[[400 Technical Outline of Aortic Valve Replacement]] # Chest Tube Placement - The chest tubes are positioned for optimal drainage, and as an early warning system for excessive bleeding - As for drainage, it is undeniable that there is good literary support for posterior pericardiotomy (in cases where the left pleura has been opened) - You are far less likely to have tamponade - You are significantly less likely to have atrial fibrillation from the irritation of accumulated pericardial blood - That said, I am too fond of the ability to distinguish pleural vs mediastinal sources of bleeding to give up my chest tube system just yet - Tube Options - A pericardial tube, a right angle directed posteriorly - Not so far in that it will press on a posterior graft - Directed left of midline for optimal drainage and to avoid RCA/rPD grafts - An anterior tube, underneath the sternum, with the tip directed in a little blow-hole in the right pleura, just big enough for the tube - The anterior blow-hole tube has just the tip in the right pleura - This stops the tube from migrating into the sternal closure, where it can be pinched between the sternal edges inadvertently - The tube doesn’t “windshield wiper” any anterior grafts - Pleural tube - Right angle tube, directed so it lays in the “gutter” formed by the most dependent part of the pleural space, where the diaphragm meets the chest wall, reaching the costo-vertebral angle as best possible - To facilitate the course of the pleural tube, the left pleural tube will emerge right of midline from the skin, and the right pleural tube will emerge from the left of midline. - Most commonly, the left pleural space is drained this way - If a RIMA was harvested, the right pleural space is also drained this way - If the right pleura was unexpectedly opened widely during sternotomy (common in COPD), and there is potential for fluid to enter the right chest easily, a right angle tube into the right chest is used to drain the right pleura - Since I like to keep the number of chest tubes at two, if I have a left pleural right angle tube and a right pleural right angle tube, I will use a heavy scissors to cut an extra side hole in the right pleural tube where it lies in the anterior pericardial space to give me a little extra pericardial drainage. - I have not personally found it necessary to go directly through the chest wall to drain the pleura. These are effective, but more uncomfortable. - Blake Drains - The most comfortable drainage tube - Easy to direct wherever you wish them to go - Good for tight spaces, less likely to push down on structures rigidly - They do require additional attention by nursing early on to strip them to encourage drainage - I have used them as the sole method of drainage early in my career, following the examply of one of my partners, but they really can’t be used for the standard “Chest Tube Timing” hemostasis assessment ritual that I find so valuable - I only use them very occasionally as adjuncts. - Typical Tube Combinations (usually two) - In an AVR or MVR, I like - First, a right angle tube directed from right of midline, posteriorly into the apical pericardial space - With a course that lies on top of the right angle tube, an anterior blowhole tube, crossing from left of midline to position a couple of centimenters of tip into the right pleural blowhole - In a CABG, I like - First, a right angle tube directed from right of midline, posteriorly into the gutter of the left pleural space - With a course that lies on top of the right angle tube, an anterior blowhole tube, crossing from left of midline to position a couple of centimenters of tip into the right pleural blowhole - Chest Tube Position - I like tubes to be fairly distant from the incision - I think this creates a nice long track that minimizes the possibility of bacterial ascension along the tube to contaminate the sternum - When the tubes are removed, this nice long track is a nice long flap valve to prevent influx of air, and to discourage contamination. - Something like the length of your index finger away from the southernmost extent of the skin incision, for reasons that will become apparent. - Chest Tube Insertion - Create a space pre-peritoneally on either side of the linea alba with the index and middle finger of the left handby sliding them right underneath the rectus abdominis. - No need to waggle them around, no advantage to this, and only can cause bleeding - Guided by the position of the fingers, make a 1.25 skin incision a little bit below the tips of the fingers with a No. 10 blade, complete with the cut electrocautery. - If there is bleeding, mercilessly cauterize - Take a tonsil clamp in the right hand, tip facing down, and drive this tip ON TO YOUR FINGERS (a very important element of this maneuver) - Turn the tip of the tonsil up so it rests on the pad of your finger, and push the tonsil in to the patient as you withdraw your finger, always maintaining contact with the finger until you can see the tip of the clamp in the incision. - Use the tip of the tonsil to grab the tapered end of the chest tube to pull it out through the tract you have created. - The tract should be nice and tight - If you have a great deal of difficulty pulling the tube through, you can twist the tonsil to corkscrew the tube, which slims the profile and hardens the plastic and facilitates the maneuver - You can “floss” the tube in the tract if you want to open it up a little. - Following this method, it should be impossible to injure any viscera because the tube will never enter the peritoneum - Beware of abdominal incisions: adhesions can pin up a loop of bowel to the anterior abdominal wall and create a risk of perforation - Midline incisions, go a little bit away from the midline, and you will be able to slide into the pre-peritoneal space. Try not to go too far away from midline so you don’t risk injury to an internal epigastric - Transverse incisions: be very careful indeed. Avoid that space, accept Blakes and direct pleural tubes if necessary. - Getting the best lie of a pleural tube - Once the right angle tube is sliding well in the tract, push it in to the left chest using your right hand outside the insertion site - With your left hand, push the side of the tube from within the left pleura to direct it into the gutter - Rotate the tube gently clockwise with your right hand as you push it in so curves along the chest wall until you reach the square black mark on the tube at the skin, - You can pull the tube out a little with a reverse counterclockwise motion to make sure it hasn’t kinked There is a specialized chest tube pulling instrument that can nicely take the place of the tonsil if you have it, called an “Alley Clamp”, which I have nicknamed the “Alley Gator” because of its appearance.