This is Tunneled Indwelling Pleural Catheter. There are multiple products on the market, including the Rocket kit and the Pleurex kit that you see here. In this video, we will focus on the placement of the Pleurex Tunneled Pleural Catheter. I'm Laura Frey and I'm faculty at the University of Wisconsin and a member of the Bronchoscopy Domain Task Force. And I'm Tim Urgo. I'm faculty at the University of Chicago and I'm the Chair of the Education Committee for CHEST. Hi, I'm Abdul El-Reyes, faculty at Rosenfrock University at the Innovation Subcommittee Education Committee at CHEST. We will quickly review the items available in your Pleurex TPC insertion kit, as well as any additional items you may wish to secure. While lidocaine is available in your kit, you may desire to have additional lidocaine available. You may also choose to use additional drapes or OR towels to create a field for your procedure. The first step is sterilization with the Chloropreps. There are two additional Chloropreps available in the kit seen here, as well as the fenestrated drape. The next step is administering the local analgesia with lidocaine. A filter needle is available in your kit, as are a 22 and a 25-gauge needle for local analgesia and entry into the pleural space. A 17-gauge angiocatheter is next inserted into the pleural space with the catheter inserted in the needle withdrawn once fluid is seen. The wire available here is inserted through the catheter. The incision is the next step, and the scalpel is seen here in your kit. You also have a tunneler and your catheter, which are assembled prior to the procedure here. Two dilators are available, including the Pilloway dilator, and there is a stiffening catheter, which is rarely needed for this procedure. The stiffening catheter may be needed for patients who are morbidly obese or have significant skin changes that make insertion of the catheter more challenging. Once your catheter is inserted, you have two sutures available, as do you have a needle driver and a pickup. You also have fenestrated gauze, multiple 4x4s, and a tegaderm. Once your catheter is inserted, you are now ready for drainage. A lockable drainage line is available with an adapter, which can be connected up to an atrium or a pleurovac. You also have the option of using the vacuum Pleurox drainage bottles, which can be connected directly to the catheter. These are available in multiple volumes with the one-liter volume seen here. With the low-frequency ultrasound probe, we're inspecting the left hemitorax, trying to identify the optimal site for inserting the catheter. Here we're seeing consolidated lung, diaphragm and spleen, and it looks like in mid-axillary line, at this position, the chest wall thickness is about two centimeters with an anechoic pleural effusion. We will mark this site as our optimal Pleurox insertion site. Our patient is appropriately positioned, in this case, in a semi-recumbent position. Using ultrasound, we have already identified our guide wire insertion site, which we will re-verify now. We will also identify a catheter exit site, which is approximately five centimeters inferior and anterior to the guide wire insertion site, keeping in mind that your patient may be draining their Pleurox catheter themselves at home, and therefore, this site needs to be accessible. The next step is to prep our sites in sterile fashion and place a drape. The Pleurox kit comes with a small, thin, straighted drape. Additional field can be created by using OR towels or a full-body drape, similar to what you would use for placement of a central line. Once our drape is placed, we will proceed with administering local anesthesia using 1% lidocaine. We will begin with creating a wheel at our guide wire insertion site and then providing lidocaine to the catheter exit site and the tract in between. Exit site is usually in the same intercostal space or a space below. We're numbing up the tract. After we have numbed the catheter exit site and the tract between, we can switch to our longer needle for administering lidocaine during an exploratory thoracentesis and potentially aspirating pleural fluid. I personally always like to keep my finger on the rib and go slightly above the rib. Inject, advance and aspirate. Inject, advance and aspirate. We're getting fluid. Pull back two or three more millimeters and just numb up the parietal pleura. I do not continue to inject pleural fluid in the subcutishes. And now our catheter entry site and our guidewire site are appropriately anesthetized. The 17-gauge guidewire introducer catheter is now inserted in our entry site, typically between the sixth or seventh intercostal space and again advanced over the rib. We will aspirate pleural fluid as we enter the space. Fluid, advance another half a centimeter while I aspirate, and then just advance the angiocath while retracting the needle. The needle and syringe are removed and the guidewire introducer is left in place. Our guidewire is now inserted through the introducer and into the pleural cavity. The guide wire introducer is now removed and the guide wire is left in place. We will now proceed with making two incisions, one at our guide wire insertion site and the other at our catheter exit site. We will begin by making a one centimeter incision at the guide wire insertion site. I try to make the incision parallel to the skin lines, if possible, and with the blade always away from the wire. We will make a second incision that is one to two centimeters in size. This will be at our catheter exit site, which has already been identified and is about five centimeters inferior and anterior to the guide wire insertion site. The tunneler is connected to the fenestrated end of the Pleurex catheter. The tunneler is then successfully passed in the subcutaneous tissue from the second incision site to the incision at the guide wire insertion site. The tunneler can now be disconnected and the catheter is pulled through the tunnel site until the cuff is advanced beyond the exit site. The cuff should be approximately one centimeter beyond the exit site to allow for retrieval if the TIPC is able to be removed. We will now proceed with dilating our tract using a 12 French dilator. The dilator is passed over the wire. The wire is grasped at the other end of the dilator. The dilator is advanced in the pleural space. Once the pleural space is entered, we ensure that we have a freely mobile guide wire with no kinks so that we can proceed with the next steps in the placement of our TIPC. The 16 French peel-away introducer sheath is now threaded over the guide wire and into the pleural cavity. Initially I go straight just like we went with the needle and the dilator, but once the pleural space is penetrated, then we orient slightly posterior and inferior. The guide wire and the dilator are removed together with the 16 French peel-away introducer sheath in place. Thumb occlusion is important to avoid spillage of pleural fluid. The fenestrated end of the catheter can now be inserted into the sheath. Once the catheter has been advanced, the sheath can be peeled away with continued advancement of the catheter. Once the peel-away has been performed, palpate the space to ensure no kinks in the catheter and that it is fully beneath the tissues. The Clorex comes with a 2-0 silk suture and a 4-0 absorbable suture. Here we will demonstrate using a 2-0 suture to close our site. We do a simple interrupted. And depending on the size of the incision, either two or three stitches are applied. Catheters can be removed when your patient returns at 10 to 14 days for evaluation of the Clorex and review of imaging. We will now demonstrate how to secure your catheter using a 2-0 silk suture. Again, one single, simple interrupted stitch, careful not to puncture the catheter. And here, you could cut the needle because you're not going to use it anymore. We use an air knot to secure to the skin. And then secure the catheter by looping this around once or twice. I like to double my knot, not a surgical knot, just because it doesn't slide that easily. Pull your knots taut, but not so taut that it interferes with drainage of the catheter. We will now proceed with drainage of our patient's TIPC using the vacuum drainage system. We will begin by locking the drainage system and connecting the catheter to the drainage system. We will then remove the stopper and proceed with drainage using the vacuum bottles. The speed can be controlled using the roller clamp for more brisk or more slow drainage. Cessation of drainage would be performed either when no more fluid is obtained or when the patient begins to note chest discomfort. Now that we've drained our fluid, we will proceed with capping our TIPC and placing a dressing. Using the enclosed alcohol prep, we sterilize the site and place the lockable cap. Should feel and hear a click when the cap is secure. We will now place a fenestrated gauze after removing our drape. The catheter will be coiled on top of the fenestrated gauze with additional 4x4s placed atop. We will then place a large tegaderm. And once the tegaderm is in place, the patient would go to recovery where a chest x-ray would be performed. The patient would be further educated on catheter use and provided with necessary drainage equipment for home use.

Pleurex Tunneled Pleural Catheter

procedure

catheter insertion

drainage system

patient education