Bloody secretions from trach-normal or no?

  1. 0
    Hi everyone, I'm a nursing student with a patient who has a continuous trach (she's had it for 3 years or so) The tube was changed to a different model during her last hospital stay which was around the end of May. I was alarmed when I found a fair amount of bloody secretions on her trach dressing and within the trach itself when I cleaned it...I reported to the charge nurse and she wasn't concerned. Her admission notes mention the blood and attribute it to the fact that the tube was recently replaced...but would this still be a valid reason 1.5 months later?

    She's an alcoholic with a history of pancreatitis and upper GI bleeds...so my first thought when I saw the blood was esophageal varices (sp?) but I'm new to trach's so I really don't have a reference point...
    Last edit by MattiesMama on Jul 14, '10 : Reason: a
  2. Get our hottest nursing topics delivered to your inbox.

  3. 11,319 Visits
    Find Similar Topics
  4. 11 Comments so far...

  5. 0
    We can't give medical advice. Call her MD.
  6. 1
    Well of course you are correct to be concerned. Sure would have someone check placement/inflation again... and yeah, she could have a GI bleed (not necessarily varices). Frank or serosanguineous secretions? Origin could also be ulceration from the tube/cuff as well as from lungs themselves... did you suction? What came up? I have seen some rather rough suctioning done, you have to be mindful when you do it. Is she inline suctioning?
    MattiesMama likes this.
  7. 5
    Mamamerlee, I took her question as a learning request from a student, not a personal request.
    skittlebear, April, RN, MattiesMama, and 2 others like this.
  8. 4
    First, a tracheostomy does not go in the esophagus. EtOH and varices might be a concern for this patient, but if you are suctioning out a variceal bleed from this patient's trachea, the patient has aspirated and would likely be very ill. I don't think that this is the scenario you are describing.

    Bloody secretions and blood at the insertion site can last for some time after a trach is changed out. From my experience, I would say that 6 weeks is on the outside of what is expected. However, if this patient has a hx of EtOH and varices like you say, they may indeed have some coagulapathy from liver disease which may explain some of the continued bleeding.

    Obviously I am not able to review the chart of this patient, but I would also look at whether or not the patient was on blood thinners, etc. That would be an explanation as well. Over-aggressive suctioning is also a common reason for trauma and bloody secretions. Bleeding could have a pulmonary etiology as previous poster mentioned. It could be one of many things.

    As an ICU nurse I usually don't worry about minor bleeding unless the patient is dropping their H/H, at which point it warrants investigation.
    DebblesRN, MattiesMama, netglow, and 1 other like this.
  9. 0
    mamamarlee I'm not asking for a consult I'm just wanted to hear from those of you who have experience if this is a common thing...

    2ndwind-she has a cuffless trach-it's reusable, and she gets it removed and cleaned daily. She breathes spontaneously and can cough up secretions herself, but someone has to swab the mucous out of the cannula. The secretions were either just mucous or blood tinged mucous for the most part, but I did see some frank blood in there too...and there was quite a bit of frank blood on the trach dressing, which had just been changed the previous shift. ..the cannula itself feels slippery and not secure at all to me. She's nonverbal but seems like she's in a lot of pain whenever trach care is done and she's constantly coughing this junk up-I had to clean it out probobly a dozen times during a 6 hour period and suction twice. So I think your explanation makes more sense...an ulceration would seem pretty likely with that much daily wear and tear...
  10. 0
    Quote from CNL2B
    First, a tracheostomy does not go in the esophagus. EtOH and varices might be a concern for this patient, but if you are suctioning out a variceal bleed from this patient's trachea, the patient has aspirated and would likely be very ill. I don't think that this is the scenario you are describing.

    Bloody secretions and blood at the insertion site can last for some time after a trach is changed out. From my experience, I would say that 6 weeks is on the outside of what is expected. However, if this patient has a hx of EtOH and varices like you say, they may indeed have some coagulapathy from liver disease which may explain some of the continued bleeding.

    Obviously I am not able to review the chart of this patient, but I would also look at whether or not the patient was on blood thinners, etc. That would be an explanation as well. Over-aggressive suctioning is also a common reason for trauma and bloody secretions. Bleeding could have a pulmonary etiology as previous poster mentioned. It could be one of many things.

    As an ICU nurse I usually don't worry about minor bleeding unless the patient is dropping their H/H, at which point it warrants investigation.
    Oh boy...lol...thanks for reminding me about the placement thing, I would've looked pretty dumb if I brought that up!

    She is on fragmin but her platelet count and RDW are very high. She's had a number of serious embolisms (PE, ischemic CVA, mesentaric artery embolism with renal infarct and an above the knee amputation due to PVD/avascular necrosis) Her H+H have dropped several times within the past year to the point where she's needed transfusions. She's been having idiopathic seizures ever since her CVA during which her b/p bottoms out and they haven't figured out why.

    I'm trying to get a good clinical picture of her but it's difficult because she didn't have any medical care until this past year and she's non-verbal. I get the feeling she's one of those patients that has been overlooked, because of her history and because she has a lot of behavior issues...but she's grown on me and I want to help her if I can. She's only 50 years old but so sick and it feels like everyone's given up on her.
  11. 2
    I think your patient is fortunate to have you on her side and caring for her.

    My first thought when reading your post was to check on the anticoags, especially considering her history. After that, if her H/H are WNL, it's probably related to wear and tear during her care.

    Continued luck and success in school!
    MattiesMama and roser13 like this.
  12. 1
    Some pretty decent assessment charting practice. You just chart what you see accurately. Also, important thing you did was tell an RN. As a student an important part of your PIE charting is your intervention... and part of that was notifying the charge.

    Just remember to look at your set of extended vitals before and after any tx. Vitals including pulseox, and lung sounds, and pain symptoms. Now that you have some ideas you can see how you might look up some labs and see if they tell you anything interesting as CNL2B suggests you do. This is how clinical can be fun at least for me it was when I started to know where I wanted to look for information, you may not find anything outragious, but someday you just might, and then, you will know where to look...
    MattiesMama likes this.
  13. 4
    MattiesMama, I know that from a student's point of view, everything is possible, but from my experience, it's being able to discern the matter of degrees that leans possibilities towards one clinical event versus another. Your question regarding this as a possible indication of bleeding esophageal varices shows that you're thinking about all the possible reasons, but have probably never seen an actual esophageal variceal bleeding event.

    Just imagine this; take a gallon bucket of blood, and pour it onto the patient's mouth and chest. That is what rupturing esophageal varices looks like. Add on top of that the patient is white as a sheet, with a rapid heart rate, and a look of impending doom on his face if he's still conscious. Or put it this way, if you've ever seen one, you'll never, ever forget it.

    Tracheostomies, especially long term ones, can form fistulas and have open communication with the esophagus, and other structures within that area of the neck and chest. Generally, these require a dye swallow test, where the patient is given a pureed food (like mash potatoes) that is mixed with methylene blue. If the area around the trach leaks dye, then a tracheal esophageal fistula is confirmed.

    Further, erosion of the surrounding tissue can also occur. If the erosion extends into a blood supply, such as with an innominate artery fistula, then it can indeed be deadly. But generally bright red blood would be rapidly accumulated around the site. Other potential complications include tracheomalacia, laryngeal damage, subcutaneous emphysema, pnuemothorax, and of course, infection.

    With this patient, despite the cuffless trach, some degree of tissue erosion may be a possibility. It may be advisable to get an ENT consult to do a full assessment of her neck (structure) and numbers (labs) to get to the bottom of the blood source.

    Good luck, it's nice to see nursing students so clinically aggressive.
    Last edit by Emergency RN on Jul 14, '10
    skittlebear, DebblesRN, MattiesMama, and 1 other like this.


Top