Timing of Chest Tube Removal Following Adult Cardiac Surgery: A Cluster Randomized Controlled Trial

OBJECTIVES

Early chest tube removal following cardiac surgery may be associated with an increased risk of pleural or pericardial effusions following cardiac surgery. This study compares the effects of two fast-track chest tube removal protocols regarding the risk of pleural or pericardial effusions, requirement of opioids, respiratory function, and postoperative complications.

DESIGN

Prospective non-blinded cluster-randomized study with alternating chest tube removal protocol in adult patients undergoing elective cardiac surgery. Monthly changing allocation to scheduled chest tube removal on the day of surgery (Day 0) versus removal on the 1st postoperative day (Day 1) provided no air leakage and output < 200 mL within the last four hours.

RESULTS

A total of 527 patients were included in the study from September 1st 2020 until October 29th 2021 and randomly allocated to chest tube removal at day 0 (n = 255), and day 1 (n = 272). More than every fourth patient required drainage for pleural effusion with no significant difference between the groups. Earlier removal of chest tubes did not reduce requirement of analgesics, improve early respiratory function, or reduce postoperative complications. The study was halted for futility after halfway interim analysis showed insufficient promise of any treatment benefit.

CONCLUSION

Fast-track protocols with chest tube removal within the first 24 h after cardiac surgery may be associated a high rate of pleural effusions.

Preoperative initiation of peripheral veno-arterial extracorporeal membrane oxygenation for a complex case of cardiac tamponade

In this case report, we present an alternative approach to the anaesthetic management of patients presenting with delayed postoperative cardiac tamponade physiology. Given that pericardiocentesis was deemed unsafe, and a protracted surgical dissection was anticipated, peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was established prior to induction of anaesthesia to prevent catastrophic circulatory failure. To the best of our knowledge, this is the first reported case of planned preoperative commencement of peripheral VA-ECMO in a complex case of cardiac tamponade. We discuss the challenges associated with this case and the process for selecting this strategy. We also describe the role of transoesophageal echocardiography in planning the surgical approach. This report is completed by a discussion on the topic of delayed postoperative pericardial effusion and tamponade.

Chest Tube Management: Past, Present, and Future Directions for Developing Evidence-Based Best Practices

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.

Pleural effusions are associated with adverse outcomes after cardiac surgery: a propensity-matched analysis

BACKGROUND

Pleural effusions commonly occur in patients recovering from cardiac surgery; however, the impact on outcomes is not well characterized. The purpose of this study is to characterize the clinical outcomes of cardiac surgery patients with pleural effusion.

METHODS

All patients undergoing cardiac surgery between 2006 and 2019 at a tertiary care university hospital were included in this observational, cross-sectional analysis using propensity matching.

RESULTS

Of 11,037 patients that underwent cardiac surgery during the study period, 6461 (58.5%) had no pleural effusion (Group 0), 3322 (30.1%) had pleural effusion only (Group 1), and 1254 (11.4%) required at least one secondary drainage procedure after the index operation (Group 2). After propensity matching, the mortality of patients who underwent secondary drainage procedures was 6.1% higher than in Group 1 (p < 0.001). Intensive care unit (ICU) stay was longer for those with pleural effusions (18 [IQR 9-32] days in Group 2, 10 [IQR 6-17] days for Group 1, and 7 [IQR 4-11] days for Group 0, p < 0.001). Patients with pleural effusions had a higher incidence of hemodialysis (246 [20.0%] in Group 2, 137 [11.1%] in Group 1, 98 [7.98%] in Group 0), and a longer ventilation time in the ICU (57 [IQR 21.0-224.0] hours in Group 2, 25.0 [IQR 14.0-58.0] hours in Group 1, 16.0 [IQR 10.0-29.0] hours in Group 0).

CONCLUSION

Pleural effusions, especially those that require a secondary drainage procedure during recovery, are associated with significantly worse outcomes including increased mortality, longer length of stay, and higher complication rates. These insights may be of great interest to scientists, clinicians, and industry leaders alike to foster research into innovative methods for preventing and treating pleural effusions with the aim of improving outcomes for patients recovering from cardiac surgery.

Impact of posterior pericardial drain and risk factors on late pericardial effusion after coronary artery bypass surgery

BACKGROUND

The blood retained in posterior pericardium can trigger an inflammatory response that increases postoperative atrial fibrillations (POAFs), and it can complicate postoperative course. We retrospectively investigated the impact of a posterior pericardial drain (PPD) in reducing late postoperative pericardial effusion (pPE) and POAFs during the first 30 postoperative days.

METHODS

Two hundred and fifty coronary artery bypass grafting patients were divided into two groups according to the presence of a PPD in addition to the anterior one. Perioperative data and the incidence of POAF were compared. Risk factor analysis was used to determine the predictors of pPE and postpericardiotomy syndrome.

RESULTS

Late pPE was present in 16% of all patients. It proved to be much more frequent in patients with a posterior drain (odds ratio 2.58; 95% confidence interval 1.23-5.79; P = 0.015) where it seemed to be almost mild and anterior. 'Anterior Drain' patients showed an increased rate of moderate (P < 0.001) and posterior effusions (P < 0.001). POAF was much more frequent in patients without a PPD (25.2 vs. 6.3%; P < 0.001). Univariate risk factor analysis revealed a significant association between late pPE and lower preoperative weight (P = 0.003), lower preoperative and postoperative serum albumin (P < 0.001) and a greater amount of blood transfusion (P = 0.02).

CONCLUSION

Even if a PPD is associated with a higher rate of pPE, the patients with only anterior drains were shown to have a greater amount of pericardial effusion and an increased risk of POAFs. Therefore, a PPD should be considered to improve postoperative course.

Occurrence and predictors of pericardial effusion requiring invasive treatment following heart valve surgery

OBJECTIVES

To describe the occurrence of significant pericardial effusion, and to investigate characteristics associated with pericardial effusion within three months following heart valve surgery.

METHODS

A retrospective, observational cohort study including adult patients undergoing heart valve surgery at Odense University Hospital from August 2013 to November 2017. Data were gathered from The Western Denmark Heart Registry and electronic patient records.Cox proportional hazard models were used to investigate the associations between characteristics associated with significant pericardial effusion during index admission and within 3 months. Results are presented as HR with 95% CI.

RESULTS

In total, 1460 patients were included (70% men, median age 71 years (IQR 63-76)) and of those, n=230 patients (16%) developed significant pericardial effusion.EuroScore II was significantly associated with an increased risk of pericardial effusion during index admission and associated with a lower risk following discharge (index admission HR 1.05, 95% CI 1.02 to 1.08, after discharge HR 0.80, 95% CI 0.69 to 0.92). Increasing age (HR 0.97, 95% CI 0.95 to 0.98 per year) and concomitant coronary artery bypass grafting versus isolated valve surgery (HR 0.58, 95% CI 0.35 to 0.97) were significantly associated with a reduced risk of pericardial effusions in both periods. Being a man (HR 2.30, 95% CI 1.32 to 4.01) and aortic valve disease versus mitral valve disease (HR 2.16, 95% CI 1.20 to 3.90) were significantly associated with an increased risk after discharge.

CONCLUSION

Significant pericardial effusions requiring drainage were present in 16% of cases following heart valve surgery, and different clinical characteristics were associated with the development of effusion.

Early removal of chest drains in patients following off-pump coronary artery bypass graft (OPCAB) is not inferior to standard care - study in the Enhanced Recovery After Surgery (ERAS) group

Introduction

Only a few studies have concerned the timing of chest drains’ removal in cardiac surgery patients following the coronary artery bypass graft (CABG). None of them pertained to the off-pump CABG (OPCAB) procedure.

Aim

To compare thoracic drainage time in OPCAB patients before the implementation of the institutional Enhanced Recovery After Surgery (ERAS) protocol and after that.

Material and methods

It was a single-center observational study concerning patients following OPCAB. Two groups of patients were analyzed: after implementing the ERAS protocol, the ERAS group, and before this period, the standard care group (STAND group). The primary outcome of this study was to compare postoperative drainage time in the ERAS and STAND groups. The other outcomes included comparing transfused blood products, postoperative complications, surgical technique, postoperative ventilation and the intensive care unit stay time.

Results

Sixty patients in the ERAS and 112 in the STAND group were analyzed. The postoperative drainage time was shorter in the ERAS than in the STAND group: 20 (17–22) vs. 30 (27–35) h, p < 0.001. The number of transfused blood products was similar in both groups. No difference was noted between groups according to surgery and anesthesia time. However, patients in the ERAS group were ventilated for a significantly shorter time after the surgery and spent less time in the ICU than the STAND group. The number of postoperative complications in the ERAS and STAND group was 14 and 27, p = 1.

Conclusions

The early removal of chest drains after OPCAB does not increase the risk of postoperative complications and demand for blood products. However, its impact on patients’ morbidity needs further studies.

Pleural effusion post coronary artery bypass surgery: associations and complications

Background

One of the most frequent complications of coronary artery bypass grafting (CABG) is pleural effusion. Limited previous studies have found post-CABG pleural effusion to be associated with increased length-of-stay and greater morbidity post-CABG. Despite this the associations of this common complication are poorly described. This study sought to identify modifiable risk factors for effusion post-CABG.

Methods

A retrospective cohort study of prospectively collected data assessed patients who underwent CABG over two-years. Data was collected for risk factors and sequelae related to pleural effusion requiring drainage.

Results

A total of 409 patients were included. Average age was 64.9±10.2 years, 330 (80.7%) were male. 59 (14.4%) patients underwent drainage of pleural effusion post-CABG. Effusions were drained on average 9.9±8.4 days post-CABG. Earlier removal of drain tubes and removal near time of extubation were associated with development of pleural effusion. Post-CABG pleural effusion was associated with post-operative renal impairment (P<0.01) and pericardial effusion (P<0.01). Patients with pleural effusion were more likely to require readmission to ICU (P<0.01), reintubation (P=0.03) and readmission to hospital (P=0.03).

Conclusions

Pleural effusion is a common complication of cardiac surgery and is associated with significant morbidity and resource utilization. This study identifies several associated complications that should be considered in the presence of pleural effusion. Modifiable associated factors in the management of drains that may contribute to accumulation of pleural effusion include: early removal of chest drains, higher outputs and removal during or close to mechanical ventilation. Further research is required to assess how adjusting these modifiable factors can decrease rates of effusion post-operatively.

Predictors of Length of Stay in Intensive Care Unit after Coronary Artery Bypass Grafting: Development a Risk Scoring System

Introduction

To determine predictors of length of stay (LOS) in the intensive care unit (ICU) after coronary artery bypass grafting (CABG) and to develop a risk scoring system were the objectives of this study.

Methods

In this retrospective study, 1202 patients' medical records after CABG were evaluated by a research-made checklist. Tarone-Ware test was used to determine the predictors of patients' LOS in the ICU. Cox regression model was used to determine the risk factors and risk ratios associated with ICU LOS.

Results

The mean ICU LOS after CABG was 55.27±17.33 hours. Cox regression model showed that having more than two chest tubes (95% confidence interval [CI] 1.005-1.287, Relative Risk [RR]=1.138), occurrence of atelectasis (95% CI 1.000-3.007, RR=1.734), and occurrence of atrial fibrillation after CABG (95% CI 1.428-2.424, RR=1.861) were risk factors associated with longer ICU LOS. The discrimination power of this set of predictors was demonstrated with an area under the receiver operating characteristic curve and it was 0.69. A simple risk scoring system was developed based on three identified predictors that can raise ICU LOS.

Conclusion

The simple risk scoring system developed based on three identified predictors can help to plan more accurately a patient's LOS in hospital for CABG and can be useful in managing human and financial resources.

The Improved Mediastinal Drainage Strategy for the Enhanced Recovery System After Esophagectomy

BACKGROUND

The improved drainage strategy was the transperitoneal placement of a single mediastinal drainage tube after esophagectomy. This study aimed to explore its effect on the incidence of postoperative complications, pain scores, and hospital stay.

METHODS

Data from 108 patients who underwent minimally invasive esophagectomy were retrospectively analyzed. Patients were divided into 2 groups: those in group A were treated with transthoracic placement of mediastinal drain and those in group B were treated with transperitoneal placement. The incidence of postoperative complications, pain scores, and postoperative hospital stay were compared.

RESULTS

The maximum pain scores in group B were significantly lower than those in group A from the first to the fourth postoperative days (PODs): POD1, 3.9 ± 0.7 vs 2.3 ± 0.7; POD2, 3.5 ± 0.8 vs 2.1 ± 0.7; POD3, 3.3 ± 0.8 vs 1.7 ± 0.8; and POD4, 3.1 ± 0.7 vs 1.7 ± 0.8 (all P < .001). Compared with group A, there were fewer postoperative analgesic drug users in group B (44.6% vs 17.9%; P = .005), fewer cases of pleural effusion (10.7% vs 0%; P = .045), and fewer cases of closed thoracic drainage due to pleural effusion or pneumothorax (14.3% vs 0%; P = .014). There were no significant differences in the incidence of anastomotic leakage, mediastinitis, major pulmonary complications, major abdominal complications, surgical site infection, and total postoperative complications, without statistical differences in postoperative hospital stay and 30-d mortality (all P > .05).

CONCLUSIONS

The transperitoneal placement of a single mediastinal drain can reduce postoperative pain and the incidence of pleural effusion, without increasing the incidence of other major postoperative complications and postoperative hospital stay.

Does Early Drain Removal Affect Postoperative Pericardial Effusion after Congenital Cardiac Surgery?

Background

Patients undergoing cardiac surgery require postoperative chest drainage. However, the drain is difficult to keep in place in children with congenital heart disease. Since 2015, at Kyungpook National University Hospital, the chest tube is removed on postoperative day 1 in patients who have undergone simple congenital cardiac surgery (i.e., closure of an atrial or ventricular septal defect). In this study, we evaluated the relationship between the duration of drain placement and the likelihood of pericardial effusion after congenital cardiac surgery.

Methods

The medical records of patients who underwent closure of an atrial or ventricular septal defect at our hospital between January 2014 and December 2016 were reviewed. In total, 162 patients who received follow-up echocardiography and had information available on postoperative pericardial effusion after the repair procedure were enrolled.

Results

Echocardiography was performed at a median of 5 days (range, 4 to 6 days) postoperatively before discharge from the hospital. Pericardial effusion occurred in 21 patients (13.0%), of whom only 3 (1.9%) had moderate or greater pericardial effusion, regardless of the drain duration. All patients improved during outpatient follow-up without invasive management. No patient had severe complications because of pericardial effusion. The duration of drain placement did not affect the incidence of postoperative pericardial effusion (p=0.069). Operative survival was 100%.

Conclusion

Based on our study, we recommend removing the drain as soon as its role is complete, generally on postoperative day 1, because early removal does not increase the incidence of pericardial effusion in patients undergoing simple congenital cardiac surgery.

Right pericardial window opening: a method of preventing pericardial effusion

AIM

In this study, we aimed to investigate the superiority of right pericardial window (RPW) versus posterior pericardial drain placing for the parameters of pericardial effusion and the postoperative complications at the patients who has undergone cardiac surgery.

MATERIALS AND METHODS

Between July and September 2018, 120 adult patients (mean age 50.30 ± 14.61) who underwent cardiac surgery without the necessity of opening the pleura were included in the study. In Group 1, the RPW was opened (n = 60), and Group 2 posterior pericardial drainage tube was placed without RPW (n = 60). Risk factors and postoperative complication were evaluated and compared between the Groups.

RESULTS

Cardiac tamponade occurrence was not significantly different between the Groups (Group 1, n = 0 and Group 2, n = 3, p = 0.079). Postoperative transthoracic echocardiographic controls revealed significant pericardial effusion in Group 2 (6.90 mm ± 13.02 mm) compared to Group 1 (2.30 mm ± 5.60 mm) (p = 0.013). Postoperative creatinine levels were 0.75 ± 0.26 in Group 1 and 0.88 ± 0.36 in Group 2 (p = 0.022). A significant decrease in glomerular filtration rate was observed in Group 2 (102.7 ± 24.5 and 91.2 ± 28, p = 0.019). Postoperative acute renal failure was significantly higher in Group 2 compared to Group 1 (p < 0.001). Postoperative new onset atrial fibrillation occurred in 4 patients in Group 1 and 8 in Group 2 (p = 0.224). The duration of intensive care unit stay was 36.00 ± 22.31 h in Group 1 and 53.60 ± 59.50 h in Group 2 (p = 0.034). Development of pneumothorax, pneumonia and pleural effusion were not statistically different between the Groups (p = 0.079, 0.171, 0.509).

CONCLUSION

RPW application is more effective on preventing postoperative complications in cardiac surgery instead of placing drains in posterior pericardium.

N, Carvalho AR, Chamlian EG, Moreira RSL, Arena R, Guizilini S. A Dedicated Stitch to Allow Early Safe Mobilization Avoiding Drain-Induced Heart Injury

Placement of a mediastinal drain is a routine procedure following heart surgery. Postoperative bed rest is often imposed due to the fear of potential risk of drain displacement and cardiac injury. We developed an encapsulating stitch as a feasible, effective and low-cost technique, which does not require advanced surgical skills for placement. This simple, novel approach compartmentalizes the drain allowing for safe early mobilization following cardiac surgery.

Performance, pain, and quality of life on use of central venous catheter for management of pericardial effusions in patients undergoing coronary artery bypass graft surgery

Different pericardial catheters have been suggested as an effective alternative method for drainage of pericardial effusion. The aim of this study was to determine the performance, pain, and quality of life on use of central venous catheter (CVC) for drainage of pericardial effusion in patients undergoing open heart surgery. Fifty-five patients who had developed pericardial effusion after an open heart surgery (2012-2015) were prospectively assessed. Triple-lumen central catheters were inserted under echocardiographic guidance. Clinical, procedural, complication, and outcome details were analyzed. Intensity of pain and quality of life of patients were assessed using the numerical rating scale and Short-Form Health Survey. CVC was inserted for 36 males and 19 females, all of whom had a mean age of 58.5±15 years, and the mean duration of the open heart surgery was 8±3.5 hours. The mean central venous pressure catheter life span was 14.6 days. No cases of recurrent effusion and complication were reported. The technical success rate of procedure was 100%. Intensity of pain and quality of life of patients had improved during follow-up. CVC insertion is a safe and effective technique for the management of pericardial effusion in patients after open heart surgery.