Consider Bleeding Around a Chest Tube to be a Sign of Bleeding in the Chest Cavity Until Proven Otherwise

Consider Bleeding Around a Chest Tube to be a Sign of Bleeding in the Chest Cavity Until Proven Otherwise

David J. Caparrelli MD

Establishing adequate drainage of the mediastinumand pleural cavities at the time of surgery plays an extremely important role in the postoperative care of patients at risk for intrathoracic or mediastinal hemorrhage. Adequate drainage allows early recognition of surgically correctable bleeding and the prevention of life-threatening complications such as cardiac tamponade and tension pneumothorax. Traditionally, such drainage has been achieved with large-bore plastic chest tubes. Typically a combination of straight and right-angle tubes measuring between 28 French (F) and 32F in diameter are used after open cardiac surgery (e.g., coronary artery bypass), whereas straight tubes alone are most often used after elective thoracic procedures (e.g., lobectomy). However, these rigid tubes can be quite painful, damage bypass grafts, impair ventilation, and cause cardiac arrhythmias. For these reasons, many surgeons have recently adopted the use of smaller (19F or 24F), more flexible, fluted Silastic drains. Clinical data have demonstrated that these drains cause less pain and are as effective as their more rigid predecessors. Currently, in cardiac surgery, many advocate the use of one rigid chest tube in the mediastinum (32F) in conjunction with flexible Silastic drains (19F) to drain the pleural spaces. Typically, the mediastinal tube is removed on postoperative day one, whereas the Silastic drains remain in place until drainage is deemed appropriately low (usually 100 cc/24 h) for removal. For noncardiac thoracic procedures, where re-expansion of the lung and the management of air leaks are more of a priority than risk of hemorrhage, large-bore rigid chest tubes still predominate.

Watch Out For

Regardless of the type of tube chosen, early recognition of significant intrathoracic hemorrhage is vital in the care of cardiac and thoracic surgical patients. In the early postoperative period, frequent monitoring of both the quantity and the quality of the chest tube output is essential. Often chest tube output will be high (>100 cc/h) over the first few hours as efforts are made to warm the patient and correct residual coagulopathy. Ongoing bleeding despite repletion of coagulation factors (usually with fresh-frozen plasma) and platelet transfusions is
suggestive of surgically correctable hemorrhage. If chest tube output is low and/or there is significant clot forming in the tubes, one must be concerned with undrained ongoing hemorrhage in any patient with persistent transfusion requirements. Moreover, significant bleeding around a chest tube should be considered a sign of hemorrhage in the chest cavity until proven otherwise; the chest tube may well allow capillary drainage around the tube, even if the lumen of the tube is not draining, perhaps due to a blockage.

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Consider Bleeding Around a Chest Tube to be a Sign of Bleeding in the Chest Cavity Until Proven Otherwise

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