? about pulling chest tubes

[st4304]

I work in a post open heart unit. When I pull chest tubes, I pain medicate the patient about 30 min. prior, and then quickly pull the CTs one at a time, pulling up on the sutures, and tying them off. Patients tolerate this very well, and seldom complain of pain during this procedure.

Yesterday, an experienced nurse new to our hosp/unit asked me to help her pull her patient's CTs. We set everything up, and she told the patient "This is going to hurt," and then proceeded to pull all three CTs at the same time. The patient cried out and visibly paled. At first he couldn't catch his breath (I was afraid she had pulled out a lung!) but he wasn't breathing because he was in so much pain! We finally got him to calm down and he did fine after that. Later, when I went in his room to check his beeping IV pump, he told me that that was the worst thing he had ever lived through (and this was a veteran of Vietnam!)

The nurse states that this is how they all pulled CTs at her former hosp/unit.

I know that at many hosps the PAs or surgeons pull the CTs, but those of you who do pull CTs, do you do them all at once or one at a time? If you do pull all of them at once, can you give me the rationale? Her rationale was "That's how I was taught."

Just curious.

Your pal,

Sherri

[Sleepyeyes]

Having recently been a victim of 2 8"long CT's, I vote for your method.

Doc later explained that I was having muscle spasms due to irritated intercostal nerves, so I needed pretty heavy pain meds to keep me breathing comfortably. He also tested me to see if the brachial plexus had any injury; it didn't. And then when I explained that I had a patch of numbness, he said it may or may not go away within 6 months.

Mind you, I had no real sx. I had just some tissue samples removed. So I came away with new respect for my poor pts. with CT's and a big determination to keep 'em medicated to help them breathe.

And PS, yes I was medicated when he took them out. I was so afraid of the pain by then, I couldn't look and braced myself bigtime--but it didn't hurt. thank god. :stone:

[ERNurse752, RN]

When I've pulled CT's before, I premedicated the pts (most often with MSO4), took out the sutures with a suture removal kit, and pulled them one at a time. Didn't get many complaints...that's how we all did it there.

Can't imagine yanking 'em all at once, with no pain meds...

[NRSKarenRN, BSN, RN]

May she get her CT some day!!

Premedicate 30 min prior removal, snip sutures and remove one at a time, apply occlusive dressing immediately. Assess lungs for inflation/ resp distress.

99.5 success rate. ( one pt 's lung had recurrent pneumpthorax within 12 hrs).

[Tinkertots]

I always premedicate! I used to work in a Tampa hospital where this incredible doctor invented a chest tube where the nurse could instill marcaine directly into the space where the chest tube ended. Basically it was a very tiny tube that ran on the outside of the chest tube. And on the end of the tube (that was outside of the body) was a little iv prn adapter. We would instill 30cc of marcaine every 6 hours and then just before pulling the CT... This kept everything numb and everyone happy!

[st4304]

I am really sorry that I left out that she had medicated him 30 min prior to pulling the CTs. Sorry about that!

I guess my concern was pulling them all at the same time just seemed soooooooo painful to him, despite being premedicated! I am glad to hear that you guys also pull one at a time.

I looked up our policy and it doesn't specify whether to pull them one at a time or all at the same time. I think I am going to mention to my manager that we might want to add that to our policy so that we are all doing it the same way.

Thanks for all your responses!

Sherri

[Sleepyeyes]

My doc pulled them one at a time, just FYI. (My daughter watched--she's gonna be a nurse.)

[Jenny P]

Working nights, I'm not involved with the pulling of chest tubes anymore. I do know that back when I worked evenings (>10yrs. ago), when chest tubes were pulled, they were often pulled (by the docs back then) all at once. Pre-medicating and helping the patient relax (instead of telling them "this is going to hurt") does make a big difference in how the pt. perceives and tolerates the procedure.

[renerian, BSN, RN]

Wow three at once would really really be more than I could bear I think. I vote for your method. Seems more humane.

renerian

[Dazedgiggle]

Sherri, where are the tubes you D/C? I'm only curious because when it comes to pleural tubes that are inserted between the ribs, the PA-C's pull them and it does seem to cause some discomort, but it seems to go away quickly. I also work on a post cardiac surgical unit and RN's pull all mediastinal/pleural tubes that the patients come out of surgery with.......inserted below the rib cage. We use 3 different types-Argyles, Atriums and Blakes. I've never pre-medicated, always pull all at the same time, sometimes 2, sometimes 3. Patients have always told me they only feel a 'pulling' feeling, never pain......otherwise I'd certainly pre-medicate. It certainly does sound like you need to add pulling only one at a time to your policy, might just be that different surgeons insert them in different ways.

[st4304]

dazegiggle --

I work in a post open heart unit and all CTs are placed medial (not through ribs). We use Atriums and Blakes. Usually leave the Blake in attached to a JP suction bulb until day before pt. goes home.

I think you might be right in how surgeons place them in different ways. The nurse I referred to in my original post stated that her patients usually tolerated all chest tubes pulled at once with very little c/o pain. I will still pull mine one at a time, if just for my own peace of mind!

Your pal,

Sherri