Deterioration due to rapid offload of pleural effusion fluid from chest drains (1 December 2020)

Summary

Pleural effusions are the accumulation of fluid between the lung and chest wall, which may cause breathlessness, low oxygen saturation and can lead to collapsed lung(s). They are a common medical problem and have over 50 recognised causes and various treatments. Large effusions, such as those caused by pleural malignancy, may require insertion of a chest drain and controlled drainage of fluid to allow the lung to inflate. If large volumes of pleural fluid are drained too quickly, patients can rapidly deteriorate. Their blood pressure drops, and they can become increasingly breathless from the potentially life-threatening complication of re-expansion pulmonary oedema. T

A review of the National Reporting and Learning System (NRLS) over a recent three-year period identified 16 incidents where patients experienced acute and significant deterioration after uncontrolled or unmonitored drainage of a pleural effusion; two of these patients died and a cardiac arrest call was made for one patient although the outcome was not reported.

Content

Actions

Review local chest drain clinical procedures/LocSSIP (or equivalent documents) to ensure they:

• Follow BTS guidelines for adults2 and/or children4 for controlled drainage of large pleural effusions.
• Include post-procedure management plans that align with BTS standards.
• Incorporate the good practice points outlined in the ARNS Good Practice Standards for adults.

Provide a bedside observation chart or monitoring document6 (electronic or paper) that embeds the key elements of the revised policy to ensure it includes:

• clear instruction on frequency of observation; including continuous direct observation for first 15 minutes
• red flag triggers for drain closure
• local escalation procedure for patient deterioration before, during and after chest drain insertion.