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Lobdell KW, Engelman DT. Chest Tube Management: Past, Present, and Future Directions for Developing Evidence-Based Best Practices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:41-48. [PMID: 36803288 DOI: 10.1177/15569845231153623] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
In the field of modern cardiothoracic surgery, chest drainage has become ubiquitous and yet characterized by a wide variation in practice. Meanwhile, the evolution of chest drain technology has created gaps in knowledge that represent opportunities for new research to support the development of best practices in chest drain management. The chest drain is an indispensable tool in the recovery of the cardiac surgery patient. However, decisions about chest drain management-including those about type, material, number, maintenance of patency, and the timing of removal-are largely driven by tradition due to a scarcity of quality evidence. This narrative review surveys the available evidence regarding chest-drain management practices with the objective of highlighting scientific gaps, unmet needs, and opportunities for further research.
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Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC, USA
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
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Diephuis EC, de Borgie CA, Zwinderman A, Winkelman JA, van Boven WJP, Henriques JP, Eberl S, Juffermans NP, Schultz MJ, Klautz RJ, Koolbergen DR. Continuous postoperative pericardial flushing reduces postoperative bleeding after coronary artery bypass grafting: A randomized trial. EClinicalMedicine 2021; 31:100661. [PMID: 33385125 PMCID: PMC7772543 DOI: 10.1016/j.eclinm.2020.100661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prolonged or excessive bleeding after cardiac surgery can lead to a broad spectrum of secondary complications. One of the underlying causes is incomplete wound drainage, with subsequent accumulation of blood and clots in the pericardium. We developed the continuous postoperative pericardial flushing (CPPF) therapy to improve wound drainage and reduce postoperative blood loss and bleeding-related complications after cardiac surgery. This study compared CPPF to standard care in patients after coronary artery bypass grafting (CABG). METHODS This is a single center, open label, randomized trial that enrolled patients at the Amsterdam UMC, location AMC, Amsterdam, the Netherlands. The study was registered at the 'Netherlands Trial Register', study identifier NTR5200 [1]. Adults undergoing CABG were randomly assigned to receive CPPF therapy or standard care, participants and investigators were not masked to group assignment. The primary end point was postoperative blood loss in the first 12-hours after surgery. FINDINGS Between the January 15, 2014 and the March 13, 2017, 169 patients were enrolled and assigned to CPPF therapy (study group; n = 83) or standard care (control group; n = 86). CPPF reduced postoperative blood loss when compared to standard care (median differences -385 ml, reduction 76% p=≤0.001), with the remark that these results are overestimated due to a measurement error in part of the study group. None of patients in the study group required reoperation for non-surgical bleeding versus 3 (4%, 95% CI -0.4% to 7.0%) in the control group. None of the patients in the study group suffered from cardiac tamponade, versus 3 (4%, 95% CI -0,4% to 7.0%) in the control group. The incremental cost-effectiveness ratio was €116.513 (95% bootstrap CI €-882.068 to €+897.278). INTERPRETATION The use of CPPF therapy after CABG seems to reduce bleeding and bleeding related complications. With comparable costs and no improvement in Qualty of Life (QoL), cost consideration for the implementation of CPPF is not relevant. None of the patients in the study group required re-interventions for non-surgical bleeding or acute cardiac tamponade, which underlines the proof of concept of this novel therapy. FUNDING This study was funded by ZonMw, the Netherlands organization for health research and development (project 837001405).
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Affiliation(s)
- Eva C Diephuis
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, location AMC, Meibergdreef 9, Amsterdam, AZ 1105, Netherlands
- Corresponding author.
| | | | - A. Zwinderman
- Clinical Research Unit, University of Amsterdam, Amsterdam, Netherlands
| | - Jacobus A Winkelman
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, location AMC, Meibergdreef 9, Amsterdam, AZ 1105, Netherlands
| | - Wim-Jan P van Boven
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, location AMC, Meibergdreef 9, Amsterdam, AZ 1105, Netherlands
| | - José P.S. Henriques
- Department of Cardiology, Amsterdam University Medical Center, location AMC, Amsterdam, Netherlands
| | - Susanne Eberl
- Department of anesthesiology, Amsterdam University Medical Center, location AMC, Amsterdam, Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Amsterdam University Medical Center, location AMC, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Center, location AMC, Amsterdam, Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Robert J.M. Klautz
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, location AMC, Meibergdreef 9, Amsterdam, AZ 1105, Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - David R Koolbergen
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, location AMC, Meibergdreef 9, Amsterdam, AZ 1105, Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, Netherlands
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Makey IA, Das NA, Jacob S, El-Sayed Ahmed MM, Makey CM, Johnson SB, Thomas M. Agitation Techniques to Enhance Drainage of Retained Hemothorax. Surg Innov 2020; 28:544-551. [PMID: 33339490 DOI: 10.1177/1553350620978002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Retained hemothorax (RH) is a common problem in cardiothoracic and trauma surgery. We aimed to determine the optimum agitation technique to enhance thrombus dissolution and drainage and to apply the technique to a porcine-retained hemothorax. Methods. Three agitation techniques were tested: flush irrigation, ultrasound, and vibration. We used the techniques in a benchtop model with tissue plasminogen activator (tPA) and pig hemothorax with tPA. We used the most promising technique vibration in a pig hemothorax without tPA. Statistics. We used 2-sample t tests for each comparison and Cohen d tests to calculate effect size (ES). Results. In the benchtop model, mean drainages in the agitation group and control group and the ES were flush irrigation, 42%, 28%, and 2.91 (P = .10); ultrasound, 35%, 27%, and .76 (P = .30); and vibration, 28%, 19%, and 1.14 (P = .04). In the pig hemothorax with tPA, mean drainages and the ES of each agitation technique compared with control (58%) were flush irrigation, 80% and 1.14 (P = .37); ultrasound, 80% and 2.11 (P = .17); and vibration, 95% and 3.98 (P = .06). In the pig hemothorax model without tPA, mean drainages of the vibration technique and control group were 50% and 43% (ES = .29; P = .65). Discussion. In vitro studies suggested flush irrigation had the greatest effect, whereas only vibration was significantly different vs the respective controls. In vivo with tPA, vibration showed promising but not statistically significant results. Results of in vivo experiments without tPA were negative. Conclusion. Agitation techniques, in combination with tPA, may enhance drainage of hemothorax.
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Affiliation(s)
- Ian A Makey
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
| | - Nitin A Das
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, TX, USA
| | - Samuel Jacob
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
| | | | | | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, TX, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
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Diephuis E, de Borgie C, Tomšič A, Winkelman J, van Boven WJ, Bouma B, Eberl S, Juffermans N, Schultz M, Henriques JP, Koolbergen D. Continuous postoperative pericardial flushing method versus standard care for wound drainage after adult cardiac surgery: A randomized controlled trial. EBioMedicine 2020; 55:102744. [PMID: 32344201 PMCID: PMC7186490 DOI: 10.1016/j.ebiom.2020.102744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Excessive bleeding, incomplete wound drainage, and subsequent accumulation of blood and clots in the pericardium have been associated with a broad spectrum of bleeding-related complications after cardiac surgery. We developed and studied the continuous postoperative pericardial flushing (CPPF) method to improve wound drainage and reduce blood loss and bleeding-related complications. METHODS We conducted a single-center, open-label, ITT, randomized controlled trial at the Academic Medical Center Amstserdam. Adults undergoing cardiac surgery for non-emergent valvular or congenital heart disease (CHD) were randomly assigned (1:1) to receive CPPF method or standard care. The primary outcome was actual blood loss after 12-hour stay in the intensive care unit (ICU). Secondary outcomes included bleeding-related complications and clinical outcome after six months follow-up. FINDINGS Between May 2013 and February 2016, 170 patients were randomly allocated to CPPF method (study group; n = 80) or to standard care (control group; n = 90). CPPF significantly reduced blood loss after 12-hour stay in the ICU (-41%) when compared to standard care (median differences -155 ml, 95% confidence interval (CI) -310 to 0; p=≤0·001). Cardiac tamponade and reoperation for bleeding did not occur in the study group versus one and three in the control group, respectively. At discharge from hospital, patients in the study group were less likely to have pleural effusion in a surgically opened pleural cavity (22% vs. 36%; p = 0·043). INTERPRETATION Our study results indicate that CPPF is a safe and effective method to improve chest tube patency and reduce blood loss after cardiac surgery. Larger trials are needed to draw final conclusions concerning the effectiveness of CPPF on clinically relevant outcomes.
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Affiliation(s)
- Eva Diephuis
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Corianne de Borgie
- Clinical Research Unit, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Anton Tomšič
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Jacobus Winkelman
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Wim Jan van Boven
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Berto Bouma
- Department of Cardiology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Susanne Eberl
- Department of Anesthesiology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Nicole Juffermans
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Marcus Schultz
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Jose P Henriques
- Department of Cardiology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - David Koolbergen
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Kara H, Erden T. Feasibility and acceptability of continuous postoperative pericardial flushing for blood loss reduction in patients undergoing coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2019; 68:219-226. [PMID: 31325107 DOI: 10.1007/s11748-019-01174-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 07/07/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Postoperative bleeding requires blood transfusion and surgical re-exploration that can affect the short- and long-term postoperative outcomes. Interventions that can be used in the postoperative period to reduce blood loss should be developed. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. This study examined the feasibility and acceptability of CPPF for reducing bleeding after coronary artery bypass surgery. METHODS This pilot study adopted a prospective and group comparison design. Between January and April 2018, 42 patients who underwent isolated coronary artery bypass surgery received CPPF from sternal closure up to 8 h postoperative. The mean actual blood loss in the CPPF group was compared to the mean of retrospectively group (n = 58). In the CPPF group, an extra infusion catheter was inserted through one of the tube incision holes and an irrigation solution (0.9% NaCl at 38 °C) was delivered to the pericardial cavity by using a volumetric pump. Safety aspects, feasibility issues, and complications were documented. The primary outcome was blood loss, and it was assessed 18 h after the surgery. RESULTS CPPF was successfully completed in 40 patients (95.24%). Method-related complications were not observed. Feasibility was good in this experimental setting. Blood loss was lower in the CPPF group (257.24 mL) than non-CPPF group (p < 0.001). CONCLUSIONS CPPF after coronary artery bypass grafting surgery is safe, effective, feasible, and acceptable. However, standardized randomized clinical trials are necessary to draw definitive conclusions.
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Affiliation(s)
- Hakan Kara
- Department of Cardiovascular Surgery, Giresun Ada Hospital, Giresun, Turkey.
| | - Tuncay Erden
- Department of Cardiovascular Surgery, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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St-Onge S, Perrault LP, Demers P, Boyle EM, Gillinov AM, Cox J, Melby S. Pericardial Blood as a Trigger for Postoperative Atrial Fibrillation After Cardiac Surgery. Ann Thorac Surg 2018; 105:321-328. [DOI: 10.1016/j.athoracsur.2017.07.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 07/17/2017] [Accepted: 07/17/2017] [Indexed: 02/07/2023]
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