Institutional protocol to standardize the chest drainage system management, from surgery to nursing care, at a regional hospital in northern Paraná

. The purpose of chest drainage is to allow lung re-expansion and the reestablishment of the subatmospheric pressure in the pleural space. Properly managing the drainage system minimizes procedure-related complications. This prospective observational study evaluated adult patients undergoing water-seal chest drainage, admitted to our hospital and accompanied by residents and tutors, aiming to check their care. One hundred chest drainages were monitored. The average age was 38.8 years old. The average drainage time was 6.7 days. Trauma was the prevalent cause (72%) for the indication of pleural drainage. The obstruction of the system occurred in 6% of the cases; 5% subcutaneous emphysema, 1% infection around the drain; 5% accidental dislodgement of the drain, and in 5% of the patients, there were some complications when removing the drain. Failures in chest drainage technique and management were present, and reflected in some complications that are inherent to the procedure, although it is known that there are intrinsic complications. This study aimed to assess the management of closed chest drainage systems and standardize the care provided in such procedure.


Introduction
Chest drainage management is one of the most important aspects in the treatment of chest surgery patients and there is no consensus on the ideal strategy to perform it appropriately (Linder et al., 2012).
Under pathological conditions, due to the accumulation of several fluids in the pleural space, there is loss in the respiratory physiology dynamics and consequent restricted ventilation.The purpose of chest drainage is to remove the fluid or air accumulated in the pleural cavity, allowing lung reexpansion and the reestablishment of the subatmospheric pressure of the space, thus avoiding complications.Considered as a relatively simple act, it may lead to complications due to the lack of care that has to be taken (Cipriano & Dessote, 2011).
The conventional closed chest drainage system consists of a drain, a connector, an extension tube, and a collection bottle with air vent, generally graduated and kept at a level that is lower than the chest.
The drains currently used are tubular, multiperforated, siliconized, and semi-rigid.The multiple fenestration facilitates the flow and prevents obstruction as it enlarges the surface for drainage.The connector consists of a tubular piece connecting the drain to the extension tube, and it is usually transparent with bore diameter equal to the rest of the system.The extension tube connecting the drainage system to the collection bottle must have a diameter that is larger than or equal to the rest of the routes, besides being transparent and having appropriate length so as to prevent fluid from siphoning back.The extension tube ends in a catheter submerged in the bottle, and remains submerged in a fluid at a depth of about 2 cm.This column works as a water seal, i.e., a unidirectional valve of the pleural cavity towards the bottle, thus avoiding pneumothorax.The drainage is hampered when the height of the fluid column in the collection bottle is excessive.The air vent allows the air to escape from inside the bottle, thus preventing a closed compartment from being created.For inserting the drain, an incision of about 2 cm, parallel to the intercostal space, is made in the superior border of the rib to avoid injury of the neurovascular bundle.The dissection of the intercostal muscles is made by using hemostatic forceps.The pleural space is inspected with the index finger and the drain moved forward in the appropriated position, apico-posterior, anchoring it with a skin suture, usually a 'U' stitch with Roman sandal suture pattern.It is recommended that a chest X-ray examination be always made immediately after inserting the drain, so that its position and lung re-expansion may be observed (Nishida, Sarrão, Colferai, Tenório, & Bandeira, 2011).
A remarkable improvement of closed drainage has been achieved with a greater understanding of the respiratory dynamics and the subsequent technical improvement (Lo Cicero & Mattox, 1989;Pearson, Cooper, & Deslauriers, 1995;Munnell, 1997).Currently, digital chest drainages have been employed, thus providing more comfort to the patient (ambulatory) and reducing complications existing in conventional drainage.One of the most frequent complications is prolonged air leak, which leads to longer time of chest drainage, longer time of hospitalization, higher complications, and increased hospital costs.Since the first digital chest drainage devices came to the market, there have been many studies aiming to demonstrate that by using this system, the subjective judgment of air leak can be eliminated through objective data provided by the computerized system of the digital device (Mier, Fibla, & Mills, 2011).The successful management of the chest drain and its removal depends on an accurate assessment of the air leak through the patient's drain (Dernevik, Belboul, & Radberg, 2007).
Among the main failures that may take place in chest drainage are: obstruction of the tube (due to clots or fibrin, inappropriate clamping, kinking caused by excessive length of the extension tube), inappropriate positioning, fixation, and connection of the drain, inappropriate height of the water seal, improper positioning of the collection bottle, obstruction of the air vent, negligence when checking oscillation of the water seal (Nishida et al., 2011).
The present study aimed to assess the management of closed chest drainage systems through the analysis of adult patients at the Regional University Hospital of Maringa, Paraná State, as well as to standardize the protocol of care provided in chest drainage and minimize its complications.

Material and methods
This was a prospective observational study that followed up adult inpatients subjected to water-seal chest drainage, under the care of the residents of chest surgery team of Regional University Hospital of Maringa, Paraná State, from August 2012 to July 2013.Data collection was made through observation, and a monitoring record was completed on a daily basis regarding the patient and the procedure made (age, sex, and inpatient care sector, indication for and total period of drainage, positioning of the drain in the x-ray, kinking, fixation with skin suture and with an omental tag of tape, obstruction and presence of a mechanism of obstruction of the drain, adjustment of the extension tube, outer diameter and length, positioning of the collection bottle and permeability of the air vent, adjustment of the system connections, complications related to the drainage).For statistical analysis of the data, the software Statistica 8.0 was used.The study was approved by the Regulation Committee for Academic Activities (Corea) of the Regional University Hospital of Maringa and the Ethics and Research Committee (Copep) of the institution.

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9. An omental tag of tape around the drain.
10. Prescription of analgesic, which is usually required after the local anesthetic wears off.3. Local anesthesia with 1% lidocaine by entering the intercostal space previously chosen for drainage, allowing a few minutes for the anesthetic to take effect.11.Radiographic control of the chest, which must be performed and assessed immediately after the drainage.4. 1-cm to 1.5 cm skin incision, divulsion of the subcutaneous and muscle planes using curved hemostatic forceps with penetration into the pleural cavity near the superior border of the rib.With the forceps in the pleural cavity, the index finger must be close to the end of the hemostatic forceps ('finger brake'), thus avoiding parenchymal injury caused by a sudden and violent entry.
12. The monitoring of the entire system must be systematized with, at least, medical visits in the morning and in the afternoon to control it.
5. After inserting the forceps, it will be opened so as to obtain appropriate space.
In cases of doubt, the index finger may be introduced to digitally explore the cavity; then, the drain will be inserted, and adjusted and prolonged in other curved hemostatic forceps.
13. Drain removal technique a. Place next to bed: surgical tape, gauze, cutting material (scissors or scalpel blade), tincture of benzoin, and antiseptic solution.b.The dressing is removed, the skin is thoroughly cleaned with dry gauze so as to improve the adherence capacity of the adhesive tape.c.Antiseptic cleansing is performed around the drain.d.The suture for drain fixation is sectioned.e.The patient is asked to stop breathing, preferably at the end of forced exhalation.f.The drain is moved by traction with a single, uniform move so as to prevent air from entering through the holes.g.The skin wound is quickly obstructed with the nylon suture fixating the drain, dry gauze, and surgical tape over it.This dressing must be changed only after 24 hours so as to prevent air from entering in the absence of total skin apposition.
6. Adjustment between the drain and the tube connected to the bottle under water seal by using a large-diameter intermediate connector.
7. Fixation of the drain to the patient's skin with a 2-0 nylon suture ('U' stitch with Roman sandal suture pattern).
8. The fluid level of the bottle will be marked with an adhesive tape so as to allow the control of drainage output.

Conclusion
Proper chest drainage management may reduce morbidity associated with the method.For such purpose, the importance of clarification and technical training of the hospital staff responsible for carrying out the procedures concerning the drainage is highlighted; especially in the case of residents in learning.Besides appropriate equipment and materials, therapeutic success is directly related to qualification and continuous training of those providing care to the patient undergoing chest drainage.Failures in chest drainage technique and management are still present in our service, reflected in some complications that are inherent to such procedure, and we will try to suppress them by standardizing a protocol in support to chest drainage management and its peculiarities.New comparative studies are expected to be conducted, after the routine use of the suggested protocol.

Table 2 .
Protocol suggested for chest drainage management.