Surveys
Sometimes it seems like the surgeons are on one page, the APPS on another and the intensivist are reading a completely different book all together.
Here is a survey to help us understand how we think about the same problem. This survey is not about right and wrong answers, but is a way to help understand how we all think about certain scenarios.
Chest Tube Management Results
S/P Heart Tranplant
61 YOM POD 5 from a heart transplant. NSR 95 BPM, pacer wires removed. Extubated and waiting transfer to the floor. The patient is scheduled for a heart biopsy in 2 days, and we are leaving introducer for biopsy.
Chest Tubes
Drain Blake 1 (Medial Mediastinal)
Drain Blake 2 (Right Chest)
Drain 3 (Medial Mediastinal)
Drain Blake 4 (Medial Mediastinal)
Outputs
4Hr:10 ml 24hr:100ml
4Hr: 0 ml 24hr: 20 ml
4Hr: 85 ml 24hr: 90ml
4Hr: 20ml 24hr: 60ml
There appears to be two different distributions here with nurses and intensivists being more conservative and surgeons and APPs being more aggressive with chest tube pulls.
There is good agreement amongst the surgeons to pull 3 tubes and leave 1 in. Their rationale for this is when the patient goes for the first biopsy, if there is bleeding leaving at least one mediastinal drain may prevent tamponade
S/P Mechanical MVR
38 YOF who presents for mechanical mitral valve. No wires with first degree AV block, heart rate of 78. Extubated but having problems with pain control on Suboxone. Currently on bival infusion with a therapeutic PTT. How would you handle anticoagulation for chest tube pull.
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Pull without holding anticoagulation
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Pause anticoagulation prior to pulling given high risk mechanical valve and restart after one hour
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Hold anticoagulation for 2 hours prior to pulling and restart after 1 hour.
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Hold anticoagulation for 4 hours and restart after 2 hours
There seems to be good agreement here amongst providers to hold for 2 hours and then pull.
Chest Tube Policy
from Policy Stat
For all cardiac surgery patients both minimally invasive or open approach, surgical chest blake drains or surgical chest tubes can be removed without stopping intravenous based anticoagulation (heparin, bivalirudin, etc) if the patient meets the following criteria:
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Is without any hyper or hypocoagulopathies (DVT/PEs, Intracardiac Thrombus, Vascular Compromise/severe PAD, etc.)
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Has an INR of less than 2.0
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Has had no blood transfusion in 24 hours
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Has had drain output of less than 100cc in last 12hrs and less than 300cc in last 24hrs
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Does not have a mechanical mitral valve or LVAD
For patients who have received a mechanical mitral valve or LVAD, surgical chest blake drains or surgical chest tubes can be removed by holding (delay function on Alaris pump) intravenous based anticoagulation with a provider order for two (2) hours prior to drain removal and one (1) hour post drain removal.
For in a patient in a hypercoagulable state (DVT/PEs, Intracardiac Thrombus, Vascular Compromise/severe PAD, etc.), stopping of anticoagulation should be done on a case by case basis in conjunction with the attending cardiac surgeon.
S/P Mechanical AVR
67 YOM POD 2 s/p elective AVR and 1V CABG LIMA to LAD. Extubated, doing well, no wires no pressors. Some lability with standing.
Chest Tubes
Drain Blake 1 (Medial Mediastinal)
Drain Blake 2 (Left Chest)
Drain Blake 3 (Left Chest)
Outputs: Thin
12Hr: 80ml 24hr: 250ml
12Hr: 0 ml 24hr: 20 ml
12Hr: 110 ml 24hr: 200ml
Here the surgeons are much more aggressive in pulling chest tubes then all other providers.
