Care of chest tube for paediatric cases

Pediatric Critical Care Columnist · Jul 28, 2012

Stripping of chest tubes is no longer a standard of practice. This creates too much negative intrapleural pressure, pain and tissue trauma. Bottles are not used for drainage collection in most of the world now. Pleurevac or Atrium collection systems are the norm and do not need to be changed until nearly full.

umcRN, BSN, RN · Jul 28, 2012

Stripping of chest tubes is no longer a standard of practice. This creates too much negative intrapleural pressure, pain and tissue trauma. Bottles are not used for drainage collection in most of the world now. Pleurevac or Atrium collection systems are the norm and do not need to be changed until nearly full.

Hi Jan,

It just so happens that I am currently in the process of reviewing our chest tube policies this year (we do this yearly and make revisions as EBP indicates)

We currently continue to strip our chest tubes, sometimes quite aggressively in our post op cardiac kiddos. Seeing that your unit doesn't how do you prevent clots? And potential tamponade in heavy bleeders? I have cared for quite a few kiddos who the attendings insisted that we strip the chest tubes even as much as every 30 minutes and there is one doc in particular who if she thinks your not doing a good enough job at it (depending on what the kiddo looks like) she'll stop by on the hour and get a little action of her own. Are you able to point me in any directions for recent research related to this? I am currently working on the lit search for the review and would love any other sources to look up.

Thanks!

itsnowornever, BSN, RN · Jul 28, 2012

STill in school, but we've always been told to never clamp a tube unless we are looking for a leak

Sun0408, ASN, RN · Jul 28, 2012

The only time I have ever had to milk or strip a CT was for an open heart heavy bleeder. Other than that, we rarely need to strip or milk one...Depending on the system used; some will have a bubbling (normal) for that system or for others bubbling = leak. So I really can't answer without knowing the system. Dressings are changed q day and the CT is sewn in place to help avoid accidental removal. We also don't use bottles anymore.

umcRN, BSN, RN · Jul 28, 2012

The only time I have ever had to milk or strip a CT was for an open heart heavy bleeder. Other than that, we rarely need to strip or milk one...Depending on the system used; some will have a bubbling (normal) for that system or for others bubbling = leak. So I really can't answer without knowing the system. Dressings are changed q day and the CT is sewn in place to help avoid accidental removal. We also don't use bottles anymore.

Well I work in a cardiac ICU so they're all open hearts, and many are on heparin drips after surgery because of their anatomy, but I know that is the case in many pedi cardiac icu's so I would also be interested in how other units manage those pts chest tubes w/o stripping them

Pediatric Critical Care Columnist · Jul 29, 2012

umcRN, we've actually been issued a directive that we RNs are NOT to milk, strip, tap or otherwise encourage drainage through our chest tubes, and that if these are needed then a physician must do it. We have very few problems with clotting, even in our post-op CVs with bleeding. We use the Atrium dry drainage system with the suction set at -15 for mediastinal tubes and -20 for pleurals. We used to use a mediastinal sump tube on our CVs to minimize clotting until the bleeding decreased then switched to Pleurevacs but found that we had more mediastinitis. Once we started using the Atrium system we got rid of those sumps and have only had one clot. Without stripping, milking, flicking or tapping.

Here are some journal articles on the subject.

Medscape: Medscape Access

Is Milking and Stripping Chest Tubes Really Necessary? -- Lim-Levy et al. 42 (1): 77 -- The Annals of Thoracic Surgery http://ajcc.aacnjournals.org/content/16/6/609.full.pdf

deepurple · Jul 29, 2012

thank you for those replying my question...

What i'd been practiced now in my ward which i handling post operative pediatric cardiac surgery.

Our surgeon was using the disposable bottle drainage which not connected with vacuum. The drainage will drain out follow the gravity. Under some circumstances, our surgeon will give order to connect CT to low suction but it's rarely.

I'd seen the ICU staff did stripping the CT on post op day. Which one is the good practice?

One more thing...what i had understand about the clamping of chest tube is to prevent back flow of drainage to pericardial or pleural and to avoid air from entering the chest tube if the connection is dislodged. Are these rationales incorrect?

umcRN, BSN, RN · Jul 29, 2012

Thanks Jan! That's the same device we use, I will definitely be taking a look at those sources. Using the same drainage system set to the same suction level I don't understand why we have clotting issues with our tubes...

Pediatric Critical Care Columnist · Aug 4, 2012

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!

umcRN, BSN, RN · Aug 5, 2012

janfrn said:
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!

We 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!

Pediatric Critical Care Columnist · Aug 5, 2012

The 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.