Anesthetizing Tissues

Full barrier precautions must be used during this procedure (sterile gown, gloves, protective eyewear and a face mask).

  1. Using antiseptic solution and gauze, create a large sterile field over the marked incision site
  2. Cover the field with sterile drapes, leaving the procedure site exposed
  3. The skin, subcutaneous tissues, parietal pleura, and periosteum of the rib below the intended insertion site (ie. the rib above the marked incision site) must be adequately anesthetized. Up to 7mg/kg of locally injected 1% lidocaine with epinephrine (1:100,000) can be used (up to 5mg/kg if not using epinephrine). Using a small gauge needle (i.e. >25 gauge), create a wheal of anesthetic in the skin overlying the landmarked spot where the incision will be made.
  4. Using the larger gauge needle (i.e. 20-22 gauge), anesthetize the subcutaneous tissues through the wheal, aspirating as the needle moves deeper.
  5. Anesthetize the periosteum of the rib that lies below the intercostal space where the tube will be inserted
  6. Once you have reached the parietal pleura, a flash of pleural fluid will fill the syringe if a pleural collection is being evacuated. If a pneumothorax is being drained, the syringe may only fill with air. Withdraw the needle, aspirating along the entire path. If air or fluid are not found, the insertion site should be changed.
Note: Insertion of a chest tube can be extremely painful, a common error is inadequate local anesthesia; another error is to forget that additional anesthetic may be required throughout the procedure.