Determining optimal fluid and air leak cut off values for chest drain management in general thoracic surgery

Is chest tube capnography effective in differentiating between true and false air leaks after minimally invasive thoracic surgery?

OBJECTIVE

Air leak (AL) is the most frequent adverse event after thoracic surgery. When AL occurs, the concentration of the principal gas in the pleural space should be similar to that of air exhaled. Accordingly, we tried to develop a new method to identify AL by analyzing pCO2 levels in the air flow from the chest drainage using capnography.

METHODS

This is a prospective observational study of 104 patients who underwent VATS surgery between January 2020 and July 2021. Digital drainage systems were used to detect AL.

RESULTS

Eighty-two patients (79%) had lung resection. Among them, 19 had post-operative day 1 air leaks (median 67 ml/min). AL patients had higher intrapleural CO2 levels (median 24 mmHg) (p < 0.001). Median chest drainage duration was 2 days (range 1.0-3.0). Univariable logistic regression showed a linear and significant association between intrapleural CO2 levels and AL risk (OR 1.26, 95% CI 1.17-1.36, p < 0.001, C index: 0.94). The Univariable Gamma model demonstrated that an elevation in CO2 levels was linked to AL on POD1 (with an adjusted mean effect of 7.006, 95% CI 1.59-12.41, p = 0.011) and extended duration of drainage placement (p < 0.001).

CONCLUSIONS

Intrapleural CO2 could be an effective tool to assess AL. The linear association between variables allows us to hypothesize the role of CO2 in the identification of AL. Further studies should be performed to identify a CO2 cutoff that will standardize the management of chest drainage.

Are chest drains routinely required after thoracic surgery? A drainology study of on-table chest-drain removals

Objectives

Advances in perioperative management for thoracic surgery have accelerated the postoperative recovery of patients by decreasing postoperative pain and the incidence of complications. We aimed to study whether it's safe to remove chest drains on table in selected cases.

Methods

This was a 5-year retrospective analysis of protocolized chest-drain removal on the operating table. The chest drain was removed in patients undergoing sublobar/wedge lung resection and other minor thoracic procedure (pleural biopsy, mediastinal mass biopsy/resection) via a thoracoscopic approach (video-assisted thoracoscopic surgery). Chest drains were removed at the end of the operation if air leak as documented by the digital drain was less than 20 mL/min. Outcome data on postdrain removal pneumothorax, effusion, and need for further intervention were obtained by reviewing the postoperative chest films, all reported by a radiologist.

Results

Between 2016 and 2021, 107 patients underwent drain removal in theater. Mean age (standard deviation) was 58 (17) years and 54 (50.5%) were male. Postdrain removal pneumothorax occurred in 22 patients (21%), pleural effusion in 6 (5.6%), and 21 of 22 postoperative pneumothoraces were managed conservatively without reinsertion of chest drain. As it is our standard policy to leave no pneumothorax in patients undergoing surgical management of primary spontaneous pneumothorax, only 1 such patient (0.9%) had a drain reinserted as a result. The median (interquartile) length of hospital stay was 1 day (1-2), and 14 patients (13%) were discharged on surgery day.

Conclusions

Our results demonstrate that on table chest-drain removal in selected cases is safe and repeatable using a digital drain, challenging the practice of routine drain insertion after thoracic surgery.

Outcomes of chest drain management using only air leak (without fluid) criteria for removal after general thoracic surgery-a drainology study

Background

Chest drain management is a variable aspect of postoperative care in thoracic surgery, with different opinion for air and drain volume output. We aim to study if acceptable safety was maintained using air leak criteria alone.

Methods

A 9-year retrospective analysis of protocolised chest drain management using digital drain air leak cut off less than 20 mL/min for more than 6 h for drain removal in patients undergoing general thoracic surgery. We excluded patients if a chest drain was not required nor removed during admission or if patients underwent volume reduction or pneumonectomy. Withdrawal criteria were suspected bleeding or chylothorax. Postoperative films were reviewed to document post-drain removal pneumothorax, pleural effusion, and reintervention (drain re-insertion).

Results

Between 2012 and 2021, 1,187 patients had thoracic surgery under a single surgeon. Following exclusion and withdrawal criteria, 797 patients were left for analysis. The mean age [standard deviation (SD)] was 61 [16] years and 383 (48%) were male. Median [interquartile range (IQR)] duration of drain insertion was 1 [1-2] day with a median length of hospital stay of 4 [2-6] days. Post-drain removal pneumothorax was observed in 141 (17.7%), post-drain removal pleural effusion was observed in 75 (9.4%) and re-intervention (reinsertion of chest drain) required in 17 (2.1%).

Conclusions

Our results demonstrate acceptable levels of safety using digital assessment of air leak as the sole criteria for drain removal in selected patients after general thoracic surgery.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Reduction of drainage-associated complications in cardiac surgery with a digital drainage system: a randomized controlled trial

Background

Thoracic chest drains are placed after cardiac surgery allowing for the clearance of blood, fluid, and air to prevent post-operative complications. Despite its importance, there is little data on the application of digital chest drainage systems in cardiac surgery. Therefore, the differences between an analog and a digital chest drainage system in cardiac surgery patients were investigated in a randomized controlled trial.

Methods

A total of 354 elective cardiac surgery patients were preoperatively randomized 1:1 between September 2016 and September 2017 to either an analog (Ocean) or a digital (Thopaz⁺) chest drainage system aiming to compare drainage-associated postoperative outcome parameters.

Results

A total of 340 patients were included in the analysis (analog: 188; digital: 152) with no significant differences in preoperative baseline parameters. Incidence of X-rays to detect air leaks was significantly lower in the digital group (analog: 20.2%; digital: 8.6%; P<0.01). Patients treated with the digital system showed a 3.3% reduction of re-thoracotomies, however, not statistically significant (analog: 5.3%; digital: 2.0%; P=0.19). Median total fluid amount did not significantly differ between study groups [median (P25; P75); analog: 705 (400; 1,333) mL; digital: 686 (404; 1,229) mL; P=0.83]; however, the use of the digital drainage system resulted in a quicker removal with a reduced median drainage duration of 16 hours (analog: 65 hours; digital: 49 hours; P≤0.01).

Conclusions

The study provides evidence that digital drainage systems can be safely applied in cardiac surgery patients. The use of the digital management system led to a decreased incidence of drainage-associated complications as well as to shortened chest tube duration. Findings require confirmation by additional studies.

Preoperative platelet to lymphocyte and neutrophil to lymphocyte ratios are independent prognostic factors for patients undergoing lung cancer radical surgery: A single institutional cohort study

BACKGROUND

The aim of this study was to assess the prognostic value for NSCLC patients who were scheduled to receive lung cancer radical resection.

METHODS

In this cohort study (Dec.2014-Feb.2016), patients with non-small cell lung cancer (NSCLC) who underwent radical lung cancer thoracotomy were enrolled and accessed at postoperative complications, one-year overall survival (OS) and relapse-free survival (RFS). The preoperative PLR and NLR of all patients were calculated based on preoperative complete blood counts. Univariate and multivariate Cox regression analyses were performed to determine the associations of PLR and NLR with OS and RFS.

RESULTS

A total of 174 NSCLC patients were studied. The results indicated that both high PLR (>148.6) and NLR (>2.9) were related to a high rate of postoperative pulmonary complications significantly (49.3%vs.29.1%, P = 0.007; 50.7% vs. 28.6%, P = 0.003). Moreover, NSCLC patients with a high PLR level (> 148.6) was significantly associated with a lower one-year OS (90.3% vs. 77.5%, P = 0.034).

CONCLUSIONS

Preoperative PLR and NLR were good prognostic factors for postoperative pulmonary complications and OS in NSCLC patients undergoing radical lung cancer surgery. Thus, blood PLR and NLR would be helpful as a prognostic tool before radical lung cancer surgery.

Enhanced recovery after surgery and video-assisted thoracic surgery lobectomy: the Italian VATS Group surgical protocol

Enhanced recovery after surgery (ERAS^®) is a strategy that seeks to reduce patients' perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted in patients undergoing open colorectal surgery. Since then, the concept of ERAS has been adopted by multiple surgical specialties. The diffusion of video-assisted thoracic surgery lobectomy (VATS-L) sets also the surgical treatment of lung cancer as a new area for ERAS development. In this paper, we present the Italian VATS Group (www.vatsgroup.org) surgical protocol as part of the ERAS clinical pathway belonging to the VATS-L national database.

The Society for Translational Medicine: clinical practice guidelines for the postoperative management of chest tube for patients undergoing lobectomy

The Society for Translational Medicine and The Chinese Society for Thoracic and Cardiovascular Surgery conducted a systematic review of the literature in an attempt to improve our understanding in the postoperative management of chest tubes of patients undergoing pulmonary lobectomy. Recommendations were produced and classified based on an internationally accepted GRADE system. The following recommendations were extracted in the present review: (I) chest tubes can be removed safely with daily pleural fluid of up to 450 mL (non-chylous and non-sanguinous), which may reduce chest tube duration and hospital length of stay (2B); (II) in rare instances, e.g., persistent abundant fluid production, the use of PrR_P/B <0.5 when evaluating fluid output to determine chest tube removal might be beneficial (2B); (III) it is recommended that one chest tube is adequate following pulmonary lobectomy, except for hemorrhage and space problems (2A); (IV) chest tube clearance by milking and stripping is not recommended after lung resection (2B); (V) chest tube suction is not necessary for patients undergoing lobectomy after first postoperative day (2A); (VI) regulated chest tube suction [-11 (-1.08 kPa) to -20 (1.96 kPa) cmH₂O depending upon the type of lobectomy] is not superior to regulated seal [-2 (0.196 kPa) cmH₂O] when electronic drainage systems are used after lobectomy by thoracotomy (2B); (VII) chest tube removal recommended at the end of expiration and may be slightly superior to removal at the end of inspiration (2A); (VIII) electronic drainage systems are recommended in the management of chest tube in patients undergoing lobectomy (2B).