How to apply your medical knowledge and plan amazing nursing care - Part 3
Let me ask you a question.
How often do you place and manage chest drains in your practice?
If a patient comes in that needs one, is it an exciting opportunity for you to use your skills, or a bit of a gulp, lump-in-throat, “I haven’t dealt with one of these in a while” moment?
Well, my goal is that, by the end of this post, you’re excited to manage a chest drain patient - even if you haven’t dealt with one for quite a while!
In the last of our 3-part nursing case study series, I’m going to introduce you to Otto - a cat who came in to see us a while ago now with pyothorax.
We’ll talk through how to manage him and his chest drain, as well as how to deliver nursing care tailored to him as an individual.
Ready to put your nursing skills to the test?
PS. If you want more information on how to look after patients like Otto, you can get all the information you need in the new VIMN pocket guide to respiratory disease. From POCUS scans to triage, and chest drain placement to managing tracheostomy tubes, I’ve got your respiratory nursing covered. If that sounds useful, you can check it out here.
Meet Otto
Otto is a 3-year-old, male neutered, British Shorthair. He presents to your clinic as an emergency in respiratory distress.
3 weeks before presentation, Otto began eating less and became increasingly lethargic. For the last 2 days, Otto has had some coughing and has been tachypnoeic.
Triage and Stabilisation
You triage Otto and find the following:
Quiet, but alert
Tachycardic at 164 beats/minute
Good quality, synchronous pulses
Slightly muffled heart sounds on auscultation
Tachypnoeic at 48 breaths/minute
Decreased lung sounds bilaterally, left worse than right
MM pink and moist
CRT 1-2s
SpO2 92%
Weight 4.8kg
You apply a topical local anaesthetic to Otto’s leg, then place him in an oxygen kennel to stabilise initially.
You then alert the veterinary surgeon with your triage findings, who obtains consent for POCUS of the chest, general anaesthesia, thoracic CT scan and treatment as necessary (including chest drain placement/thoracocentesis as needed).
In the meantime, you monitor Otto’s demeanour, respiratory rate, pattern and effort every 30 minutes, and place an IV catheter when Otto is settled.
Procedures
Otto stabilises well on oxygen and is weaned off of O2 after a few hours. He remains stable with a respiratory rate of 56 breaths/minute (slightly stressed in the ward) and pink mucous membranes, with a SpO2 of 94%.
POCUS
A point-of-care ultrasound scan reveals free fluid in Otto’s pleural space. This fluid is hypoechoic and flocculent, increasing the veterinary surgeon’s suspicion of a pyothorax.
A thoracocentesis sample is taken and analysed in-house, which reveals high numbers of neutrophils with bacteria.
Chest Drain Placement
After Otto has stabilised, you anaesthetise him with the veterinary surgeon and assist with chest drain placement. These are placed before his CT scan, to allow pre-imaging drainage and better evaluation of his lungs without the pleural fluid limiting ventilation.
You clip and aseptically prepare both sides of Otto’s chest, before infiltrating local anaesthetic into the intercostal muscles to provide additional analgesia. The veterinary surgeon places bilateral chest drains via the Seldinger technique, and you drain 50ml from the left side and 61ml from the right.
The fluid is turbid and purulent, with a strong odour. When examined under the microscope, it shows a mixture of degenerate WBCs alongside cocci and rods (intracellular and extracellular).
CT
Otto’s CT scan shows that both drains terminate in thick material. There is adequate lung inflation, but fibrous material and residual fluid are still present within the pleural space.
Otto’s anaesthetic is stable, and he recovers well with no need for oxygen supplementation on recovery. Once Otto is awake, you submit samples for bacterial culture and cytology.
Treatment
The veterinary surgeon asks you to begin the following treatment in recovery:
IV fluid therapy with Lactated Ringer’s solution at 3ml/kg/hour
Buprenorphine 0.02mg/kg IV every 6-8 hours depending on pain scores
Clindamycin 10mg/kg slow IV every 12 hours
Marbofloxacin 2mg/kg IV every 24 hours
Thoracic drainage and lavage every 6 hours
Nursing Care
There’s a lot to think about in Otto’s case. What would you do when nursing him? Think about the following areas:
Chest drain management
Comfort
Fluid balance
Nutrition
Monitoring and general nursing care
Here are my considerations when nursing patients like Otto:
Chest Drain Management
With Otto’s chest drain, we want to empty this at an appropriate interval based on how much fluid it is producing, and his respiratory status.
Initially, we’ll drain him every 6 hours. If the drain is producing large volumes, or Otto’s respiratory rate, pattern or effort deteriorates, we may need to increase this.
Drainage
Otto’s drain needs to be emptied carefully, paying close attention to gate clamps and one-way valves, and minimising excessive negative pressure which can traumatise the pleural membranes.
Lavage
Pyothorax patients often have thick, consolidated debris that is hard to drain by normal methods. This means we may need to use thoracic lavage to help loosen this material and facilitate its removal.
When lavaging the chest, we usually administer 10-20ml/kg of warmed crystalloid solution into the drain using aseptic technique. We’ll leave this in situ for up to 20 minutes, ideally encouraging some movement from the patient to help loosen the pleural material, then remove it again.
The goal is to remove more fluid than you instil. Bear in mind, though, that you’re increasing the patient’s pleural fluid volume and that this will impair ventilation temporarily. Monitor Otto closely, alert the vet and remove the fluid sooner if you have any concerns.
Aseptic Management
Asepsis is an important consideration when managing chest drains. Sterile gloves should be worn when lavaging or draining, and when handling the tube insertion site. The site should be cleaned and redressed regularly, and chest drain ports covered with alcohol disinfectant caps to protect against contamination.
Comfort
Chest drains are painful, and regular analgesia and pain scoring is an important part of managing patients like Otto. Pain levels should be assessed using a combination of physiological parameters (vital signs) and behaviour parameters (using validated pain assessment tools like the Glasgow Composite Pain Scale), and appropriate analgesia provided.
We can also use the chest drain to administer local anaesthetic agents like bupivacaine (under veterinary direction) to provide additional analgesia.
Nutrition and Hydration
We are removing large volumes of pleural fluid from Otto’s chest, and this means he’s at risk of dehydration if we don’t manage his fluid balance carefully.
Keep an eye on his skin tent, eye position, body weight and mucous membrane dryness, and if signs of dehydration are present, discuss them with the vet - Otto’s fluid rate may need adjusting.
Nutrition is also an important consideration in Otto’s case.
We know he’s been hyporexic before presentation, so we need to ensure he’s consuming enough of his RER each day. Volumes offered should be calculated carefully and amounts eaten measured and recorded.
We also need to be addressing any underlying cause for his hyporexia - like pain, in this case - to encourage him to eat normally.
If prolonged hyporexia or anorexia persists, we need to think about further nutritional support (for example, placing a naso-oesophageal tube). This is a great use of our skills as veterinary nurses!
Monitoring
In addition to general nursing care and feline-friendly nursing considerations, there is a lot for us to keep an eye on with Otto, including:
Respiratory rate, pattern and effort
Heart rate and rhythm
Pulse quality
Lung sounds
SpO2 (if possible)
Temperature
Mucous membrane colour and moistness
Capillary refill time
Demeanour
Bodyweight
Food intake
Water intake
Eliminations
Pain/discomfort levels
Stress levels
Chest drain output
Pleural lavage volumes
Pleural fluid cytology
Chest drain site appearance
IV catheter site appearance
Serial point-of-care ultrasound appearance
We want to tailor the frequency of these checks according to the importance of each parameter, Otto’s clinical condition, and his temperament.
There are so many opportunities for us to use our skills with patients like Otto - from chest drain management to POCUS scans, feeding tube placement to thoracic fluid cytology, all of these tasks can be performed by nurses!
So the next time you’re nursing a patient like Otto, think about these nursing considerations and which of them you can factor into your patient’s care!
How did your considerations compare to these? DM me on Instagram and let me know!
Want to learn more about nursing patients like Otto?
If you want to learn more about how to care for respiratory patients, including more information on placing and managing chest drains, administering oxygen therapy, performing respiratory examinations, and preparing for respiratory emergencies
You can grab a copy of the new pocket guide to respiratory disease here.
References and Further Reading
Stillion JR and Letendre JA. A clinical review of the pathophysiology, diagnosis, and treatment of pyothorax in dogs and cats. J Vet Emerg Crit Care 2015; 25:113–129.
Day SL. Thoracostomy tube placement, drainage and management in dogs and cats. Vet Nurse J 2014; 29: 42–46.
Demetriou JL, Foale RD, Ladlow J, et al. Canine and feline pyothorax: a retrospective study of 50 cases in the UK and Ireland. J Small Anim Pract 2002; 43:388–394.
Aldridge P and O’Dwyer L. Nursing considerations in the critical patient. In: Aldridge P and O’Dwyer L (eds). Practical emergency and critical care for veterinary nurses. Chichester: Wiley-Blackwell, 2013, pp 198–207.
