Category Archives: General

Nursing: When Is Drain Output Too Bloody?

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.
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Interesting Concept: Predicting Recovery From Surgery With A Blood Test

Most people recover from major surgical procedures in a predictable fashion. However, as anyone who manages these patients knows, there are always a few outliers. A negative laparotomy patient who has an ileus for over a week. Hip fracture patients who take forever to get out of bed.

We usually chalk this up to human variability or varying degrees of frailty. But could there be more to it? Could it even be predictable?

A group of anesthesiologists and immunologists at Stanford used a new cell-mapping technique to attempt to correlate immune system signatures in blood during the first hours after operation with recovery time. They used a technique called mass cytometry, which flushes different tagged antibodies through a blood sample. This allowed the investigators to determine which immune cells were present, as well as which signalling molecules were being produced.

Here are the factoids:

  • 32 patients undergoing hip replacement surgery were studied at various times up to 6 weeks after the procedure
  • Antibodies directed at 21 cell surface proteins and 10 intracellular proteins associated with the immune response
  • Recovery from fatigue, pain, and recovery of hip motion were quantified using validated objective scoring tools
  • As expected, there was a considerable amount of variability in recovery parameters among the patients
  • Activation of CD14+ monocytes accounted for 40-60% of the variability in recovery times observed
  • Patients with higher activations were more likely to take at least 3 weeks to recover. Those with low activation recovered more quickly.

Bottom line: This is heady stuff, and it is based on a very small group of patients. However, it does suggest that immune system overdrive may be responsible for more evil: slow recovery from surgery. At some point, it may be possible to predict recovery time from a preop blood test. This would be very helpful to know before surgery, and at some point may allow us to give drugs that blunt these processes and speed up surgical recovery.

Related post:

Reference: Clinical recovery from surgery correlates with single-cell immune signatures. Science Translational Medicine 6(255):255ra131 1-12, 2014.

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September Newsletter Released To Subscribers This Weekend!

The September Trauma MedEd Newsletter will be released to subscribers over the weekend. I’ll be covering chest trauma. Articles include:

  • Finger vs needle thoracostomy
  • Chest tube air leaks and how to manage them
  • Pneumothorax in children
  • And more!

Anyone on the subscriber list as of 8PM Saturday (CST) will receive it on Sunday, October 5. I’ll release it to everyone else next week via the blog. So sign up for early delivery now by clicking here!

Pick up back issues here!

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Prone Positioning After Trauma Laparotomy

Patients with serious abdominal injury may require a laparotomy, and a subset of these may need a temporary closure for damage control surgery. Concomitant spine injury may have your spine surgeons asking “is it safe to prone the patient who is postop with a midline incision or an open abdomen.” What to tell them?

There’s not much guidance out there in the literature. One paper from 2000 looked at four patients who were proned for severe ARDS and found that one suffered a wound dehiscence. However, this patient had severe generalized edema and was on several pressor agents. 

The use of temporary abdominal closure techniques has revolutionized the early management of severely injured trauma patients and has greatly decreased the incidence of complications from abdominal compartment syndrome. Several authors have now demonstrated that putting those patients in the prone position is well tolerated. 

As far as patients who have a closed laparotomy, proning appears to be well tolerated as well. One caveat: consider carefully if the patient is having wound complications or if they are morbidly obese.

The bottom line: Consider the risks and benefits carefully in any post-laparotomy patient you are considering prone positioning for. Other than in morbidly obese, it is generally considered safe, even in patients with damage control dressings in place. However, make sure the trauma surgeon re-evaluates the wound again as soon as the patient is returned to the supine position.

References: 

1. The “open abdomen” is not a contra-indication to prone positioning for severe ARDS (abstract). Schwab, et al. Chest. 1996;110:142S.

2. Complications of Prone Ventilation in Patients with Multisystem Trauma with Fulminant Acute Respiratory Distress Syndrome. Offner et al. Journal of Trauma-Injury Infection & Critical Care. 48(2):224-228, February 2000.

3. The Management of the Open Abdomen in Trauma and Emergency General Surgery: Part 1-Damage Control. Diaz et al. Journal of Trauma-Injury Infection & Critical Care. 68(6):1425-1438, June 2010.

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Inline Stabilization vs Inline Traction of the Cervical Spine

Members of the trauma team must frequently protect the cervical spine when moving the patient or performing certain procedures. In most cases, a cervical collar is placed which does a fine job of this. Occasionally, though, the collar must be removed to provide access to areas near or under the collar.

When the collar is off, someone must be charged with immobilizing the cervical spine. Sometimes this is incorrectly referred to as providing inline traction and not inline stabilization.There is a big difference!

Inline traction is used to try to realign cervical vertebra that are malpositioned due to fracture or ligamentous injury. This should only be performed under the guidance of a neurosurgeon!

Inline stabilization merely means that the patient (or trauma professional) is restrained from moving the cervical spine. This is commonly needed while intubating the patient, so that the intubator does not extend the neck when trying to visualize the cords.

Why is this important? Check out the images below. If a severe injury has already occurred, traction on the neck may have devastating consequences! Inline stabilization is the only way to go.

Spine injury AO dissociation

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