Gently grasp and retract skin from over 10th intercostal space, advancing incision site cranially to 7th intercostal space. Using a surgical blade, create a full-thickness skin incision over 7th intercostal space. The surgical blade may be used to incise the underlying intercostal muscles at this time. Insert tip of trocar through skin and muscle incision.
Step 4. (4a.) Redirect trocar into vertical position to be almost perpendicular with thoracic wall. Direct penetration toward patient's opposite elbow.
(4b.) With one hand, grasp trocar just 2 to 3 cm above skin to stabilize it and avoid overpenetration into thoracic cavity.
Place palm of other hand over head end of stylet. Apply firm, consistent pressure, and in a single motion advance trocar tip through intercostal space. Considerable pressure is needed to penetrate through intercostal muscles. To avoid lung trauma, we advocate incising through skin and intercostal muscles. Once through pleura, reduce angle of trocar so it is parallel with ribs. Back stylet out of tube very slightly by twisting it. Advance entire tube and stylet cranially to the predetermined distance.
Step 5. Once tube is in place, stylet may be withdrawn. However, before withdrawing stylet completely, clamp tube to prevent iatrogenic pneumothorax.
(5a.) We recommend using the handle portion of a hemostat, rather than the jaw, to occlude the tube lumen to avoid damaging the tube. A nylon tube clamp may be inserted over the plastic tubing once the stylet has been removed. This also protects against pneumothorax during chest tube management and should be closed unless the pleural space is being evacuated.
Procedure Pearl: The chest wall in cats is much more compliant than in dogs. In our experience, considerable pressure is needed to penetrate a flexible structure with either a trocar or hemostat. In contrast, the chest walls of large-breed dogs are not very compliant.
Step 6. (6a.) Place a tube adaptor into end of tube and secure it with suture or tissue glue. Attach 3-way stopcock to tube adaptor, and close remaining two ports with injection caps.
Step 7. To stabilize tube, place purse-string suture at skin incision, leaving long suture tags. These tags may be used to make a Chinese finger trap or Roman sandal pattern. An alternative is to create a "butterfly," using 1-inch white tape around the tube, just distal to the purse-string suture. Wings of the butterfly must be long enough to avoid penetrating tube when suturing tape to the skin. Lastly, a second suture may be placed several inches caudally, further anchoring tube to skin.
8. Before bandaging the chest drain, take thoracic radiographs to confirm tube placement.
(8a.) Cover skin wound with antiseptic ointment and sterile gauze squares. Create thoracic wrap using layers of gauze covered with Vetrap (3M, St. Paul, MN) to further protect the drain. Change entire wrap daily. At this time, examine skin incision for signs of infection and check tube placement.
Chest drain removal can generally be performed without sedation and a thoracic wrap applied as mentioned in Step 8.