CT Stripping/Milking

[CCU BSN RN]

Recently switched institutions. Old hospital policy was not to strip CT, okay to gently milk, due to intrathoracic pressure changes and no solid body of evidence that it actually provided any benefit to patients. There were instances where a tube clotted off and required aggressive stripping, which we would do ourselves or have the mid level staff do, depending on the situation, RN, etc.

New institution has it directly in their postop orders that you're to Strip/Milk tubes to maintain patency, I think every couple of hours, and most of the nurses and midlevels aggressively strip tubing every time they round.

Background, mostly CABG and OHS patients, in both institutions.

I've seen a couple old threads on this, one from '05 and one with posts as recent as last year, but what's the current consensus/evidence on this?

[Rose_Queen, BSN, MSN, RN]

I don't know about evidence, but according to the surgeons I work with, since we use channel drains instead of traditional chest tubes that have multiple openings in a solid tube, the concern about creating negative pressure in the chest is unfounded. If we give something like Factor VII, they tell us to aggressively strip the tubes or they will clot off.

[Linka]

http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=4&sid=2a2b970f-8e7f-48df-a3e5-ea1b1adb07d1%40sessionmgr1

Flynn Makic, M. B., Rauen, C., Jones, K., & Fisk, A. C. (2015). Continuing to Challenge Practice to Be Evidence Based. Critical Care Nurse, 35(2), 39-50. doi:10.4037/ccn2015693

just in case you can't find the article, i copied everything in the article about chesttube patency

Review of Current Evidence

The earliest method to maintain patency of chest tubes, primarily mediastinal tubes, was known as stripping.The clinician would grasp the drainage tube veryclose to the patient's body and while collapsing the tubebetween the thumb and fingers, pull down the tube fromthe insertion site. The rationale for this procedure was to increase the vacuum pressure in the tube to assist inthe removal of the drainage within the chest and removeany clots that might be forming within the tube. Whenstripping was performed, clinicians (the author included)were taught, and probably taught others, that this was avery important procedure to maintain tube function andpatency, and to prevent infection, pericardial tamponadeand the need for emergent reoperation, and even cardiacarrest. A rolling device was sometimes employed to assistwith the stripping procedure for clinicians who mightnot have the hand strength to ensure consistent pressure

based on single studies,” the conclusion wasthat there was no difference in output, cardiac tamponade,or surgical re-entry between stripping, milking, andno manipulation.

Day and colleagues determined that no manipulation of drainage tubes should be done on a routine basis.

Finally, the 6th edition of the AACN Procedure Manual for Critical Care echoes the recommendations offered by Day et al. The manual states, at level C evidence, that stripping and milking of closed chest drainage systems are contraindicated.

Implications for Practice

No manipulation of drainage tubes should be done on a routine basis.

The management of these tubes should be based on the best evidence available. If current practice, unit protocols,or even physicians' orders suggest stripping or milking chest tubes, which does not match the evidence-based practice recommendations, clinicians need to review the evidence and consider changing their practice. The research and evidence available on care of chest tubes clearly indicates that stripping and milking are not necessary to maintain chest tube patency and probably cause more harm than good