Chest tube removal after cardiac surgery

Comparison of two pain-management strategies during chest tube removal: Relaxation exercise with opioids and opioids alone

PURPOSE

The purpose of this study was to determine whether the use of a slow deep-breathing relaxation exercise, when used as an adjunct to opioid analgesia, decreases pain during chest tube removal (CTR) after coronary bypass surgery.

DESIGN

A two-group quasi-experimental pretest/posttest design was used.

SAMPLE

A convenience sample of 40 adults who had undergone coronary artery bypass graft surgery and met all inclusion criteria were recruited before CTR.

SETTING

Data were collected in the Cardiothoracic Surgical Intensive Care Units of three acute care facilities in the Midwestern United States.

METHOD

A 10-cm vertical Visual Analog Scale was used to measure pain at three points: before CTR, immediately after CTR, and 15 minutes after CTR. The experimental group received slow breathing relaxation exercises in addition to the usual opioid doses administered.

FINDINGS

Data were analyzed using analysis of variance, and multivariate analysis of covariance yielded a significant difference in pain ratings immediately after CTR and 15 minutes after CTR for the group receiving relaxation exercise as an adjunct to opioid analgesic.

CONCLUSIONS

This study supports the use of a slow deep-breathing relaxation exercise as an adjunct to the use of opioids for pain management during CTR among patients who have undergone coronary bypass surgery.

Nurses’ knowledge of chest drain care: an exploratory descriptive survey

Chest drains are a common feature of patients admitted to acute respiratory or cardio-thoracic surgery care areas. Chest drains are either inserted intraoperatively or as part of the conservative management of a respiratory illness or thoracic injury. Anecdotally, there appears to be a lack of consensus among nurses on the major principles of chest drain management. Many decisions tend to be based on personal factors rather than sound clinical evidence. This inconsistency of treatment regimes, together with the lack of evidence-based nursing care, creates a general uncertainty regarding the care of patients with chest drains. This study aimed to identify the nurses' levels of knowledge with regard to chest drain management. The research objective of this study was to describe the nurses' levels of knowledge regarding the care of the patient with chest drains. The data were collected using survey method. The results of the study revealed deficits in knowledge in a select group of nurses. Several service-led options exist with regard to improving knowledge in this area, such as service study days as well as ward-based tutorials. However, in an era of increasing accountability together with the impetus for each nurse to provide evidence-based care, it is crucial for individual nurse responsibility in the pursuit of knowledge in this area. Nurses must be supported by local practice development and through personal portfolio use to identify gaps in knowledge and seek appropriate training and resources.

Timing of Chest Tube Removal After Coronary Artery Bypass Surgery

AIM

Assessing the impact of chest tube removal timing following a coronary artery bypass grafting surgery on the clinical outcome.

METHODS

Eighty-three consecutive patients were randomly assigned to either have the chest tube removed 24 hours (Group A) or 48 hours (Group B) postoperatively. Chest tubes were removed on the condition that drainage was less than 100 cc for the last 8 hours. Pre- and postoperative data were analyzed.

RESULTS

The following preoperative and intraoperative risk factors were more prevalent among Group A patients: previous MI (60.5% vs 40.7%, p = 0.11), previous CVA (9.1% vs 0%, p = 0.11), hypertension (72.7% vs 55.6%, p = 0.14), pump time (111.6 min vs 96.8 min, p = 0.07), and cross-clamp time (73.8 min vs 64.4 min, p = 0.07). Postoperatively, there was a lower demand for analgesics in Group A (2.1 times for 12 hours at 36 hours vs 3.6 p = 0.09), lower white blood cell count (10,947 at 48 hours vs 11,576, p = 0.39) a higher oxygen saturation (91.9% at 48 hours vs 88.9%, p = 0.07), higher expiratory volumes (594 mL at 36 hours vs 514 mL p = 0.08) and earlier mobilization (23% walking at 48 hours vs 4%, p = 0.01). Pleural effusion and atelectasis were less frequent in Group A in both chest X-rays (66% vs 73%, p = 0.6 and 64% vs 75%, p = 0.47, respectively) and CT scans (19% vs 41%, p = 0.1 and 84% vs 96%, p = 0.42, respectively). There was no difference between the two groups in the prevalence of serous wound discharge and the length of hospital stay and there were no reported cases of pneumonia throughout the study.

CONCLUSION

In cases where no excessive drainage accumulates, early removal of the chest tubes was found to be a policy that improves the postoperative outcome and decreases the need for supportive treatment such as analgetics, physiotherapy, nurse care, and oxygen. This policy did not involve significant residual effusions.

Removing chest drains - a critical reflection of a complex clinical decision

Decision-making is a fundamental element of nursing work (Boblin-Cummings et al, 1999; Berggren and Severinsson, 2000; Bucknall, 2000) which fluctuates according to experience, location and personal boundaries. Nursing judgements are said to portray the nature of nursing knowledge and practice (Thompson, 1999; Buckingham and Adams, 2000a) and can affect others either favourably or adversely (Gordon et al., 1994), with Buckingham and Adams (2000a) emphasizing the benefits to be gained from understanding the process, including improved clinical effectiveness and self-knowledge. It is said that all decisions are made in one of two ways--hypothetico-deductively or intuitively (Dowie and Elstein, 1988; Thompson, 1999; Buckingham and Adams, 2000a)--although different titles are used interchangeably for the same modes. Both of these modalities are examined. Hypothetico-deductive reasoning entails exposure to information before and during the patient encounter. These data are grouped and used to generate a hypothesis or possible diagnosis. The second stance in decision-making is founded upon intuition and closely associated with expertise. The presence of chest drains after cardiothoracic surgery is known to cause severe pain, thereby interfering with respiratory mechanics and the ability to take part in physiotherapy exercises (Owen and Gould, 1997; Fox et al., 1999; Charnock and Evans, 2001; Lazzara, 2002). This work therefore aims to examine the decision-making processes in relation to the prompt removal of chest drains by analysing the options available and the skills required to utilize them effectively.

The efficacy of X-rays after chest tube removal

BACKGROUND

The insertion and subsequent removal of chest tubes are frequently performed procedures. We hypothesize that routine chest radiographs obtained after chest tube removal to confirm the absence of any post-procedure complications have little impact on clinical management.

MATERIALS AND METHODS

A 5-year retrospective study of 73 patients with tube thoracotomies was performed in a level II trauma center's intensive care unit. Patients were identified from billing records for chest tube placement. Medical records and official chest x-ray film reports, both before and after removal, were reviewed, and demographic data were collected.

RESULTS

Of the 73 patients examined, only 8 had postprocedure reports that differed from the preprocedure reports. Two of these 8 patients required reinsertion of a chest tube to treat the recurrence of a significant pneumothorax. However, the decision to reinsert the chest tube was based on the patient's clinical appearance rather than on the x-ray findings.

CONCLUSION

Chest radiography following the removal of chest tubes should not be a routinely performed procedure, but should preferably be based on the good clinical judgement and discrimination of the surgeon.

Sensations experienced during removal of tubes in acute postoperative patients

The major purpose of this study was to determine the types and intensity of sensations that patients experience when chest tubes (CTs) and Jackson-Pratt (JP) abdominal tubes are removed. A convenience sample of 62 hospitalized subjects, 31 with CTs and 31 with JP tubes, participated. Each subject was interviewed after tube removal. Sensations were identified, and intensity of sensation was marked on a 100-mm Visual Analogue Scale. Similar sensations were reported by both groups. Intensity of sensation was consistently higher in the JP group. The most frequently reported sensations were pain (77%) on JP tube removal and pulling (90%) upon CT removal.