Chest Tube Question

[lima470]

Hi all,

I recently encountered a situation with a patient. I work in an ICU. This patient was on a ventilator and was pretty sick. The chest tube was kinked and therefore stopped working. The patient had no symptoms (cardiovascular collapse etc.) except a low 02sat. I noticed it was kinked and straightened it out. Pt's 02 sat starts to improve. Lung re-expands. The patient then probably 30 mins later begins to have problems with blood pressure and BP quickly drops from 60's to 30's and the pt dies despite resuscitative efforts. I am wondering for my own learning do you think the partial pneumothorax could have caused the circulatory collapse? I know it is possible to not have symptoms resolve immediately after lung re-expansion. This patient was pretty unstable and on a lot of pressors. I feel guilty for not noticing the tube was kinked under the gown. What do you think?

[CVmursenary]

Just because its kinked doesnt mean it caused a pneumothorax; if it was bleeding or draining sanguinous fluid quickly then that is possible. Did much drainage come out after it was straightened out?

[Esme12, ASN, BSN, RN]

I think it's coincidental......for unkinking the tube would resolve the symptoms not worsen them.

[machaix]

Hmm... Not an answer to the question, but just related to the topic. Is it true that Chest Drains should be ideally checked every hour for the bubbling, draining and swinging? Thanks!

[turnforthenurse, MSN, NP]

Hmm... Not an answer to the question, but just related to the topic. Is it true that Chest Drains should be ideally checked every hour for the bubbling, draining and swinging? Thanks!

Check your hospital policy. They need to be checked frequently because critical situations CAN and DO happen, like a tension pneumothorax or sudden increase in drainage. Typically drainage of >100cc/hr needs to be reported, but again, check your hospital policy and it is also physician preference. It is also not uncommon to have >100cc/hr when the chest tube is first placed, but the amount of drainage should taper off.

[machaix]

Oh i see, thanks! :)

[Anicwalters]

Check your hospital policy. They need to be checked frequently because critical situations CAN and DO happen, like a tension pneumothorax or sudden increase in drainage. Typically drainage of >100cc/hr needs to be reported, but again, check your hospital policy and it is also physician preference. It is also not uncommon to have >100cc/hr when the chest tube is first placed, but the amount of drainage should taper off.

I thought this thread was interesting. Only last week I had a fresh post op CABG. Pt rolled out around 2 in the afternoon. At 7 during shift change I only had a total of 70 for my chest tube output. Everything seemed to be going well. Around 10 or 11 that night BP started dropping and CI began coming down and all of a sudden the patient dumped about 150. And through the night but out about 1100. Our concern was tamponade. So I check my drains very diligently for fluid as we hadn't much warning. Things change so quickly!!!!

[Guest343211]

You must frequently assess pleural or mediastinal chest tubes for many things, but remember this. If the tubes are kinked and there isn't the propert facilitation of drainage, blood could collect in the pericardial space, of if mediastinal, clots and clogs can prevent drainaining and lead to tamponade. as well.

There are surgical reasons for lack of chest tube drainage or too much chest tube drainage. There are also other clinical reasons or mechanical reasons--issues with suction, kinking, as you have stated. You can have medical reasons, such as the development of a coagulopathy or other dynamic changes, or changes related to various medication/s.

This is why so much is continually monitored in the immediate minutes and hours post open heart surgery. I have never worked in any OHS unit, for example, that didn't require q 1 hour or closer--can be q 5 minutes, q 15 minutes (depending on when the pt was brought to you out of the OR or if there was some acute change) and in some cases, it's pretty much continuously every minute. Part of this continual or at least very frequent assessment is checking chest tubes for drainage and the possibility of anything untoward every hour at the least--again more if there is something going on. Also, fresh out post-op is q 15 minutes, and back in the day, we used to shoot a lot of cardiac indices. You followed a whole system, and by the time you reassessed, re-shot, re-drew labs, drew ABG/CBGs, called for another chest film, drained and checked your tubes, foley, any other drainage systesm ,etc, titrated the appropriate medications, etc, it was time to do it all over again. But some things are different nowadays, also d/t the minimally invasive work coming from the OR. (I moved to kid hearts, so PA cathethers aren't what is usually followed for them--very rare in many kids, to shoot cardiac outputs.)

There is a huge protocol for immediate post-op recovery we followed at the best centers. And people watched until they were sure you knew what you were doing and following it. Too much can go wrong too quickly.

I know this doesn't seem like a fresh from the OR post-op unit player, but really, if someone is considered guarded or stable (within what that means in the critical care area), I still will check all lines and tubes for flow and proper function every hour, and I will document that I did so on the flow sheet.

Being anal retentive for good cause can be your best friend when working in these areas.

[respiratoryanna]

number 1 dont feel guilty- learn from this horrible experience. This could have happened whether there was a kink in the tube or not. Take care and think about writing a reflective account for your own learning and therapy. Talk to someone you trust. love a. xx