Chest Drain Insertion (surgical drain) 
 
Equipment 

Personal & Monitoring 
Gloves (sterile), gown, eye protection 
Observation machine to check vital signs 
Oxygen (and mask) 

Sterile Field 
Sterile drapes 
Antiseptic solution (commonly chlorhexidine or iodine) 
Sterile gauze 

Local Anaesthetic 
Lidocaine 1% or 2% (max 3 mg/kg without adrenaline) 
10–20 ml syringe 
Green (21G) and blue (23G) needles 

Instruments 
Scalpel (size 10 or 11) 
Curved artery forceps 
Straight forceps 
Sutures (e.g. 0 or 1-0 silk) 
Needle holder and scissors 

Chest Drain System 
Chest drain tube (size depends on indication) 
Pneumothorax: 12–18 Fr 
Fluid/blood: 20–28 Fr 
Underwater seal bottle (± low thoracic suction device) 
Connecting tubing 
Occlusive dressing (e.g. tegaderm) 
Clamp (only used if indicated) 
Sterile water – 1 litre 
 
Anatomy and Insertion Site 

‘Triangle of Safety’ 
Bounded by: 
Anterior border of latissimus dorsi 
Lateral border of pectoralis major 
Line superior to nipple (5th intercostal space) 
Apex below axilla 
Usually 4th or 5th intercostal space, mid-axillary line 
Note: An Ultrasound should be undertaken to help guide drain position 
 
Procedure (Step-by-Step) 

1. Preparation 
Explain procedure and obtain consent 
Position patient at 45°, arm abducted behind head 
Full aseptic technique 
Give oxygen, if indicated, and monitor patient 

2. Local Anaesthesia 
Infiltrate skin, subcutaneous tissue, periosteum of rib and pleura 
Anaesthetise over the top of the rib (to avoid neurovascular bundle) 
Aspirate as you advance to confirm pleural entry 
Inject more local anaesthetic if necessary 

3. Incision 
2–3 cm horizontal incision 
Just above the rib below the chosen intercostal space 

4. Blunt Dissection 
Use curved forceps to dissect through: 
Subcutaneous tissue 
Intercostal muscles 
Pierce pleura with controlled force 

Insert finger into tract to: 
Confirm pleural entry 
Sweep for adhesions 
Protect lung 

5. Drain Insertion 
Insert drain using forceps  
Direction: 
Pneumothorax → anterior and apical 
Fluid → posterior and basal 
Ensure all side holes are inside chest 

6. Secure and Connect 
Suture drain securely (Roman sandal or mattress suture) 
Add a purse string suture if using a large bore drain 
Connect to underwater seal 
Do NOT clamp routinely 
Apply occlusive dressing 
Add low thoracic suction (-3KPa) if indicated 

7. Post-Procedure Care 
Observe swinging and bubbling 
Check respiratory status 
Obtain chest X-ray 
Document: 
Size and site 
Volume drained 
Complications 

Complications 
Pain 
Bleeding 
Infection 
Organ injury (lung, liver, spleen) 
Drain dislodgement 
Re-expansion pulmonary oedema (reperfusion injury) – ensure not to drain too quickly (usual practice is to clamp after 1000mls and wait for an hour; this should be directed by clinicians)