Reversible cardiogenic shock due to chest tube compression of the right ventricle

Post-surgical External Coronary Artery Compression: A Rare Cause of ST Elevation Myocardial Infarction

Iatrogenic ST elevation myocardial infarction (STEMI) after aortic valve surgery is a rare complication. Myocardial infarction (MI) due to mediastinal drain tube compression on the native coronary artery is also seen rarely. We present a case of ST elevation inferior myocardial infarction due to post-surgical drain tube placed after aortic valve replacement compressing on the right-sided posterior descending artery (rPDA). A 75-year-old female presented with exertional chest pain and was found to have severe aortic stenosis (AS). After a normal coronary angiogram and proper risk stratification, the patient underwent surgical aortic valve replacement (SAVR). One day after surgery in the post-operative area, the patient was complaining about central chest pain suggestive of anginal pain. Electrocardiogram (ECG) revealed that she has ST elevation myocardial infarction in the inferior wall. Immediately, she was taken to the cardiac catheterization laboratory, which revealed that she has occlusion of the posterior descending artery due to compression by a post-operative mediastinal chest tube. All features of myocardial infarction resolved after simple manipulation of the drain tube. The compression of the epicardial coronary artery after aortic valve surgery is very unusual. There are a few cases of other coronary artery compression due to mediastinal chest tube, but posterior descending artery compression causing ST elevation inferior myocardial compression is unique. Though rare, we need to be vigilant about mediastinal chest tube compression, which can cause ST elevation myocardial infarction after cardiac surgery.

Comparison of intra-wound drainage tubes after cardiac surgery: Blake drains versus Multichannel drains

BACKGROUND

Blake and Multichannel drains have been used in our department. Although both are made up of silicone, they differ in structure. We investigated the drainage effects of these two types of drains and the factors related to their occlusion.

METHODS

We enrolled 100 consecutive cases (50 using Blake drains and 50 using Multichannel drains) of cardiovascular surgery performed in our department from July 2017 to April 2018. The formation of thrombi in the groove and tube of the drains was evaluated in each case. The tube portion was checked for the presence of occlusion, and the groove portion was examined for the number and ratio of thrombi formed in the grooves.

RESULTS

The clot formation rate in the groove part was slightly higher in the Multichannel cases than in the Blake cases. In addition, analysis within the Multichannel cases revealed that the thrombus formation rate between the catheter lumen and the three grooves (without the catheter lumen) was significantly different, with the highest groove clot formation rate occurring in the catheter lumen. Out of 34 cases of occlusions, there were 26 cases (52%) of Multichannel drains, and only 8 cases (16%) of Blake drains (p < 0.01). A multiple logistic regression analysis revealed that the most important contributory factor in tube obstruction was the drain type.

CONCLUSIONS

The catheter lumen of the Multichannel drain was more susceptible to thrombus formation than the groove. The tube part of the Multichannel drain was more prone to occlusion than that of the Blake drain.

Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications

INTRODUCTION

Although seemingly straightforward, tube thoracostomy (TT) has been associated with complication rates as high as 30 %. A lack of a standardized nomenclature for reporting TT complications makes comparison and evaluation of reports impossible. We aim to develop a classification method in order to standardize the reporting of complications of TT and identify all reported complications of TT and time course in which they occurred to validate the reporting method.

METHODS

A systematic search of MEDLINE, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews from each databases inception through November 5, 2013 was conducted. Original articles written in the English language reporting TT complications were searched. This review adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards. Duplicate reviewers abstracted case reports for inclusion. Cases were then sorted into one of the five complication categories by two reviewers, and in case of disagreements, settled by a third reviewer.

RESULTS

Of 751 papers reporting TT complications, 124 case reports were included for analysis. From these reports, five main categories of TT complications were identified: insertional (n = 65); positional (n = 36); removal (n = 11); infective and immunologic (n = 7); and instructional, educational, or equipment related (n = 5). Placement of TT has occurred in nearly every soft tissue and vascular structure in the thoracic cavity and intra-abdominal organs.

CONCLUSION

Our classification method provides further clarity and systematic standardization for reporting TT complications.

Accuracy of targeted wire guided tube thoracostomy in comparison to classical surgical chest tube placement - A clinical study

BACKGROUND

Chest tube malfunction, after the tube thoracostomy, is often the result of an inappropriate chest tube tip position. The aim of this study was to analyse the precision of chest tube placement using the targeted wire guide technique (TWG technique) with curve dilator and to compare it to the classical surgical technique (CS technique).

MATERIALS AND METHODS

In this clinical study 80 patients with an indication for thoracic drainage, due to pneumothorax or pleural effusion were included. Experimental group contained 39 patients whose chest tube was placed using the TWG technique. The control group contained 41 patients whose chest tube was placed using the CS technique.

RESULTS

The comparison of the outcomes of the two techniques applied suggests that the TWG technique was significantly more successful in achieving adequate (precise) chest tube placement, irrespective of patient diagnosis (TWG vs. CS in all patients, 78.4% vs. 36.6%, p<0.001). In the pleural effusion group, TWG and CS had success rates of 78.2% and 37.5% (p=0.005), respectively, while in pneumothorax group, TWG and CS had success rates of 78.6% and 35.3% (p=0.029), respectively.

CONCLUSIONS

Using a curved dilator and the TWG technique for the thoracic drainage procedure we found statistically significant advantage to the TWG technique in comparison to the CS technique (78% vs. 37%) regarding precise chest tube placement within the pleural cavity. Introducing the materials and technique used in this clinical trial into clinical practice may improve the quality of thoracic drainage, including residual volume of air and/or fluid, poor functioning of the chest tube, and, as a consequence of both, prolonged hospitalisation.

Thoracostomy tubes: A comprehensive review of complications and related topics

Tube thoracostomy (TT) placement belongs among the most commonly performed procedures. Despite many benefits of TT drainage, potential for significant morbidity and mortality exists. Abdominal or thoracic injury, fistula formation and vascular trauma are among the most serious, but more common complications such as recurrent pneumothorax, insertion site infection and nonfunctioning or malpositioned TT also represent a significant source of morbidity and treatment cost. Awareness of potential complications and familiarity with associated preventive, diagnostic and treatment strategies are fundamental to satisfactory patient outcomes. This review focuses on chest tube complications and related topics, with emphasis on prevention and problem-oriented approaches to diagnosis and treatment. The authors hope that this manuscript will serve as a valuable foundation for those who wish to become adept at the management of chest tubes.

Influence of pleural drain insertion in lung function of patients undergoing coronary artery bypass grafting

BACKGROUND AND OBJECTIVES

Longitudinal, prospective, randomized, blinded Trial to assess the influence of pleural drain (non-toxic PVC) site of insertion on lung function and postoperative pain of patients undergoing coronary artery bypass grafting in the first three days post-surgery and immediately after chest tube removal.

METHOD

Thirty six patients scheduled for elective myocardial revascularization with cardiopulmonary bypass (CPB) were randomly allocated into two groups: SX group (subxiphoid) and IC group (intercostal drain). Spirometry, arterial blood gases, and pain tests were recorded.

RESULTS

Thirty one patients were selected, 16 in SX group and 15 in IC group. Postoperative (PO) spirometric values were higher in SX than in IC group (p<0.05), showing less influence of pleural drain location on breathing. PaO(2) on the second PO increased significantly in SX group compared with IC group (p<0.0188). The intensity of pain before and after spirometry was lower in SX group than in IC group (p<0.005). Spirometric values were significantly increased in both groups after chest tube removal.

CONCLUSION

Drain with insertion in the subxiphoid region causes less change in lung function and discomfort, allowing better recovery of respiratory parameters.

An uncommon cause of myocardial ischemia after coronary artery bypass grafting: "the dangerous drainage"

The most common causes of myocardial ischemia and myocardial infarction early after coronary artery bypass grafting surgery are early graft occlusion/thrombosis or occlusion/ thrombosis of coronary arteries due to advanced coronary heart disease. We describe a case of postoperative myocardial ischemia due to an uncommon and quickly reversible cause: mechanical compression of a vein graft by a 19F flexible silicone mediastinal drainage tube.

Targeted wire-guided chest tube placement: a cadaver study

OBJECTIVE

Chest tube thoracostomy is a standard procedure for pleural fluid and air drainage. The aim of this study is to compare the success rate of the targeted tube thoracostomy using two different techniques: a targeted wire-guided (TWG) technique and a classical surgical (CS) technique.

METHODS

The study was performed on 153 human cadavers without documented pleural pathology, mechanically ventilated during the procedure. They were divided into two groups and to each cadaver a software generated random number was assigned. The TWG technique was applied on 76 and the CS technique on 77 cadavers. The TWG and CS groups were divided into four subgroups according to the four intended positions of the chest tube tip (target position in the pleural cavity): back-down-right, front-up-right, front-up-left and back-down-left. The precise position of the chest tube tip after thoracostomy was determined by autopsy. The placement of the thoracostomy tube was marked successful if the chest tube tip was located at an intended position.

RESULTS

The success rate with the TWG technique was 79%, whereas with the CS technique it was 30%.

CONCLUSION

A higher success rate was achieved with the TWG than with the CS thoracostomy technique.

Experimental assessment of the drainage capacity of small silastic chest drains

Recently, flexible fluted small silicone drains have been used widely as chest drains after cardiac surgery. Despite the clinical advantages of using smaller silastic chest drains over conventional chest tubes, an experimental comparison of the drainage capacity between these two drain tubes has not yet been performed. The drainage capacity of 19F silicone drains and 28F conventional tubes was tested. In an in vitro study, both tubes were set in a water bath and drained at a pressure of 10 mm Hg. In an in vivo study, the drains were inserted into the hemithorax in 8 adult pigs. Blood was infused at 20 mL x min(-1) into both chest cavities and the tubes were drained at 15 cm H(2)O for 30 min. In the in vitro study, the drainage capacity of the conventional chest tube was 9-times higher than that of the smaller silicone drain (103.8 vs. 11.6 L x hr (-1)). However, in the in vivo study, there was no difference in drainage capacity between the two different tubes over time. This experiment demonstrated that the smaller silastic chest drain has sufficient drainage capacity, almost identical to the conventional chest tube, in the clinical setting.

Effect of posterior pericardial drainage on the incidence of pericardial effusion after ascending aortic surgery

OBJECTIVE

Pericardial effusion and cardiac tamponade after ascending aortic surgery are higher than anticipated after cardiac surgery. We evaluated a thin closed-suction drain system to prevent posterior pericardial effusion in patients undergoing ascending aortic surgery.

METHODS

One hundred forty patients who underwent ascending aortic surgery were prospectively randomized into group A and group B. In group A (n = 70) we used a 32F drain placed anteriorly overlying the heart and a 16F thin drain placed retrocardially. In group B (n = 70) only a 32F drain placed anteriorly was used. In group A we removed the large drain on the first postoperative day and continued drainage with the thin drain until the drainage was less than 50 mL in a 24-hour period. In group B we removed the drain after the first postoperative day when the drainage was less than 50 mL in an 8-hour period. Preoperative, perioperative, and postoperative parameters of the patients were compared.

RESULTS

No significant posterior pericardial effusion and late cardiac tamponade developed in patients in group A. In group B 10 (14.3%) patients experienced significant posterior pericardial effusion and 4 (5.7%) patients experienced late cardiac tamponade; the incidence of significant pericardial effusion in group B was significantly higher (P = .001). Postoperative new-onset atrial fibrillation developed in 6 (10.4%) patients in group A and in 18 (32.7%) patients in group B (P = .03).

CONCLUSIONS

We demonstrated that effective posterior drainage is important to prevent posterior pericardial effusion, and use of a thin drain placed retrocardially appears to be sufficient for these results.

A method for chest drainage after pediatric cardiac surgery: A prospective randomized trial

OBJECTIVES

The purposes of this study were to evaluate the clinical safety and efficacy of 10F, 15F, and 19F Blake drains (Ethicon, Sommerville, NJ) in a pediatric population after cardiac surgery and to compare their clinical effect with that of conventional chest drains.

METHODS

From January 2002 through December 2004, a prospective randomized trial was conducted on 189 patients who underwent surgical intervention for congenital heart disease at our institution. Statistical analyses were conducted to test the null hypothesis that there was no difference in the incidence of pericardial or pleural effusion requiring drainage. Secondary end points included total volume of drainage, drain size, and time to drain removal.

RESULTS

Ninety-eight patients (group A) received Blake drains, and 91 patients (group B) received conventional chest drains. There were no statistically significant difference in age, weight at the time of surgical intervention, open- and closed-heart procedures, and number of drains applied. Statistically significant differences were detected in the frequency of pericardial effusion (group A: 1.1% vs group B: 4.8%, P < .01), pleural effusion (group A: 1.1% vs group B: 5.3%, P < .01), size of the drain (group A: 12.37 French +/- 1.72 French vs group B: 16.81 French +/- 0.70 French, P < .001), and time to removal (group A: 43.75 +/- 20.76 hours vs group B: 55.62 +/- 26.48 hours, P < .001).

CONCLUSIONS

Blake drains are safer and more efficient than conventional chest tubes in pediatric populations after cardiac surgery. In comparison with conventional chest tubes, they showed fewer occurrences of effusions and the same amount of fluid drained but smaller size and earlier removal.

Optimal design of small-diameter silicone chest drain devices

To overcome the complications due to the use of noncompliant large diameter conventional chest drain devices, a flexible small diameter chest drain device was designed and simulated based on computational fluid dynamics (CFD) techniques. It was clearly shown that the pressure drop and velocity increase of the most distal drainage holes, which are located near the suction end, are dominant over other drainage holes. A conventional chest drain device with circular side holes showed higher mass flow rate due to larger cross sectional area. It also showed less dependency on the side hole placement compared to open channel, closed cavity chest drain with rectangular side holes. When all holes are opened the conventional chest drain showed 6% increase in flow rate while the open channel, closed cavity drain device showed 47% increase in flow rate reflecting a better design performance. These results provide an insight into the CFD-based optimal design of chest drain devices for potential applications in clinical intraoperative procedures.

Efficacy of BlakeR Drains for Mediastinal and Pleural Drainage Following Cardiac Operations

BACKGROUND

Mediastinal and pleural drainage following cardiac operations has traditionally been achieved with large bore, semirigid chest tubes. The purpose of this study was to evaluate the safety and efficacy of drainage by means of small, soft, and flexible 19 F Blake drains.

METHODS

This is a review of all patients who underwent heart surgery over a 3-year period at a single institution. Chest tubes and Blake drains were removed on postoperative day 1 to 5 depending on patient's condition, amount of drainage, and surgeon's preference. The criteria for drain removal did not vary with type of drain.

RESULTS

There was no significant difference in the amount of drainage between both groups. Postoperative mediastinal exploration occurred in 3.47% of patients (12/346) in the chest tube group and in 2.08% of patients (8/385) in the Blake group (p = 0.27). Significant pleural effusions requiring a subsequent drainage procedure occurred in 9.54% of patients (33/346) in the chest tube group and in 9.87% of patients (38/385) in the Blake group.

CONCLUSIONS

No significant differences were noted in the number of mediastinal explorations in patients drained with conventional chest tubes as compared to Blake drains during cardiac operations. Though not statistically significant, there may actually be an advantage of Blake drains over conventional chest tubes in this regard. There was also no significant difference in the incidence of postoperative pleural effusions. Blake drains appear to be at least as effective and safe as conventional chest tubes in draining the mediastinum and pleural spaces following cardiac surgery.

Silastic drains vs conventional chest tubes after coronary artery bypass

STUDY OBJECTIVES

To investigate differences in drainage amounts and early clinical outcomes associated with the use of Silastic drains, as compared with the conventional chest tube after coronary artery bypass grafting (CABG).

DESIGN

Retrospective nonrandomized case control study.

SETTING

A tertiary teaching hospital.

PATIENTS AND PARTICIPANTS

Outcome data from 554 patients who underwent postoperative pericardial decompression using small Silastic drains were compared with those from 556 patients who had conventional chest tubes after first-time CABG at our institution between January 1 and August 1, 2000.

MEASUREMENT AND RESULTS

Univariate analysis of preoperative characteristics was used to ensure similarity between the two patient groups. Operative mortality, mediastinitis, reoperation for bleeding, and early and late cardiac tamponade occurred in 9 patients (1.6%), 6 patients (1.1%), 6 patients (1.1%), 6 patients (1.1%), and 1 patient (0.2%), respectively, in the Silastic drain group, compared with 11 patients (2.0%), 9 patients (1.6%), 4 patients (0.7%), 2 patients (0.4%), and 6 patients (1.1%) in the conventional group. No statistically significant differences between the two drains were identified. Drainage amounts (mean +/- SD) were 552.2 +/- 281.8 mL and 548.8 mL +/- 328.7 mL for the Silastic and conventional groups, respectively (p = 0.51). Postoperative length of stay was longer for the conventional chest tube group (median, 5 d; range, 1 to 119 d) when compared to the Silastic drain group (median, 4 d; range, 1 to 66 d; p = 0.01).

CONCLUSIONS

We demonstrated that small Silastic drains are equally as effective as the conventional, large-bore chest tubes after CABG with no significant risk of bleeding or pericardial tamponade. Additionally, use of Silastic drains allows more mobility than the conventional chest tubes. As a result of this study, there was a change in our clinical practice toward the exclusive use of Silastic drains after all cardiac surgical procedures.

The use of smaller, more flexible chest drains following open heart surgery : an initial evaluation

STUDY OBJECTIVES

To evaluate the safety and efficacy of smaller-caliber drains in patients undergoing open heart surgery.

DESIGN

A retrospective analysis of the medical records and chest radiographs assembled data on total amount of drainage, number of days of drainage, length of postoperative stay, appearance of postoperative chest radiographs, and need for further drainage from either the pleural or pericardial spaces.

SETTING

A large university-based teaching hospital, where > 800 open-heart procedures are performed yearly.

PATIENTS AND INTERVENTIONS

A total of 202 patients underwent standard open heart surgery by one surgeon, and postoperative pleural and pericardial decompression was undertaken using small caliber, more flexible drains connected to bulb suction.

RESULTS

Tubes were left in an average of 2.4 days, with a mean of 826.7 mL collected during that time. The average postoperative length of stay was 6.7 days (median, 5 days). At or before 6-week follow-up, chest radiographs revealed moderate or large effusions in 19 patients (9.4%) in a pleural space that had been drained postoperatively. Twelve patients (5.9%) required an additional postoperative procedure for pleural drainage (eight thoracenteses, four tube thoracostomies). Four patients (2.0%) required reexploration of the pericardium for tamponade.

CONCLUSIONS

Use of smaller-caliber drains have been found at our institution to be an adequate means of decompression of the pleural and pericardial spaces following open heart surgery, with patients rarely having clinically significant pleural effusions at 6-week follow-up.

Pleural Disease in the Intensive Care Unit

Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.

Selective use of chest tubes in thoracotomies for congenital cardiovascular procedures

BACKGROUND

Advantages and complications have been reported from the use of chest tubes (CT). To reduce the incidence of complications we have employed a selective use of CT in thoracotomy for congenital cardiovascular procedure; ie, in absence of air leaks and fluid to be drained, no CT was inserted.

METHODS

The lung was reexpanded and air evacuated during the chest closure. Early and 6 hours chest roentgenograms were performed on every patient. This study retrospectively reviews the results of this selective approach in 546 patients operated on between 1980 and 1998 mainly for patent ductus arteriosum ligation, pulmonary artery band, aortic coarctation, Blalock-Taussig shunt. Four hundred and eighteen patients did not receive a CT at the initial surgery (group I), and 128 patients received a CT either before or at surgery (group II).

RESULTS

40 patients in group I developed an air or fluid collection large enough to require a CT. Only one patient had complication, from an undetected hemothorax. Nine patients in group II required another CT, and one patient developed a pneumothorax upon pulling out the CT. No death in either group was related to the use or lack of use of the CT. A total of 378 CTs and collecting chambers were saved.

CONCLUSIONS

A selective approach to the use of CT in thoracotomies for cardiovascular procedures can be employed with minimal complications, more comfort for the patient, and cost savings.

Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital

STUDY OBJECTIVE

To evaluate all tube thoracostomies (TTs) done by pulmonary/critical care fellows and attending physicians in the Medical University of South Carolina's health-care system documenting patient demographics, indication for placement, size and characteristics of the tube, and associated problems.

DESIGN

Prospective.

SETTING

University health-care system, including a university hospital, a Veterans Affairs hospital, and a county hospital.

PATIENTS

All adult patients requiring consultation by a member of the pulmonary/critical care staff for a tube thoracostomy.

RESULTS

One hundred twenty-six tube thoracostomies were performed over a 24-month period in 91 patients. The most common initial indication for a TT was pneumothorax (69/103, 67%). Overall mortality in the patient population was 35% (32/91). Early problems (< 24 hours following placement) occurred in 3% (4/126); late problems (> 24 h after placement) occurred in 8% (10/126). Problems occurred in 36% (4/11) of small-bore tube placements vs 9% (10/115) of standard TT placements (p=0.02).

CONCLUSIONS

Tube thoracostomy can be safely performed by pulmonologists with relatively few associated problems.

Computed tomography of malpositioned thoracostomy drains: a pictorial essay

Chest drain placement is essential to the management of patients with abnormal thoracic collections of air or fluid. Frequently, in these critically ill patients, drain position can only be assessed by portable frontal radiographs. However, evaluation by axial chest CT in some cases reveals unexpected malplacement that may prompt repositioning to reduce morbidity and improve drain function.

Selected topics in chest trauma

Trauma is the leading cause of death of young adults in the United States, and chest trauma is one of the leading causes of trauma-related fatalities. This article presents an approach to the radiological evaluation and diagnosis of pneumothorax, pneumomediastinum, traumatic aortic rupture, and thoracic spine injuries. Also discussed is the radiological assessment of vascular catheters, endotracheal tubes, and thoracostomy tubes.

Chest tubes: indications, placement, management, and complications

Use of tube thoracostomy in intensive care units for evacuation of air or fluid from the pleural space has become commonplace. In addition to recognition of pathological states necessitating chest tube insertion, intensivists are frequently involved in placement, maintenance, troubleshooting, and discontinuation of chest tubes. Numerous advances have permitted safe use of tube thoracostomy for treatment of spontaneous or iatrogenic pneumothoracies and hydrothoracies following cardiothoracic surgery or trauma, or for drainage of pus, bile, or chylous effusions. We review current indications for chest tube placement, insertion techniques, and available equipment, including drainage systems. Guidelines for maintenance and discontinuation are also discussed. As with any surgical procedure, complications may arise. Appropriate training and competence in usage may reduce the incidence of complications.

Delayed pulmonary perforation. A rare complication of tube thoracostomy

Tube thoracostomy is a standard therapy for a number of pulmonary disorders. The procedure is associated with a certain incidence of morbidity related to the technique of insertion, the patient population selected, and the length of time the tube remains in place. Complications of tube placement previously described include empyema, residual pneumothorax, lung perforation, placement of the tube in the chest wall, diaphragmatic perforation, perforation of intraabdominal organs (such as spleen, liver and stomach), unilateral pulmonary edema, bronchopleural fistula, hemothorax, cardiogenic shock and Horner syndrome. A case of a delayed pulmonary perforation developing several days after placement of a chest tube is described with a discussion of the clinical and radiographic findings associated with this complication. A possible pathophysiologic mechanism by which this complication may have occurred is proposed.