OT notes · Thoracic / Trauma

Intercostal chest drain insertion

Usual anaesthesia
Local infiltration (lignocaine), with analgesia or sedation as needed
Position
Supine or propped up, arm on the side of insertion abducted to 90 degrees
Setting
emergency

Operative note template for insertion of an intercostal chest drain by the open technique, with a filled example for a traumatic right haemothorax drained in the emergency department under local anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • pain at the site
  • bleeding from intercostal vessels
  • injury to lung, diaphragm, liver or spleen
  • tube in the wrong place (in the chest wall or a fissure) needing re-insertion
  • surgical emphysema
  • infection of the pleural space (empyema) or the wound
  • persistent air leak
  • pneumothorax when the tube is removed

Pre-operative details for this operation

  1. IndicationPneumothoraxTension pneumothorax (after needle decompression)HaemothoraxHaemopneumothoraxPleural effusionEmpyematraumatic or not; clinical signs
  2. SideRightLeftconfirmed on X-ray / ultrasound and by examination at the bedside
  3. Imagingchest X-ray, eFAST or ultrasound findings
  4. Vitals before insertionpulse, BP, RR, SpO2 and oxygen given
  5. Coagulation / anticoagulantsif not an emergency
  6. ConsentWrittenVerbal, emergencywho gave it

Anaesthesia and position

  1. PlaceEmergency departmentWardICUOT
  2. PositionSupine, arm abducted 90 degrees
  3. Local anaestheticlignocaine strength and volume (maximum 5 mg/kg); skin, rib periosteum, intercostal muscle, pleura
  4. Antiseptic and drapesantiseptic used; sterile gown, gloves, drapes
  5. Antibioticsingle prophylactic dose for trauma: drug, dose, time

Operative findings

  1. On entering the pleuraRush of airBloodSerous fluidPusNothing
  2. Finger sweepNo adhesionsAdhesions broken downDiaphragm felt
  3. Initial drainageair; blood or fluid volume in ml and colour
  4. Swing of the water column with breathingPresentAbsent
  5. Bubbling (air leak)NoneOn coughing onlyWith every breathContinuous

Procedure (steps)

  1. SiteSafe triangle, 4th or 5th intercostal space, mid-axillary lineUltrasound-guided site (loculated collection)safe triangle: behind the lateral border of pectoralis major, in front of the mid-axillary line, above the 5th intercostal space
  2. Local anaesthetic infiltratedlayers infiltrated, volume
  3. Skin incisionlength (1.5 to 2 cm, longer in obese patients); over the rib below the chosen space
  4. Blunt dissectionStraight into the spaceShort subcutaneous tunnel from one space belowKelly / artery forceps over the upper border of the rib
  5. Pleura entered with controlled pressure
  6. Finger sweep done
  7. Tube insertedOpen technique with clampGuided by fingerPercutaneous (Seldinger) techniquesize in Fr; directed posteriorly and to the apex; length inside chest (all holes inside); no trocar
  8. Tube rotated to check it is not kinked
  9. Connected to drainage systemUnderwater seal bottleCommercial chest drainage unitsuction (cm H2O) or no suction
  10. Tube securedsuture material and type (e.g. 0 silk anchor); mattress or U stitch left for closure at removal; tape

Closure, drains and dressing

  1. Wound around tubeNot neededClosed with interrupted sutures
  2. Purse-string / mattress stitch for removalPlaced, left untiedNot placed
  3. Dressingtype; tube taped to chest wall
  4. Mark on the tube at skin levelcm mark, to detect slipping

Specimens and implants

  1. Pleural fluid sentYesNotests requested
  2. Tubesize (Fr), make, lot number if the unit keeps it

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Chest X-rayafter insertion, to check tube position and lung expansion
  2. Vitalspulse, BP, RR, SpO2, at set intervals
  3. Drain chartoutput in ml hourly at first then per shift; colour; swing; bubbling
  4. Suctionon (cm H2O) or off
  5. Chest physiotherapycough and deep breathing, change position to help drainage
  6. Analgesiadrug, dose, frequency
  7. Call doctor ifsudden rise in drainage, tube falls out or disconnects, breathlessness, surgical emphysema
  8. Removal planwhen no air leak and output under 200 ml/day; X-ray after removal

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. H.D., 38 years, 62 kg, motorcycle fall 2 hours ago. Right chest pain, reduced breath sounds and dull note on the right. Chest X-ray: right haemothorax with fractured right 6th and 7th ribs. Pulse 104/min, BP 116/74 mmHg, SpO2 93% on room air.

Case details

Date: 22/08/2026. Emergency. Emergency department, resuscitation bay 2.

Start 21:40. End 22:00.

Done by: Dr A. (MS General Surgery, 1st year). Supervised by Dr B. (senior resident).

Nurse: Sr E.

Indication and pre-op

Indication: traumatic right haemothorax. Side confirmed on X-ray and by examination at the bedside.

eFAST: right pleural fluid, no pericardial fluid, no free abdominal fluid.

Verbal and written consent from patient in Gujarati, wife present.

Inj cefazolin 2 g IV at 21:35, single prophylactic dose.

Anaesthesia and position

Supine, right arm abducted 90 degrees, elbow flexed. On oxygen by face mask.

Site: right 5th intercostal space, mid-axillary line, inside the safe triangle, at nipple level. Marked.

Painted with povidone-iodine and draped. Sterile gown and gloves.

1% lignocaine 15 ml (150 mg, below 5 mg/kg) infiltrated into skin, periosteum of the 6th rib, intercostal muscle and pleura.

Procedure

2 cm skin incision over the upper border of the 6th rib. Blunt dissection with Kelly forceps over the top of the rib into the 5th intercostal space. Pleura entered with controlled pressure.

Findings: dark blood gushed out. Finger sweep: no adhesions, lung felt.

28 Fr chest tube held in a clamp, distal end clamped, inserted and directed posteriorly and towards the apex. All holes inside. Tube at 10 cm at skin. Rotated freely.

Connected to underwater seal bottle. 650 ml of dark blood drained at once. Water column swinging with breathing. No bubbling.

Closure

Tube anchored with 0 silk. Horizontal mattress stitch placed around the tube and left untied for closure at removal. Dressing applied and tube taped to chest wall.

Specimens and implants

No specimen. Tube 28 Fr, make as per packet.

End of procedure

Blood drained 650 ml (recorded as drain output, not blood loss). No other bleeding.

No complications. Pulse 96/min, BP 120/78 mmHg, SpO2 97% on oxygen.

Chest X-ray after insertion: tube in right pleural space, tip towards apex, lung expanded, small residual haze.

Post-op orders

Pulse, BP, RR, SpO2 every 15 min for 1 hour, then hourly.

Drain output hourly for 4 hours, then 4-hourly. Record swing and bubbling. Inform surgeon on call if output rises suddenly, the tube disconnects, or breathlessness increases.

Suction at -20 cm H2O through the bottle.

Encourage coughing and deep breathing, sitting up and turning on both sides.

Analgesia as charted.

Removal when no air leak and output under 200 ml per day. Chest X-ray after removal.

Signature

Dr A., JR-1, General Surgery. Reg. no. ________. 22/08/2026, 22:10.

Must document for this operation

  • Side, and how the side was confirmed before insertion. A drain on the wrong side is a serious error, and the note is the proof that the side was checked.
  • Intercostal space and line (e.g. 5th space, mid-axillary line). A low insertion risks liver, spleen or diaphragm injury, and the site is the first thing checked if one occurs.
  • Tube size and the length inside, with the cm mark at the skin. The ward team uses the skin mark to spot a tube that has slipped out.
  • What drained at insertion: air, or blood or fluid volume in ml. In a haemothorax the output is watched closely over the next hours, and the next doctor needs the starting figure to judge it.
  • Swing and bubbling at the end of the procedure. Loss of swing later points to a blocked or kinked tube, and ongoing bubbling points to an air leak.
  • Local anaesthetic dose in mg against body weight. Lignocaine toxicity is dose-related, and the dose must be counted if more is needed later.
  • Post-insertion chest X-ray finding. Confirms the tube is in the pleura and not in the chest wall or a fissure.

Common mistakes in these notes

  • Writing 'ICD inserted' with no side, space or tube size.
  • Not recording the volume of blood drained at insertion.
  • No mention of swing or bubbling.
  • Local anaesthetic volume written without the strength, so the dose cannot be worked out.
  • Post-insertion X-ray ordered but its finding never written.

Indian practice and paperwork

  • Informed consent is needed before any invasive procedure, not only surgery in OT. A chest drain in the emergency department needs recorded consent unless it is a life-saving emergency. (NABH 5th ed., PRE.2(g))
  • Consent must be explained in a language the patient understands, and be taken by the person doing the procedure. (NABH 5th ed., PRE.4(c) and (e))

Sources

  • Demetriades D, Inaba K, Velmahos G, eds. Atlas of Surgical Techniques in Trauma. Cambridge University Press; 2015, Ch 3, Thoracostomy tube insertion (Demetriades D, Schlitzkus LL), pp. 37-48.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 22, Cardiothoracic surgery for the general surgeon: chest tube insertion, underwater seal, chest trauma, pp. 498-503.
  • Scott-Conner CEH, ed. Scott-Conner and Dawson: Essential Operative Techniques and Anatomy. 4th ed. Lippincott Williams & Wilkins (Wolters Kluwer); 2014, Ch 26, Tube Thoracostomy, Thoracotomy, Partial Pulmonary (Wedge) Resection, and Pleural Abrasion (Gerken MV, Camp PC Jr), pp. 173-176.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV adult (3 g if 120 kg or more). academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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