Q: While anesthetizing the chest area to insert thoracostomy tube (chest tube) - think of a step missing from below as the anesthesia needle moves forward.
1. Apply lidocaine to skin and subcutaneous (SC) tissues
2. Apply lidocaine to the periosteum of the rib above and the rib below
3. Avoid the lower rib margin
4. Apply lidocaine into the muscles of the intercostal space where the chest tube is planned
5. Apply lidocaine to the area of the parietal pleura where the tube will enter the pleural space.
Answer: The objective of this question is to highlight an important step frequently missed by the operators while anesthetizing the area for the chest tube insertion.
After applying lidocaine to the skin and the SC tissues, and going forward, the anesthesia needle should be aspirated back to make sure that the needle is not in the intercoastal artery or vein. The damage to an intercoastal vessels can be fatal. In lean and thin patients this may need to be done as a first step.
References:1. Kwiatt M, Tarbox A, Seamon MJ, et al. Thoracostomy tubes: A comprehensive review of complications and related topics. Int J Crit Illn Inj Sci. 2014;4(2):143-155. doi:10.4103/2229-5151.134182