Chest tubes/Open Heart Surgery

[AmyCardsNP, RN, NP]

I had a patient ask me this question the other day, and I dont think the answer I gave was very complete (read: technical) so I was hoping someone could fill in the gaps for me:

After open heart surgery, what exactly is the chest tube draining? And why does it need to be there?

I understand the use of chest tubes in hemo/pneumothorax, pleural effusion, empyema situations on non-operative or post-operative patients as well as the purpose of the chest tubes directly post-op when the patient is actively bleeding. But I'm wondering more about a day or two down the road... when the chest tubes are in for a few days and continue to drain (besides for the initial dump when the patient gets out of bed for the first few times). Is that still blood that was caught in the chest cavity during surgery? If the chest tube was not in place would the fluid be reabsorbed into the tissue like it is in abdominal surgeries? (aside from frank bleeding immediately post-op, of course)

Thanks in advance

[Corey Narry, MSN, RN, NP]

There are usually 2 types of tubes used after cardiac surgery. Mediastinal tubes are placed in the pericardial space after surgey and are used to drain post-operative bleeding and pericardial effusion that usually occurs after heart surgery. Pleural tubes are sometimes used when the pleural space is entered such as when the LIMA was used as a graft. In this case, a left pleural chest tube will also be placed before closing the chest to drain blood, pleural fluid, or evacuate air introduced during surgery. Similarly, a right pleural tube is also used in some occasions when the right pleura was entered during surgery.

During the immediate post-op period, monitoring of chest tube drainage is of extreme importance because that is how we can tell if the patient is bleeding from a vessel that was not cauterized during closure of the chest, or in extreme cases, a ruptured graft. If the blood is not allowed to drain, this blood will collect in the pericardial space and cause tamponade that will impede cardiac pumping and decrease cardiac output. In these cases the patient is taken back to the OR for re-exploration. It is also important to make sure that the mediastinal tubes do not become clogged with clots during the immediate post-op period as this can prevent blood from draining and possibly cause tamponade. In less severe cases, non-surgical bleeding causes an increase in chest tube drainage such as when the patient is coagulopathic and/or hypothermic. These are corrected at the bedside.

You were wondering what is being drained a day or two after surgery when the initial dump of blood after sitting up has occured. There are varying opinions on this. If you notice, the drainage after a day or two tends to be more serous than anything else. Some surgeons say that the fact that the chest tube is left in place causes increased build up of pleural fluid and that is what we are seeing. There is a growing opinion that chest tubes should be removed as early as possible after cardiac surgery (even as early as within the first 24 hour period). Most places remove tubes if they have drained less than 100 ml in the last 8-hour period. A study I am attaching below showed that early chest tube removal was beneficial in minimizing post-operative pain, thus, contributing to increased use of incentive spirometry and deep breathing strategies to prevent atelectasis post-operatively.

[skilet]

Hi I will like to enquire what is LIMA and LAD? Why LIMA and LAD lead to insertion of pleural and mediastinal tube? Thanks.

By the way anyone know how much is the cost of a Edward VAMP? Usually the reservoir can conserve the blood for how long? Thanks.

[dean54]

Left Internal Mammary Artery (LIMA)

Left Anterior Descending Artery (LAD - Also known as the "widow maker," as high death rate when this artery occludes and causes an MI)

[joeyzstj, LPN]

Hi I will like to enquire what is LIMA and LAD? Why LIMA and LAD lead to insertion of pleural and mediastinal tube? Thanks.

By the way anyone know how much is the cost of a Edward VAMP? Usually the reservoir can conserve the blood for how long? Thanks.

As dean mentioned, the Left Internal Mammary Artery is on the inside of the chest wall cavity and is used very commonly due to the fact that is one of the few vessels in the body not effected by atherosclerosis, which means that it is ususally a pretty "clean" vessel to use. Using the LIMA has also been shown to have significatly less of a mortality rate and problems down the road for the patient. Its a goal for most hospitals to use it whenever possible as it decreases ICU time, Ventilator times and has better outcomes overall.

[skilet]

Thanks Dean and Joey :) Between do u have any articles to support the LIMA and the LAD indicate why they chosen LIMA and LAD that lead to the pleural and mediasternal chest drains?

Like Joey, u mentioned about the adavntages of the LIMA. Do u have the articles that I can read further? Once again thanks.

[skutt]

it helped me to think of the chest and lungs as a glass jar and balloons. The balloons fit inside the glass jar and are full of air. When surgery (thoracic or cardiac) is performed and one of the balloons looses air and the space between it and the glass fills with serous and or bloody drainage. This drainage must have some where to go if it is a large amount which most likely it is. Therefore the need for chest tubes to drain it away. In my facility the tubes are removed when drainage is 150 to 200 ml in 24 hours. Most often this is the second or third day, occassionaly the first day. Pts usually do much better after removal of the tubes mainly due to pain issues. Most of our pts go home on the third day after surgery.