Are the 3 chambers on the pleur evac a running total since placement that run over once one fills?
Yes.
It is hard to give a general outline for "chest tubes" because there are many different indications for a tube and each institution/attending has their own general style for managing tubes. Generally, however there are 3 things you should be watching out for every day: air leak, amount of drainage, type of fluid. I'll go through these in turn:
1) Air leak: Is there one or isn't there? If yes, is it a constant blowing leak (inspiration and expiration)? If yes, your first thought should usually be mechanical problem - poor seal somewhere (airtight dressing that isn't, disconnected tube, etc). However, if you've ruled that out and you truly have a massive air leak from the lung during inspiration AND expiration, this is a problem. Call your senior/staff as this could be a sign of serious badness. In the meantime, put the tube to water seal, try and minimize TV and PEEP and await further instruction. If it is a smaller amount of bubbling or during a cough only, continue on course - keep to suction and for the most part air leaks will seal up in 48-72 hours. If there is a relatively stable degree of air leak over several days, consider Heimlich valve... most leaks seal up. Eventually. Once the leak goes away, water seal or clamp and repeat a CXR in 4 hours and if the PTX is the same or smaller it is generally safe to pull the tube (but ask before you pull any tube) assuming 2) and 3) (below) are fine as well.
2) Amount of drainage: record this yourself. This is where there is a reasonable amount of variation in practice. First of all, don't just look at the amount of drainage, look at the trend over the past several hours/days (depending on the scenario). Is it going up? Down? If you have a patient who has persistently high outputs in the setting of chest/cardiac surgery, check a TG/Chylomicron level in the fluid and r/o chylothorax. If it is negative and the fluid is mostly serous, the patient is probably volume overloaded and is essentially undergoing pleural dialysis. Diurese and get them back to euvolemia. If TG/chylomicrons are positive, then it's a chylothorax and they likely need TPN for a period of time followed by an ultra low fat diet. If it's a ton of blood... that is bad. See below. There is no hard and fast rule for when to pull a tube based on outputs, it will be based on the clinical scenario and context of the patient. A reasonable rule of thumb is <200cc/day but this could be
highly variable depending on the clinical situation and reason for the tube (empyema tubes stay in for weeks and are slowly backed out even if there is minimal to no drainage, for example).
If the patient is a fresh postop, you should be looking at cc/hr and a good basic rule for needing to go back to the OR is the 4/2/1 rule: 400cc/hr for 1 hour, 200cc/hr for 2 hours, 100cc/hr for 4 hours
may merit a return trip to the OR but you should ask someone senior first. It is not uncommon for patients to "dump" several hundred cc (to a liter even) immediately after coming up from the OR to the ICU when they are moved around in the bed. Don't freak out about this, but instead make sure that it quickly slows down to something reasonable.
If a patient has been consistently draining several hundred ccs and it suddenly tapers off to nothing... the tube may be clogged in which case repeat a CXR and think about what can be done to unclog it.
3) What type of fluid is it? If a patient dumps a liter of straw colored serous fluid, I'm not going to be worried that much. Just moderately annoyed that the patient is likely going to have to stay on my consult list for a few more days. If they dump a liter of blood, I am going to be very concerned and at the very least transfusing if not on the phone to the OR depending on how quickly it's draining. If it's pus, I am also going to be worried, but more along the lines of "start antibiotics or broaden spectrum, get cultures, etc." If it's milky white then think chylothorax and send trigs.
These are some very general guidelines. You really just need experience managing tubes and getting used to what is normal and what is not through repetition and also learn your institution specific practices and you will slowly start to get comfortable managing tubes.
