Intercostal Drain Insertion


  • exclude contraindications
  • consent
  • IV access (analgesia, resuscitation medications or products)
  • monitoring (SpO2, ECG, BP)
  • confirm affected side (clinically + CXR)
  • position: supine with arm abducted and hand under head
  • local anaesthesia: lignocaine with adrenaline = 7mg/kg


  • chlorhexidine
  • drape
  • scalpel
  • forceps
  • clamp
  • 2.0 suture
  • gauze
  • dressing
  • 32 Fr drain (blood)
  • underwater seal drainage system (primed)


  • full asepsis (G/G/H/M/C)
  • landmarks = anterior to mid-axillary line, 5th IC space, nipple line (T4), palpate ribs and ICS
  • 2-3cm transverse incision on top of rib
  • blunt dissection down to pleura (just superior to rib -> avoid neurovascular structures)
  • end point: pleural cavity (hiss or blood)
  • sweep with finger
  • insert clamped drain using curved forceps to guide in
  • connect to UWSD
  • check for drainage and respiratory swing
  • suture
  • sterile dressing



  • CXR
  • watch for complications:

-> not draining (check for kinking)
-> organ injury (lung, liver, spleen, heart, vessel) – careful insertion
-> blood loss– careful observation
-> surgical emphysema (small hole and good suturing)
->infection (sterile technique)

Features of a Pleural Drainage System

  • modern drains incorporate three separate bottles into one unit
  • bottle A = fluid trap
  • bottle B = underwater seal drain
  • bottle C = allows suction to be attached

Safety features:

1. first tube connecting drain to drainage bottles must be wide to decreased resistance
2. volume capacity of this tube should exceed ½ of patients maximum inspiratory volume (otherwise H2O may enter chest)
3. volume of H2O in bottle B should exceed ½ patients maximum inspiratory volume to prevent indrawing of air during inspiration
4. drain should always stay at least 45cm below patient (prevention of removed fluid or H2O refluxing into patient)
5. clamp drain when moving
6. H2O level above tube in bottle C determines the amount of suction applied before air drain through tube (safety suction limiting device)

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  1. Naveen says

    with due respect, I suggest the ICD should not be clamped during transfers as there is a risk of tension pneumo

    • says

      Thanks for the comment Naveen
      Agree as a general rule ICC for PTX should not be clamped, but if so should be under direct supervision
      Clamping can be used to control flow in massive hemothroax or pleural effusion
      There are also other situations such as post-pneumonectomy when an ICC may be clamped
      The ICC should not be clamped for the entirety of transport, but may be worth doing when moving the ICC across the bed, etc, to lessen the risk of backflow further
      I will clarify this coment on the page
      Appreciate the peer review -- don’t let anyone be wrong on the Internet!