TUBE THORACOSTOMY : Procedure, Indications & Complications

Indications

To drain abnormal large-volume air or fluid collections in the pleural space

+ Hemothorax, chylothorax, empyema

  • Pneumothorax, if:
  • Large or progressive
  • Patient is on mechanical ventilation
  • Bronchopleural fistula
  • Tension pneumothorax


+ To facilitate pleurodesis:

  • i.e. obliteration of the pleural space by instilling talc or doxycycline to cause fibrosis and adherence of parietal and visceral pleura
  • Indicated for recurrent pleural effusions (often malignant)

+ For long-term drainage of malignant effusions

Procedure

+ Tube size – varies according to indication; larger tube for more viscous drainage

+ Insertion site- typically 4th or 5th intercostal space in anterior axillary or mid-axillary line

+ Technique:

  • Local anaesthetic
  • -2 em skin incision
  • Kelly clamp for blunt dissection to the pleural space, taking care to pass over the top of the rib to avoid neurovascular bundle
  • Tube is inserted and sutured in place
  • Tube is attached to a pleural drainage system (suction/underwater seal, usually -20 mmH20)
  • Post-insertion CXR to ensure proper tube placement (posterior apex of lung for pneumothorax, base oflung for fluid)

+ Removal:

  • When drainage <100 cc/d, no air leak, and lung is fully expanded
  • Consider clamping tube for 4-6 h then obtain CXR to ensure lung remains expanded
  • Brisk removal after patient expires and holds breath


Complications

Overall complications are rare (1-3%)

Malposition (most common complication), especially by inexperienced operators:

  • Tubes may dissect along the external chest wall, or may be placed below the diaphragm

Bleeding (anticoagulation is a relative contraindication)

Local infection, empyema

Perforation oflung parenchyma

Risk of re-expansion pulmonary edema when large volumes of air or fluid are drawn off quickly (> 1.0-1.5 L)

Understanding of Cricothyroidotomy: Type, Indications & Procedure

Cannula (Needle) Cricothyroidotomy

Indications

  • Cannula (needle) Cricothyroidotomy is a method of minimally invasive access into the airway for the purpose of emergent re-oxygenation.
  • This procedure should only be performed by personnel who have received proper training and have the proper equipment available because this procedure is associated with high complication and failure rates. Clinicians should pursue advanced airway training prior to using this technique.


Contraindications

  • Inability to identify the cricoid-thyroid membrane
  • Transected airway
  • Laryngeal injury
  • Surgical cricothroidotomy is not recommended in patients <12 years of age unless the cricothyroid membrane is clearly identifiable.

Equipment Checklist for Needle Cricothyroidotomy

  • Specialized translaryngeal catheter or 14-gauge IV needle when the patient must be oxygenated but catheters are not available. Standard IV catheters are prone to kinking catheters available from Cook Critical Care, (Bloomington, IN) and VBM (Germany).
  • 10-cc syringe
  • High pressure (20–50 psi) oxygen source with pressure reducing regulator

Procedure

  • Anatomic landmarks: The cricothyroid membrane is one finger-breadth below the thyroid notch. The larynx is immobilized with the left thumb and middle finger. The index finger is then used to identify the thyroid cartilage and the cricothyroid membrane.

Needle Cricothyroidotomy

  • Clean and drape the anterior aspect of neck (if time permits).
  • Palpate the larynx and identify the cricothyroid membrane as described.
  • Stabilize the larynx with the thumb and middle finger. Attach the needle-cannula to a 10-mL syringe (with or without fluid).
  • Puncture the skin and cricothyroid membrane at a 90-degree angle to the plane of the neck while continuously aspirating until air can be aspirated from the larynx.
  • Once air is aspirated, aim the needle-cannula 45 degrees caudad, insert the cannula into the airway, and withdraw the needle.
  • Confirm aspiration of tracheal air.
  • Attach the regulated high-pressure oxygen source and inject oxygen at 20 cm H2O pressure for 1 second. Repeat with an inspiration: expiration ratio of 1:3.
  • Adjust timing and pressure to achieve chest expansion and recoil.

 Large-Bore Cricothyroidotomy (Melker)

Percutaneous Large-Bore Cricothyroidotomy

  • Clean and drape the anterior aspect of the neck.
  • Immobilize the trachea with the thumb and middle finger and feel the cricothyroid membrane with the index finger.
  • Make a vertical incision over the cricothyroid membrane—first through the skin and subcutaneous tissue.
  • Attach the included stainless steel needle to a syringe (with or without fluid) and insert it through the cricothyroid membrane into the trachea at a 90-degree angle to the plane of the neck. Aspiration of air confirms that the needle is in the trachea.
  • Aim the needle 45 degrees caudad.
  • Remove the syringe and pass a guide wire through the needle.
  • Ensure that the wire is directed caudad, then remove the needle.
  • Pass the assembled dilator-airway (included in the kit) over the wire and into the airway.
  • Remove the dilator and inflate the airway cuff (if included).
  • Secure the airway to skin and ventilate with a self-inflating bag or the anesthesia machine circuit.


Complications

  • Bleeding from the cricothyroid artery or anterior thyroid vein
  • Barotrauma or pneumothorax caused by jet ventilation
  • Subcutaneous emphysema caused by high-pressure air forced into the subcutaneous space
  • Injury to the posterior wall of the trachea

Endometrial Biopsy

Endometrial biopsy is an office technique for obtaining tissue samples from the lining of the uterus.

INDICATIONS

Dysfunctional uterine bleeding, postmenopausal bleeding, menorrhagia, infertility (selected cases), endometrial or pelvic infections (e.g., tuberculosis), or other situations in which a tissue diagnosis is indicated. Because it is associated with some discomfort and a small but not insignificant risk of perforation or infections and carries not only the cost of the procedure but also the cost of histologic diagnosis, this procedure is best suited for diagnosis, not screening.

CONTRAINDICATION

Pregnancy, active pelvic inflammatory disease, significant vaginal infection, profuse bleeding, blood dyscrasia. Endometrial biopsy should generally be performed during the first 14 to 16 days of the menstrual cycle to avoid inadvertent disruption of an undiagnosed pregnancy. (Biopsies performed within 10 to 14 days beyond a temperature rise or luteinizing hormone surge will generally not interfere with implantation during that cycle.)

EQUIPMENT

  • Disposable endometrial sampling device (e.g., Accurette, Explora, Gynocheck, Pipelle, Z-Sampler, and others) or reusable curette (Novak or other curette)
  • Sterile single-tooth tenaculum (optional)
  • Sterile uterine sound (optional)
  • Sterile lacrimal duct probe (optional)
  • Skin preparation materials (generally an iodine-based antibacterial solution such as Betadine)
  • Suitable tissue preservation/transportation medium (10% formalin solution or similar)
  • Pelvic examination equipment (examination gloves, lubricant, speculum, light source)

TECHNIQUE

The discomfort of endometrial biopsy may be decreased by premedicating with a single oral dose of a nonsteroidal anti-inflammatory agent given in doses usually used to treat dysmenorrhea. Although this is an office procedure, informed consent is generally considered necessary. The patient is prepared and positioned as for a routine pelvic examination. After the cervix has been visualized, it is disinfected with a topical antiseptic (e.g., Betadine).

When the patient is parous, endometrial sampling often may be accomplished without stabilizing or dilating the cervix; both of these procedures produce mild to moderate discomfort and should be avoided when possible. The sampling device is gently introduced into the uterine cavity and the depth is noted. For suction devices such as the Pipelle or Z-Sampler, the piston is withdrawn (producing a vacuum), and the curette itself is gradually withdrawn by use of a spiral or twisting motion. If an adequate tissue sample is obtained, it should be placed in fixative, completing the procedure. If additional tissue is needed, the piston may be advanced to a point just short of expelling the sample, the device again advanced into the uterine cavity, and the procedure repeated. (If tissue already obtained is to be expelled before attempting a second or subsequent try, care must be taken to avoid contact with the fixative solution or any bacterial contamination.)

Open curettes, such as the Novak, or rigid suction cannula should be gently inserted to the apex of the uterine cavity and then withdrawn in a straight line, using light pressure against the uterine wall. Tissue obtained may be removed from the opening of the curette using the point of a broken (but still sterile) wooden cotton-tipped applicator.

If significant cervical stenosis is encountered (or there is significant patient discomfort) a paracervical block using a few milliliters of 1% lidocaine (or similar) may be appropriate. The use of a lachrymal duct probe may assist in finding the path of the endocervical canal, but its fine size also increases the risk of a “false passage.”

COMPLICATION

Uterine perforation (1 to 2/1000), infection (endometrial, myometrial, pelvic). Vasovagal syncope during the procedure may occur but is generally transient.

Tubal Occlusion Procedure: A Nonsurgical form of Permanent Birth Control

Procedures can be performed either postpartum (during cesarean  section or immediately after vaginal delivery) or interval (remote from a pregnancy). An interval tubal occlusion should be performed in the follicular  phase of the menstrual cycle in order to avoid the time of ovulation and possible pregnancy.

LAPAROSCOPIC TUBAL OCCLUSION

Eighty to ninety percent of tubal occlusions are done laparoscopically. All methods occlude the fallopian tubes bilaterally.

ELECTROCAUTERY

  • This involves the cauterization of a 3-cm zone of the isthmus. It is the most popular method (very effective but most difficult to reverse).


CLIPPING

  • The Hulka-Clemens clip (also Filshie clip), similar to a staple, is applied at a 90-degree angle on the isthmus. It is the most easily reversed method but also has the highest failure rate.

BANDING

    • A length of isthmus is drawn up into the end of the trocar, and a silicone band, or Fallope ring, is placed around the base of the drawn-up portion of fallopian tube.
    •  Small polyester/nickel/titanium/steel coil implant is placed in the proximal  fallopian tube.

  •  Minimally invasive.
  •  Two-year data shows 99.8% efficacy.
  • Alternative contraception needed until tubal occlusion proved by hysterosalpingogram 3 months after implant placed.
  • Mechanism of action: Scarring forms around implant over 3 months and prevents sperm to enter the fallopian tube.

POSTPARTUM TUBAL OCCLUSION

  • Pomeroy method: A segment of isthmus is lifted and a suture is tied around the approximated base. The resulting loop is excised, leaving a gap between the proximal and distal ends. This is the most popular method.
  • Parkland method: A window is made in the mesosalpinx and a segment of isthmus is tied proximally and distally and then excised.
  • Madlener method: Similar to the Pomeroy but without the excision, a segment of isthmus is lifted and crushed and tied at the base.
  • Irving method: The isthmus is cut, with the proximal end buried in the myometrium and the distal end buried in the mesosalpinx.
  • Kroener method: Resection of the distal ampulla and fimbriae following ligation around the proximal ampulla.
  • Uchida method: Epinephrine is injected beneath the serosa of the isthmus. The mesosalpinx is refl ected off the tube, and the proximal end of the tube is ligated and excised. The distal end is not excised. The mesosalpinx is reattached to the excised proximal stump, while the long distal end is left to “dangle” outside of the mesosalpinx.

PARTIAL OR TOTAL SALPINGECTOMY

Removal of part or all of the fallopian tube.

LUTEAL-PHASE PREGNANCY

A luteal-phase pregnancy is a pregnancy diagnosed after tubal sterilization but conceived before. Occurs around 2–3/1000 sterilizations. It is prevented by either performing sensitive pregnancy tests prior to the procedure or performing the procedure during the follicular phase.

REVERSIBILITY OF TUBAL OBSTRUCTION

Around one-third of tubal ligations can be reversed such that pregnancy can result. Pregnancies after tubal ligation reversal are ectopic until proven otherwise.