Re: chest tube removal

Originally Posted by grano5

Can anyone tell me the proper procedure for closure of the chest tube wound once the tube has been successfully removed. Patient after 3 mos. still has open incision. Is this normal practice? Is it supposed to close on its own. Patient is 78 yr. old and diabetic. What sort of complications can result from the open incision. Should we contact a surgeon to close it? Patient is in SNF.

Some pts have a purse string to close the wound.

Those without should heal in a week or two.

An open wound is set up for infection. The presence of infectious signs- rubor (erythema), tumor (swelling), calor (warmth), and dolor (pain) needs an eval. Also look for drainage.

The pt could have a simple sinus tract into the incision, which can be probed with a long qtip to assess for depth. If the incision is subxiphoid you are about 6-8 cm from the medastinum most likely. Diabetics are more prone to these problems due to relative immune compromise.

The extent of the tract and signs of infection will determine the need for ABX. Otherwise it's local wound care, good nutrition and time.

A wound this old should not be closed but allowed to heal inside-out by secondary intention.

Re: chest tube removal

My colleague accidentally cut off the purse string stitches on the mediastinal chest drain before removing it. We continue to remove the drain but close the wound with steril-strip. However, she was very upset but I reassured her that patient is fine and no risk of pneumothorax. Could someone help me better explain this in terms of anatomy and physiology.

Re: chest tube removal

Originally Posted by Joelocato

My colleague accidentally cut off the purse string stitches on the mediastinal chest drain before removing it. We continue to remove the drain but close the wound with steril-strip. However, she was very upset but I reassured her that patient is fine and no risk of pneumothorax. Could someone help me better explain this in terms of anatomy and physiology.

Mediastinal tubes are generally inserted subxiphoid, and there is a soft tissue tract of 3-5 cm between the skin and the mediastinum. This tract will collapse down on itself after the tube is out. For this reason some folks don't even put in purse strings at this site. It is nearly impossible to entrain air in, even w/ deep inspiration; additionally if the pleural spaces were not entered, the tract communicates only w/ the mediastinum so no PTX.

Intercostal tubes have a higher risk of PTX, especially if the skin insertion site is at the same level as the pleural entry site (instead of cutting skin one level lower). If you lose a purse string here you can place vaseline gauze over the site to create an air seal.

I have had plenty of times when I pull a tube and the pt breathes in at the wrong time, sucking some air in. This is OK and can be monitored conservatively. The only real risky situation is a pt w/ a known air leak, eg post pulmonary resection, emphysematous bleb rupture etc. Those pts need to be followed more diligently.