Care of chest tube for paediatric cases - page 2
by deepurple 9,904 Views | 13 Comments
Hi everyone...i want to ask for help about the care of chest tube. I list the responsibilities of nurses for chest tube care. From your experiences, is there any info to add in the list below from all of you. TQVM, You're most... Read More
- 0Aug 4, '12 by umcRNQuote from janfrnWe don't seem to have clots in the dependent tubing (which we usually hang as much off the bed as possible with no loops) but more clotting within the chest tube closest to the patient and the part within the patient, where we can't see it. Drainage might stop, we get an xray and there's massive fluid build up within the chest, tube is stripped and clots are pulled out and then it drains, so to prevent that our docs like for us to aggressively strip the tubes, even days after surgery or extubation, so these kids aren't always heavily sedated and it hurts!One of those references indicates that dependent loops in the tubing are a cause of many drainage failures. I like to coil my tubing on the bed and whenever I notice fluid sitting in the coils I walk it down to the chamber. I also tend to disregard our directive to a certain degree. If I see fluid at the 5-in-1 I've been known to gently squeeze the tube just above that point to make sure it's not static. Then I walk it down. I do the same with my foley catheters but instead of coiling the tubing on the bed I run it down to the foot and hang the bag there so that there's a straight line for it to drain. Ditto for my PD collection set. Saves a lot of time and effort. I choose to work smart, not hard!
- 0Aug 4, '12 by NotReady4PrimeTime Senior ModeratorThe fluid doesn't clot in the dependent loops, but it does completely fill the lumen so that your suction can't get to the pointy end. Coiling the tubing on the bed lets the fluid sort of spread out so that the suction isn't attenuated so much. (I think!) Our chest tubes are usually out by POD 2 unless the kid is sick. They'll usually pull the LA line on POD 1 and if there's no bleeding and the drainage is minimal then the chest tube could be pulled several hours later. So I'm wondering why your kids bleed so much. We're really aggressive with getting the bleeding stopped, and give protamine, platelets and sometimes FFP if needed.
The last kid we had tamponade was older, large, difficult to anticoagulate (idiosyncratic heparin metabolism), had no chest tube for 2 days already, looked great the day before and had been extubated. The big crump came in the middle of Saturday morning rounds and our surgical team was already in house for a semi-elective sternal debridement. Stat echo, a quick trip down the hall and everything was fixed.
- 0Aug 4, '12 by umcRNChest tubes out POD 2? Ha, more and more our docs have been sending kiddos out to the floor still with their chest tubes (not always but I feel more so than when I started on the unit)
I would say that our biggest bleeding issues are with the single ventricle kids (regardless of the stage) and they are always on heparin drips post op. I have noticed that other kiddos bleed quite a bit too, even some who really shouldn't be bleeding that much (LPA sling?) as well as Tets and a rapid deploy ecmo kid I had once we were practically replacing his body volume continuously through the shift (and he was 3). Is it something the surgeons are doing? I don't know. We certainly use plenty of blood products. I get what you're saying about the blood filling the tube and possibly decreasing suction to the end of the tube so I'll keep that in mind.
- 0Aug 4, '12 by NotReady4PrimeTime Senior ModeratorWe almost never send a kid out to the floor with their chest tubes still in. JPs maybe, but not chest tubes. (There's a perception that chest tubes can't be managed on the wards. Neither do they administer antibiotics. Or oxygen, and any number of other things that can ONLY be provided in PICU... ) Any time there's significant and persistent post-op bleeding we give the surgeons the hairy eyeball... because it's almost always their fault. A few years ago we had a new surgeon whose patients always bled, and had other complications. Over time he got a lot better. We have 5 cardiac anaesthetists who do an excellent job of bringing the kids back in the best possible state.
Many of our kids are on heparin too; we don't start it until 4 hours after any post-operative bleeding has slowed right down, their INR is less than 1.5 and their PTT is less than 50. We target an unfractionated heparin level of 0.35 to 0.5, even on our ECMO kids. Our rapid deploy ECMO kids all need a ton of product in the first couple of days but eventually settle down to maybe 10 mL/kg/shift of platelets and packed cells.
Do your surgeons ever make use of a Fogarty catheter to restore patency to your chest tubes?