Mediastinal Bleeding and Turning

joeyzstj, LPN · Sep 23, 2008

If you have a patient less than 12 hours post op CABG with bleeding greater than 100ml/hr from mediastinal tubes what is your hospitals policy regarding turning this patient?

We dont have a policy that addresses this specificially. We do turn people, however we usually do it if we suspect that they are bleeding and are showing early signs of tamonade.12 hours post op bleeding at that rate would problably need a review of the coags, possibly some FFP/platelets/cryo/Protamine/vitaminK, ect, ect or possibly even taken back to explore. We dont get that excited about bleeding rates anywhere close to 100 initially, however I would start to be concerned after that long at that rate.

ICU/CCU, BSN, RN · Sep 23, 2008

I agree with joeyzstj that products may be indicated or the patient may need to return to the OR. Our policy doesn't specifically cover turning, but it will help to get the blood out and it is doubtful that would cause the bleeding to increase. Our policy does state to call the CV surgeon if the pt has 100cc/h x 2 hours. If that continues, something has to be done.

allnurses Guide · Sep 23, 2008

No policy, but anecdotally we always did turn them to shake things loose, esp if the drainage dropped off suddenly.

ghmccart · Sep 25, 2008

if we have MT bleeding > 100 ml/hr x2 hr or >200 ml/hr x1 we call, then most likely check serial coags/cbc, consider underlying cause medical or surgical, then consider tight BP control, consider adding 10 of peep, focused med management etc. Our surgeon is a serious blood conservationist, we hate hate hate to transfuse patients so I am all over any signs of incresing mediastinal bleeding. Oh and always be aware of tamponade, get a chest film to assess for mediastinal widening! Proactive instead of reactive is my policy.

mtwedt · Sep 25, 2008

Our institution has no policy regarding this situation, but I agree with the other respondents. The issue is the bleeding at a rate of 100ml/hr. beyond the first few hours. A coagulopathy work up is indicated. Turning facilitates drainage and therefore reduces potential tamponade. We have an early extubation protocol and most of us "rock and roll" the patient from side to side to get them off their surgical linen and evaluate drainage. Did they just dump or are they going to keep it up? We also generally don't remove chest tubes until the patient has been up in the chair in uncomplicated recovery. Again, an opportunity to dump. I have never heard of, nor would I countenance, turning as the "cause" of someone's bleeding. An agitated, intubated patient who is bucking the vent and dancing all over the bed, certainly could increase their rate of bleeding by jacking their BP all over the place. I prefer to take my bleeding patients to an SBP of 100 and keep them sedated and intubated until I have the matter sorted out either with or without return to CVOR.

jbp0529 · Sep 26, 2008

Reminds me of a story:

Had a pt the other week who INITIALLY did not bleed much (we're talking, about 40 cc's per hour for the first 4 hours since arrival from OR). Then suddenly, started putting out 100 cc's/hr. Hmm... Then dumped a TON...400cc's for one hour. I resent an H/H, coags, fibrinogen... the O/A labs from OR were normal though.

Called the surgeon...."give him some albumin". Ummmm.....ok..... Gave the albumin. Next 1/2 hour...300 ml. Called again. Hgb back...down from arrival of 11.7 to 9.0. Coags normal. Fibrinogen normal. CVP running ~ 3, down from 6-8. PAD running about 6-8, down from 10-12. BP marginal, low 90's. Index = 2.1. Nitro stopped. Told the doc all this... the guy's dry and bleeding. "More albumin" he says. "And go up on the Epi". Clearly, this guy's gonna need a transfusion...but whatever. Next hour...total of 500 ml out ( !!!!!), BP 70-80's, CVP = 1-2, Index now 1.8, Hgb now 7.7. Called again (now I'm getting upset) "can we PLEASE give this guy blood!! And can you PLEASE come in and fix this!!" Doc: "ok give him 2 units. I'm gonna shower. Be in soon." :angryfire

So he casually strolled in a little later, ordered a few more packed cells, mobilized the OR team, took the pt back, fixed the bleeder. Pt did ok afterward.

Just frustrating when there is no sense of urgency on the other end of the telephone sometimes. :banghead:

Anyway, not sure what our policy is, but this guy didnt get turned much on my shift lol