Vacuum-assisted venous drainage in adult cardiac surgery: a propensity-matched study

Comparative Effectiveness of Surgical Drainage Techniques and Postoperative Interventions for Reducing Complications: A Systematic Review of Randomized Controlled Trials

This systematic review assessed the comparative effectiveness of surgical drainage techniques and postoperative interventions in reducing complications across various surgical fields. We conducted a comprehensive search across multiple databases, including PubMed, MEDLINE, Embase, the Cochrane Library, and CINAHL, covering studies from January 2019 to September 2024. Ten randomized controlled trials met our inclusion criteria, focusing on human surgical patients and comparing outcomes such as seroma, hematoma, infection rates, and postoperative pain. Techniques such as pigtail catheters and vacuum sealing drainage (VSD) demonstrated statistically significant improvements in thoracic and orthopedic surgeries, reducing postoperative pain (effect size: 0.35, p < 0.05), pleural effusion (risk ratio: 0.68, p < 0.01), and hospital stays (mean difference: -2.5 days, p < 0.01), while also accelerating wound healing. However, inconsistent results were observed for hemostatic agents like topical gelatin-thrombin matrix sealant and polysaccharide agents, which did not consistently reduce complications in spinal and breast surgeries (effect size range: 0.10-0.20, p > 0.05). These findings suggest that drainage techniques should be tailored to specific surgical procedures and that the routine use of hemostatic agents requires more critical evaluation. Based on these insights, the review recommends prioritizing the use of pigtail catheters and VSD in appropriate contexts while further investigating the effectiveness of hemostatic agents in different surgical fields. This review underscores the need for additional long-term studies and personalized approaches to optimize drainage management in diverse patient populations. Overall, it provides clinicians with concrete recommendations and a framework for improving postoperative care and guiding clinical decision-making.

Insight Into Kidney Protection by Vacuum-Assisted Venous Drainage in Adult Cardiac Operation - A Multicenter Study

BACKGROUND

The relationship between venous congestion and acute kidney injury (AKI) in cardiac surgery after cardiopulmonary bypass has not thoroughly investigated. Vacuum-assisted venous drainage (VAVD) reduces venous congestion, so we hypothesized that it would reduce the incidence of AKI in cardiovascular surgery.

METHODS AND RESULTS

We used a retrospective propensity score-matched analysis to evaluate the effect of VAVD on AKI in adult patients undergoing cardiac surgery. The primary outcomes were AKI and renal replacement therapy (RRT). Multivariable logistic regression was used to explore the association between VAVD exposure and adverse kidney outcomes. Of 15,387 eligible subjects, 13,480 and 1,907 had gravity drainage (GD) or VAVD, respectively, during cardiopulmonary bypass. On the basis of propensity scores, there were 1,468 matched patient pairs for GD and VAVD. The average central venous pressure (CVP) in the GD group was higher than in the VAVD group (4.43±1.23 mmHg vs. 2.30±0.98 mmHg, P<0.001). The occurrence of AKI and RRT was statistically significantly different in the 2 groups [(600/1,468, 40.87%) vs. (445/1,468, 30.31%), P<0.001; (36/1,468, 2.45% vs. 8/1,468; 0.54%), P<0.001, respectively)]. Multivariate logistic regression analysis revealed that VAVD was effective in protecting kidney function.

CONCLUSIONS

VAVD was associated with a lower CVP and lower incidence of AKI, suggesting it protects adult cardiac patients from adverse renal outcomes.

Hematic Antegrade Repriming: A Reproducible Method to Decrease the Cardiopulmonary Bypass Insult

The current practice of cardiopulmonary bypass (CPB) requires a preoperative priming of the circuit that is frequently performed with crystalloid solutions. Crystalloid priming avoids massive embolism but is unable to eliminate all microbubbles contained in the circuit. In addition, it causes a sudden hemodilution which is correlated with transfusion requirements and an increased risk of cognitive impairment. Several repriming techniques using autologous blood, collectively termed retrograde autologous priming (RAP), have been demonstrated to reduce the hemodilutional impact of CPB. However, the current heterogeneity in the practice of RAP limits its evidence and benefits. Here, we describe hematic antegrade repriming as an easy and reliable method that could be applied with any circuit in the market to decrease transfusion requirements, emboli, and inflammatory responses, reducing costs and the impact of CPB on postoperative recovery.

Implementation of a Prescriptive Extracorporeal Circuit and Its Effect on Hemodilution and Blood Product Usage during Cardiac Surgery

The use of cardiopulmonary bypass (CPB) contributes significantly to intraoperative anemia. The use of a prescriptive circuit that is tailored to the patient size could significantly reduce priming volumes, resulting in less hemodilution. The purpose of this study was to determine whether a prescriptive circuit resulted in decreased hemodilution, reduced blood product usage, and improved outcomes. In total, 204 patients prospectively received the prescriptive protocol between March 2019 and November 2019. This protocol was composed of three circuit sizes: small [body surface area (BSA) ≤ 1.85 m²], medium (BSA 1.86-2.30 m²), and large (BSA ≥ 2.31 m²). Data for CPB and post-bypass transfusions were collected, along with postoperative outcomes. These patients were then 1:2 propensity score matched to 401 patients who were retrospectively reviewed who had undergone cardiac surgery using a one-sized CPB circuit. The prescriptive protocol cohort had more patients with renal disease, whereas the conventional cohort had more history of hypertension. Intraoperative results show the prescriptive circuit had lower mean prime volume and total prime volume after reverse autologous prime (1,084 mL vs. 1,798 mL, p < .0001; 725 mL vs. 1,181 mL, p < .0001). Ultrafiltration was higher in the prescriptive group (872 vs. 645 mL, p < .0001), which likely balanced the increased use of del Nido cardioplegia in the prescriptive group (1,295 vs. 377 mL, p < .0001). The drop in hematocrit (HCT) from baseline was less in the prescriptive group (15.1 ± 4.91 vs. 16.2 ± 4.88, p = .0149), whereas the postoperative HCT was higher (32.79 ± 4.88 vs. 31.68 ± 4.99, p = .0069). Transfusion of packed red cells did not change between the two groups. Implementation of a prescriptive circuit did not reduce on-bypass or intraoperative blood product usage. However, there was a significant reduction in on-bypass hemodilution and increased postoperative HCT.