Questions about Mediastinal Sumps

[NotReady4PrimeTime, RN]

Here're a few questions for those nurses who work in a unit providing post-op CV surgical care...

1] Do your surgeons use mediastinal sump chest tubes in the initial post-op period?

2] What is your unit's protocol for maintaining patency of these?

3] How often does your unit have problems with clotted CTs?

4] What is your unit's protocol for sump CTs when the sternum is open?

5] Who makes the switch to water seal suction? The RN or the surgeon/fellow?

All of our CV surgical patients have mediastinal sumps in the first hours to days post-op. Our usual practice is to flush with sterile saline (frequency seems to be left up to the nurse... I usually will flush every fifteen minutes until the character of the drainage changes, especially with an open sternum) and when the sternum is open, to use intermittent lowish suction. Last night I took over care of an 11 day old who'd had VSD and PDA closure and coarct repair done on days who also had an open sternum. The nurse who had admitted him from the OR is one of our relatively junior nurses. My first order of business after report with these little gaffers is always to assess patency of the CT and you guessed it... it was clotted. The admitting nurse hadn't even left the unit when this was revealed. The PICU fellow, the CV surgery fellow and I took turns for three hours trying to reestablish patency of this tube. We ended up using the dreaded $500 Fogarty embolectomy catheter. This is the second time I've been through this particular experience, both times on the night shift on the operative day and both times following a junior nurse. It's making me wonder just what they're being taught about how to manage these tubes, and what they're not. I'm locally famous for my surveys and I've just invited you all to take part in my most recent one! Thanks in advance for your replies.

[jenpicuRN]

Our CT surgeons are very anal when it comes to their patients. Unfortunately they do not leave much up to the RN to do whrn it comes to critical elements such as CTs. They come to the unit so often that they fool with patency issues. They like to be very much in control.

[nursprl]

The cardiac surgeons I've worked with insert a flexible and large diameter CT that we can strip...starting near the insertion site and down the length of the tube. For fresh post-ops or those actively bleeding, they want us to strip at least every hour to remain patency and the pleuravac containers are always on suction until the CT are DC'd. We dont flush out CT tubes and if it clots we'll let the surgeons know...from there they may come up and suction out the clot or change it out but only if its dire, but it's up to us to "strip" the tube well.

[NotReady4PrimeTime, RN]

Our CV post-op chest tubes are always sump tubes which HAVE to be flushed to keep them patent. We used to use PleurEvacs to maximum wall suction (except in kids with open sternums) right from the OR, but the redesigned dry systems are not recommended for use in that way and our hospital is all about economies of scale, so those are the only PleurEvacs we stock now. SO instead, the tube drains into a Medi-Vac 200mL cone-shaped canister piggybacked onto the larger standard Medi-Vac suction set-up, with the regulator set for either continuous high suction for closed sternums, or medium intermittent suction for open ones. Nurses are not really supposed to strip these tubes but we all do it if the suction in the flush lumen is decreased. Often this is enough to get things moving again, but there are times when it doesn't help. Once the volume of drainage decreases to a minimum, we convert the tubes to PleurEvac dry suction by putting an antireflux valve (closed end) into the flush port to seal it off.

I spoke with our clinical educator today and she had no idea there were all these problems with our sump tubes...

[nursprl]

We are allowed to strip the CT because you will not have a MD sit at the bedside stripping the CT unless the patient is crashing. We ended up switching to the dry suction pleuravacs and they seem to work pretty well.