Milking chest tubes

gracieD · Feb 22, 2011

First of all, Milking and Stripping a chest tube are really two totally different things.

Joey - I guess I have used and heard these terms used interchangeably - what is the difference?

TakeBack · Mar 2, 2011

I've been doing this a while and have NEVER seen a negative outcome from any sort of CT maneuver- milking, stripping or suctioning.

I HAVE seen tubes that drain several hundred ccs after clearing them by any of the above methods.

If you have a tube with a single port- like a garden hose- then it potentially could suction to a structure. Most tubes have multiple ports and these act like a pressure relief valve (think of the side hole on a yankeur).

Gentle milking/stripping is fine. Even forceful stripping is unlikely to cause a problem other than a sore hand and the likelihood of pulling the tube out!

richard1980 · Mar 2, 2011

Depends if they are bleeding or not. I always strip my chest tubes on CT surgery pts. Sometimes its only a couple times the first shift they come up from the OR...other times you're stripping until you hands feel like they're gonna fall off. You really can't get clots out from the insertion site just by "milking." You have to strip the hell out of the tube sometimes. Other times its not necessary. I've only stripped a pleural tube at the request of the surgeon....anastomotic leak from esophagogastrectomy and the chest tube was putting out pure nastiness. As far as the AACN procedure manual goes, I don't know...never checked what they have to say about "stripping." But they also say you shouldn't have your sxn for ETT suctioning turned up very high. If your ETT is clogging because theres so much crap coming out of it you do what you gotta do.... Best practice doesn't fit every patient every time.

richard1980 · Mar 2, 2011

As long as we're on the subject.... whats the most output you've seen in the shortest period of time out of a mediastinal chest tube? Couple years ago I had a guy come up and dump 3+L in the first hour and a half before going back to surgery.

TakeBack · Mar 3, 2011

As long as we're on the subject.... whats the most output you've seen in the shortest period of time out of a mediastinal chest tube? Couple years ago I had a guy come up and dump 3+L in the first hour and a half before going back to surgery.

A few liters in 10-15 mins. We didn't wait the full hr to get the chest open.

tahoe77 · Mar 23, 2011

There is a difference between milking and striping the Chest tube.

I went to a class at stanford and they showed pictures of a heart where

the nurses had been striping the CT after CABG. The negative

pressure from striping actually sucked the grafts off the heart

and the picture was taken on autopsy.... need I say more?

Milking is when you just pinch brief the tube WITHOUT sliding

it down to try to move any fluid along that might accumulated

in the tube.... but I am sure you already know all this.

So milking is different from Striping.

richard1980 · Mar 24, 2011

There is a difference between milking and striping the Chest tube.
I went to a class at stanford and they showed pictures of a heart where
the nurses had been striping the CT after CABG. The negative
pressure from striping actually sucked the grafts off the heart
and the picture was taken on autopsy.... need I say more?
Milking is when you just pinch brief the tube WITHOUT sliding
it down to try to move any fluid along that might accumulated
in the tube.... but I am sure you already know all this.
So milking is different from Striping.

"A class at Stanford" eh? When did they become the authority on CT management...? Just kidding. :-P All sarcasm aside, the competent nurse should use his or her judgement on the selection of gentle "milking" or aggressive "stripping." There is a place for both practices in the care of post cardiothoracic surgical patients. I've seen a surgeon cut the CT and stick a sterile yaunker with full suction into someones chest to suck out clots. Thats a hell of a lot more negative pressure (considering he pinched the sides of the chest tube wall) than I could generate stripping a tube....

I'm not encouraging reckless stripping of tubes but faced with the outcome of a tamponade you do what you have to do to generate the best end-outcome for the patient.

tahoe77 · Mar 24, 2011

Well yes obviously when faced with life threatening emergency such

as tamponade in which case you have obviously contacted the surgeon and are simply

trying to keep the pt alive sure. But surely you are not

condoning striping as a regular practice as a whole.

And if the surgeon wants to cut the chest tube and insert

a yankie than that is their call during that emergency.

Even still there is a difference between this one time emergency

and the regular practice of striping the chest tube every shift

repeatedly which I guess some nurses do.

All I am saying is that I say the picture of the autopsy and

the grafts were no longer attached. it was attributed to aggressive striping. (now theres a

funny phrase "aggressive striping")

tahoe77 · Mar 24, 2011

"http://http://ajcc.aacnjournals.org/content/16/6/609.full.pdf+html"]http://http://ajcc.aacnjournals.org/content/16/6/609.full.pdf+html[/url]

http://ajcc.aacnjournals.org/content/16/6/609.full.pdf+html

Hopefully the above links worked. From the study titled "To strip or not to strip: the physiologic effects of chest tube manipulation"

Under the paragraph "adverse clinical consequences" they say the pressure created from striping 5 inches of chest tube has a median

of -87 cm H20.

Now you gotta think about how far you actually strip the tube. Most people I would say at least strip a foot. So that's over double that amount of pressure!

If I find the picture of the autopsy from my class I will scan and post it here. :nurse:

richard1980 · Mar 24, 2011

Well yes obviously when faced with life threatening emergency such
as tamponade in which case you have obviously contacted the surgeon and are simply
trying to keep the pt alive sure. But surely you are not
condoning striping as a regular practice as a whole.
And if the surgeon wants to cut the chest tube and insert
a yankie than that is their call during that emergency.
Even still there is a difference between this one time emergency
and the regular practice of striping the chest tube every shift
repeatedly which I guess some nurses do.
All I am saying is that I say the picture of the autopsy and
the grafts were no longer attached. it was attributed to aggressive striping. (now theres a
funny phrase "aggressive striping")

I will continue to strip chest tubes as needed as I have been instructed by my surgeon and are written into our post op heart orders. I think if theres any question, ask the surgeon what he or she wants.

richard1980 · Mar 24, 2011

Addendum: In 6 plus years of taking care of heart patients I have never had or seen a negative outcome from keeping the tubes patent...only from letting them occlude by not being aggressive enough.

TakeBack · Mar 24, 2011

"A class at Stanford" eh? When did they become the authority on CT management...? Just kidding. :-P All sarcasm aside, the competent nurse should use his or her judgement on the selection of gentle "milking" or aggressive "stripping." There is a place for both practices in the care of post cardiothoracic surgical patients. I've seen a surgeon cut the CT and stick a sterile yaunker with full suction into someones chest to suck out clots. Thats a hell of a lot more negative pressure (considering he pinched the sides of the chest tube wall) than I could generate stripping a tube....
I'm not encouraging reckless stripping of tubes but faced with the outcome of a tamponade you do what you have to do to generate the best end-outcome for the patient.

Agree. I use ETT suction caths to evacuate CTs all the time.