Sponges are unfortunately one of the most common retained foreign bodies. This is due to their small, flimsy nature. The surgeon usually looks at the obviously visible areas of the abdomen or other body cavity before closing. She can also feel around in the “nooks and crannies”, but sponges feel very similar to the other organs surrounding it.

But what about more substantial items, like surgical instruments? Surely these are so obvious as to not leave behind?

Unfortunately, not so. Take a look at these items. This is a large pari of surgical forceps.

This is a malleable retractor, a long, thin sheet of pliable metal that can be bent to any desired shape.

And finally, a pair of Metzenbaum scissor, a common surgical instrument for cutting tissue.

Bottom line: It doesn’t matter how small or large, anything can and will be left behind in emergent and trauma cases. Recognizing that this can occur, no matter how confident you are that it has not, is the key. Always count, but followup with an x-ray that covers all areas of the surgical field before closing.

Related post:

• What does a retained surgical sponge look like?

The September newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is chest trauma.

In this issue you’ll find articles on:

• Why I didn’t like finger thoracostomy
• Advanced needle thoracostomy
• Trochar vs needle for tension pneumothorax
• Troubleshooting chest tube air leaks
• Chest tube collection systems gone wild
• Managing chest tube air leaks
• Pneumothorax in children

Subscribers received the newsletter first last weekend. If you want to subscribe (and download back issues), click here.

Click here to download and/or subscribe.

Trauma surgeons frequently place some type of drain in their patients, whether it be a chest tube, a damage control system, or a bulb suction drain near the pancreas. On occasion, nursing may become concerned with the character of the output, wondering if the patient is bleeding significantly. How can you tell if the output is too bloody?

First, most drains are in place to drain serous fluid which may have a little blood in it. Drainage that is mostly bloody is very uncommon from these drains, which are typically placed after orthopedic, spine or abdominal surgery. However, some drains are placed in areas where unexpected bleeding may occur, such as:

• Damage control drain systems – as patients warm up, arterial sources that were not surgically controlled may open up
• Pericardial drains – more common in cardiac surgery, not trauma
• Chest tubes in patients with penetrating trauma

What should you do if you have concerns about your patient’s drain output?

• Familiarize yourself with what kind of drain it is and what it should be draining
• Look at the volume of output – it takes 500cc of pure blood to drop the patient’s hemoglobin by about 1 gram. Low outputs are not dangerous, even if it is pure blood.
• Look at the change in output– if it is increasing significantly or changes color, call the physician to evaluate.
• Look at the color of the output – most drainage ranges from clear to something like cranberry juice and appears to be partially transparent. Look carefully if it appears to be darker or more opaque, and compare it to the blood that you would see in a blood collection tube. Even the darkest drain output usually looks a little watery compared to whole blood. Bright red output needs to be evaluated by a physician.
• If in doubt, check the fluid’s hematocrit. Whole blood has a hematocrit of 30% or more. Most bloody-looking drain output maxes out at about 5%. If the value is closer to whole blood, have a physician evaluate the patient.