A prospective study of risk factors associated with persistent pleural effusion after total cavopulmonary connection with special reference to serum cortisol level

Quality Report: Postoperative Guideline Implementation Reduces Length of Stay after Fontan Procedure

Introduction

Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely.

Methods

We implemented standardized postoperative clinical practice guidelines in April 2020. We designed guidelines using previously published protocols. Key features included an ambulatory PleurX drain (BD, Franklin Lakes, N.J.), diuresis with fluid restriction, and pulmonary vasodilation with supplemental oxygen and sildenafil. All patients were discharged from the hospital with a PleurX drain in place. We compared clinical outcome variables before and after guideline implementation. As a balancing measure, we tracked 30-day readmissions.

Results

One hundred seven patients underwent the Fontan procedure before guideline implementation from January 2015 to January 2020, with an average hospital LOS of 23 days. Postguideline implementation, 35 patients underwent the Fontan procedure from April 2020 to July 2022, with an average hospital LOS of 8 days in 2020, which further improved to an average hospital LOS of 7 days. There was no change in 30-day readmission after guideline implementation (24% pre versus 23% post; P = 0.86).

Conclusion

Implementing clinical practice guidelines for patients following the Fontan procedure led to an over 50% reduction in hospital LOS without increasing 30-day readmission.

Comparison of pleural effusion between fenestrated and nonfenestrated extracardiac Fontan: A prospective randomized study

BACKGROUND

Fenestration of the baffle/conduit is believed to reduce pleural effusion following the Fontan operation. However, equivocal results have been observed with or without fenestration. This study aims to evaluate the efficacy of fenestration on the amount and duration of pleural effusion following the Fontan operation.

METHODS

About 40 patients undergoing extracardiac Fontan (ECF) were randomized into two groups: one with fenestration (ECF-F; n = 20) or without fenestration (ECF-NF; n = 20). Primary outcome was the amount and duration of pleural effusions. Secondary outcomes were time to removal of the chest tubes, hospital stay, and readmission to the hospital because of recurrent pleural within 30 days of the operation.

RESULTS

Mean age was 11.5 ± 5.07 (range, 8.7-13.5) years in the ECF-F group and 13.6 ± 0.4 years (range, 10.5-15.5) in the (ECF-NF) group. The total drain output was 7.89 mL/kg/d in ECF-NF compared with 6.9 mL/kg/d in the ECF-group (P = .14). Time for removal of pleural tubes was 14.6 ± 0.95 days in the ECF-NF group compared with 11.6 ± days in the ECF-F group. Total duration of hospital stay was higher but not significant in the ECF-NF group compared with the ECF-F group. Two patients in ECF-NF required readmission to the hospital within 30 days following discharge, while there were no readmissions in the ECF-F group.

CONCLUSION

Contrary to the literature, the creation of a fenestration in the ECF circuit was not clearly associated with a reduction in the amount and duration of pleural effusion compared with a non-fenestrated Fontan. These findings may be debatable in high risks versus low risk candidates. However in the present study, in a low risk canditates undergoing the Fontan operation, the daily amount of pleural drainage was no different. Larger studies are needed to confirm these findings.

Risk Factors for Prolonged Pleural Effusion Following Total Cavopulmonary Connection Surgery: 9 Years' Experience at Fuwai Hospital

Background: Prolonged pleural effusion (PPE) contributes to adverse outcomes after total cavopulmonary connection (TCPC) completion. We aimed to identify risk factors for PPE following TCPC surgery. Methods: We studied a retrospective cohort of 525 who undergoing TCPC surgery from 2010 to 2019. We defined PPE as the duration of pleural effusion exceeding 14 days. Logistic regression was applied to identify risk factors for PPE and Cox regression was used to identify risk factors for predicting the duration of pleural effusion. The impacts of PPE on the short-term outcomes were evaluated. Results: The rate of PPE was 27.4% in our study and independent risk factors for PPE included: young age, no fenestration, low postoperative total protein, prolonged mechanical ventilation and chylothorax. These predictors were also achieved in the Cox regression for predicting the duration of pleural effusion. The applicability of the model was acceptable in different subgroups, which derived from the total cohort. Patients with PPE were associated with more renal replacement treatment, longer length of ICU and hospital stay, more hospitalization costs and a higher rate of in-hospital mortality. Conclusions: PPE in our study occurs at a relatively lower rate than that reported in previous studies and patients with PPE was associated with higher rate of in-hospital mortality when compared to patients without PPE. Young age, no fenestration, low postoperative total protein, prolonged mechanical ventilation, and chylothorax were identified as independent risk factors to predict PPE. A preventive strategy that targets the identified risk factors to reduce the incidence of PPE following TCPC surgery could be beneficial for in-hospital outcomes, and the model needs further validation before its application.