Intercostal catheter insertion

What it is

Chest drain (intercostal catheter, ICC) insertion for drainage of air (pneumothorax), fluid (effusion/empyema), or blood (haemothorax) from the pleural space
Seldinger (small-bore, guidewire) technique has largely replaced blunt/trocar large-bore insertion for most indications, given lower complication rates

Standard "safe triangle" landmark: bordered by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at the nipple level (5th intercostal space) - avoids the internal mammary vessels anteriorly and major vascular/neural structures posteriorly

Small-bore (Seldinger) catheters are sufficient for most pneumothorax and simple effusion drainage
Large-bore drains are still preferred for haemothorax (risk of clot blocking a small catheter) and some empyema

Always insert above the rib (the neurovascular bundle runs along the inferior rib margin)
Pre-procedure ultrasound for effusion drainage - reduces organ injury risk, now standard of care
Complications: bleeding, organ injury (liver/spleen/lung), infection, re-expansion pulmonary oedema (limit fluid removal to ~1-1.5L per session and clamp/slow if the patient becomes symptomatic)
Confirm position with CXR after insertion; assess for "swinging" (patent) and "bubbling" (active air leak) in the drainage system

Persistent air leak beyond ~3-5 days, or failure of lung re-expansion, prompts consideration of surgical intervention (pleurodesis, VATS)

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