Questions- I just don't get it..

CCU BSN RN · May 26, 2017

Okay, lot of good questions, I'll give it a shot.

Typically after CABG, patients will come back with a few mediastinal chest tubes. Typically 2, typically located centrally, exiting a few inches below the distal pole of the sternal incision. These drain blood and fluid from the mediastinum to prevent tamponade. Typically around 2 days postop, but some patients are just oozier than others. Sometimes they were on blood thinners or antiplatelets pre-op, resternotomies are typically oozier, etc.

Typically will also have at least one pleural tube, especially if the LIMA is used as a graft site. Sometimes bilateral pleural tubes. They're the same type of tube used for an effusion, but sometimes they're placed closer to the apex of the lung if the intention is to prevent/treat pneumothorax as opposed to effusion. It's not entirely atypical to have 2 chest tubes in the same pleural space, one at the apex for air and one closer to the base for effusion.

In an ideal world, all these tubes would be out by postop day 2, yes. In reality, patients ooze, they get pneumos, they have huge volume shifts which create effusions, etc. Plenty of patients keep their tubes for several days, if they're in for drainage, most surgeons have a 24 hour goal for drainage that must be met before tubes can be pulled. Many will want the patient OOB to make sure no additional fluid dumps prior to making the decision to pull them.

Now we get into some GI/GU questions that make me assume you're talking about a specific family member or close contact, and which are going to be very difficult to answer without additional information.

If the patient is oliguric for a few days and then anuric, and didn't have kidney failure before CABG, they were probably hypotensive/in hypovolemic shock at some point postoperatively for a prolonged period which caused AKI. Hopefully short term dialysis can correct it. If they had renal failure and were on dialysis pre-op, then they'll continue on it, and yes CABG will worsen renal function in a patient with CKD in a lot of cases.

Where does the fluid go? Pleural effusions and third spacing (e.g. edema, ascites, anasarca, etc.). We give diuretics to try to remove fluid, but if a patient is already on dialysis, we would remove more fluid in dialysis. Fluids are also removed via thoracentesis or chest tubes, yes.

A pleural effusion in and of itself will not typically cause abdominal distention, but you mentioned things not coming out of the GI system, so is it possible that we are talking about an ileus or SBO? Ascites is also an option when talking about the abdomen in the setting of renal failure and excess volume.