warranted if: 7, 6
- Persistent sepsis despite chest tube drainage, antibiotics, and fibrinolytics
- Organized empyema with thick pleural peel on imaging
- Multiloculated empyema not responding to medical management
- Bronchopleural fistula with pyopneumothorax