Pigtail Catheter Insertion Procedure and Pearls

Dr. Paul Frankish & Dr. Matt Greer

1. Obtain informed consent if possible, obtain all supplies needed, have drainage system opened and ready to go.
2. Sterile prep, drape, gown/glove.
3. Identify triangle of safety (5th IC, mid axillary, pectoralis). – or use PoCUS to guide site safety and depth (DL)
4. Anesthetize skin, subcutaneous, rib, intercostal, and pleura. Consider procedural sedation.

PEARL – May need up to 20 cc of local, consider refreezing with larger spinal needle, withdraw until the air bubbles stop to freeze the pleura.

5. Insert large “seeker” needle at desired IC space, with fluid filled syringe attached, withdraw as you go.

PEARL – Mark the depth where you hit air bubbles for when you dilate the tract

6. Slide over superior aspect of rib and stop when you withdraw air bubbles/fluid.
7. Detach syringe and insert guide-wire through needle. There should be no resistance. Only about 10 cm inside the thoracic cavity is required. Remove needle while leaving the guide-wire in place.
8. Make a small incision with 11-blade alongside guide-wire, then dilate needed depth, then insert pigtail with obturator over wire to appropriate depth.

PEARL – Do not forget to remove the obturator before attaching to drainage system.

9. Insert as far as possible until resistance is felt to ensure all fenestrations are within the thoracic cavity.

PEARL – You can always pull it back out if it’s in too far.

10. Attach 3-way stopcock, tubing extension, then to either Heimlich valve or underwater seal/wall suction.
11. Suture in place as per usual chest tube technique. Ensure dressing optimizes skin seal (sticky/occlusive).
12. Confirm placement with chest x-ray.