Active clearance vs conventional management of chest tubes after cardiac surgery: a randomized controlled study

Active Chest Tube Clearance Added to an Enhanced Recovery After Cardiac Surgery (ERAS) Program Improves Outcomes and Reduces Resource Utilization

OBJECTIVE

We initiated a cardiac enhanced recovery after cardiac surgery (ERAS) program in early 2019, protocolized it and applied it to all patients in 2020, and added the use of active chest tube clearance (ATC) in 2022. Prospective data collection of ATC patients was compared with historical controls to determine the impact of the device on outcomes.

METHODS

The study comprised 1,334 patients with 650 in the control group (group 1) and 684 in the ATC intervention group (group 2). Group 1 (historical control) consisted of 650 patients from January 1, 2020, to October 31, 2020, and January 1, 2021, to October 31, 2021. From October 31, 2021, to December 31, 2021, we introduced ATC use per protocol. Group 2 (ATC) consisted of 684 patients treated consecutively from January 1, 2022, to August 31, 2023, with ATC. The preoperative characteristics and operative procedures between groups were similar.

RESULTS

Patients in the ATC intervention (group 2) experienced a 41% reduction in the composite of retained blood syndrome (8.2% in group 1 vs 4.8% in group 2, P = 0.014). Postoperative atrial fibrillation was 17% reduced for group 2 (178 [33.8%] in group 1 vs 158 [28.1%] in group 2, P = 0.049). Group 2 had a 30% reduction in median intensive care unit (ICU) hours (51.6 [30.1 to 76.9] h in group 1 vs 36.3 [20.7 to 687] h in group 2, P < 0.001). Twenty-one patients (3.2%) were readmitted to the ICU after initial discharge to the step-down unit in group 1 and only 8 (1.17%) in group 2 (P = 0.013).

CONCLUSIONS

The addition of the ATC intervention to an established ERAS program in a high-volume private practice setting decreased complications, improved outcomes, and decreased resource utilization.

The impact of a chest drainage system on retained blood-associated complications after cardiac surgery

OBJECTIVES

Ineffective drainage can lead to retained blood syndrome (RBS), bleeding-associated complications and more postoperative atrial fibrillation (AF). The present study compares outcomes of conventional, active tube clearance (ATC) and portable digital drainage systems after myocardial revascularization.

METHODS

Data from 1222 patients undergoing elective myocardial revascularization with or without a concomitant aortic or mitral valve procedure were considered; data from 1065 patients were retrieved and data from 1049 patients were analysed retrospectively. Patients who received conventional treatment were compared to those treated with ATC and portable digital drainage. Propensity weighting, including comorbidities, medication and perioperative characteristics, was applied for outcome assessment.

RESULTS

In propensity-adjusted patients, 14.6% of conventional patients had interventions for RBS, with 4.1% underdoing early re-exploration for bleeding. In the ATC group, 6.9% required interventions for RBS [odds ratio (OR) 0.43, P < 0.001] with a 3.7% re-exploration rate. Patients in the portable digital drainage group had RBS in 5.1% (OR 0.31, P < 0.001) with a 1.2% rate of re-exploration (OR 0.29, P < 0.001). Postoperative AF dropped by 37% from 29.8% in the conventional to 18.7% in the portable digital drainage cohort (OR 0.31, P < 0.001). In-hospital mortality was similar with 1.6% (6 of 369) in the conventional versus 1.1% (2 of 188) in the ATC versus 0.8% (4 of 492) in the portable digital drainage cohort (P = 0.358).

CONCLUSIONS

Active tube clearance and portable digital drainage cohorts had fewer RBS interventions. In addition, portable digital drainage was associated with reduced early re-exploration for bleeding and lower postoperative AF. Immediately effective chest drainage is crucial to minimize RBS complications postoperatively.

Automated line-clearing chest tubes reduce postoperative pain and atrial fibrillation after cardiac surgery

Objective

Recent advancements in chest tube technologies have gained interest for their ability to enhance postoperative recovery via reduction of retained blood syndrome after cardiothoracic surgery. The present study investigates the effect of the Centese Thoraguard automated line-clearance chest tube system on postoperative pain and recovery after cardiac surgery.

Methods

This was a single-center retrospective review of 1771 adult patients undergoing nonemergency cardiac surgery between January 2021 and December 2022. Perioperative data were analyzed in 184 patients undergoing surgery with Thoraguard automated clearance chest tubes and 1587 patients with conventional chest tubes. Postoperative outcomes were compared in a propensity-matched cohort of 133 patient pairs with similar preoperative characteristics.

Results

Patients undergoing cardiac surgery with automated clearance chest tubes demonstrated significant reductions in pain scores (0-10) compared with conventional chest tubes on the third postoperative day (5 vs 6, P = .02) and at hospital discharge (0 vs 3, P = .04). Automated clearance chest tubes were associated with a shorter time on the ventilator (5.3 vs 5.8 hours, P < .001). There was a significant reduction in postoperative atrial fibrillation (18.1% vs 30.8%, P = .02) in patients receiving automated clearance chest tubes. There were no significant differences in mortality, myocardial infarction, or stroke between automated line-clearing and conventional chest tubes.

Conclusions

The use of the Thoraguard automated line-clearing chest tube system in routine cardiac surgery was associated with improved postoperative pain control, decreased ventilator duration, and decreased postoperative atrial fibrillation without increased morbidity or mortality.

Small incisions still require great anesthesia: anesthesiology techniques to enhance recovery in robotic coronary bypass grafting

Robotic coronary artery bypass grafting (CABG) has emerged as a promising minimally invasive surgical technique for the treatment of coronary artery disease. This paper provides an in-depth analysis of the anesthetic management for robotic CABG. Challenges associated with robotic CABG are discussed and various anesthetic techniques, perioperative elements and pain management modalities that can contribute to enhanced patient recovery are explored.

Improved early risk stratification of deep sternal wound infection risk after coronary artery bypass grafting

BACKGROUND

Deep sternal wound infection (DSWI) following open heart surgery is associated with excessive morbidity and mortality. Contemporary DSWI risk prediction models aim at identifying high-risk patients with varying complexity and performance characteristics. We aimed to optimize the DSWI risk factor set and to identify additional risk factors for early postoperative detection of patients prone to DSWI.

METHODS

Single-centre retrospective analysis of patients with isolated multivessel coronary artery disease undergoing myocardial revascularization at Paracelsus Medical University Nuremberg between 2007 and 2022 was performed to identify risk factors for DSWI. Three data sets were created to examine preoperative, intraoperative, and early postoperative parameters, constituting the "Baseline", the "Improved Baseline" and the "Extended" models. The "Extended" data set included risk factors that had not been analysed before. Univariable and stepwise forward multiple logistic regression analyses were performed for each respective set of variables.

RESULTS

From 5221 patients, 179 (3.4%) developed DSWI. The "Extended" model performed best, with the area under the curve (AUC) of 0.80, 95%-CI: [0.76, 0.83]. Pleural effusion requiring intervention, postoperative delirium, preoperative hospital stay > 24 h, and the use of fibrin sealant were new independent predictors of DSWI in addition to age, Diabetes Mellitus on insulin, Body Mass Index, peripheral artery disease, mediastinal re-exploration, bilateral internal mammary harvesting, acute kidney injury and blood transfusions.

CONCLUSIONS

The "Extended" regression model with the short-term postoperative complications significantly improved DSWI risk discrimination after surgical revascularization. Short preoperative stay, prevention of postoperative delirium, protocols reducing the need for evacuation of effusion and restrictive use of fibrin sealant for sternal closure facilitate DSWI reduction.

TRIAL REGISTRATION

The registered retrospective study was registered at the study centre and approved by the Institutional Review Board of Paracelsus Medical University Nuremberg (IRB-2019-005).

Evaluating the Clinical Equivalence of Truwax® and Ethicon® Bone Waxes for Sternal Wound Hemostasis: A Prospective Randomized Study

BACKGROUND

Incidence of sternal dehiscence, wound infection, and mortality are prevalent following sternotomy. Bone wax is widely used over the sternal edges for augmenting hemostasis. This study evaluated the clinical equivalence of Truwax® (Healthium Medtech Limited, Bengaluru, India) with Ethicon® (Johnson & Johnson, New Brunswick, New Jersey, United States) bone wax for sternal wound hemostasis in subjects undergoing surgical procedures by sternotomy.

METHODS

The primary endpoint of this prospective (May 2022-April 2023), parallel-group, two-arm, randomized, single-blind, multicenter study was to evaluate the proportion of subjects having sternal dehiscence within 26 weeks of median sternotomy closure. Secondary endpoints assessed the average time to hemostasis on sternum sides, bone wax properties, number of dressing changes, sternal bone instability (clinically/chest radiography), pain, perioperative/postoperative complications, blood and blood products used, duration of intensive care unit (ICU)/hospital stay, reoperations, time taken to return back to work and normal day-to-day activities, subject satisfaction and quality of life (QoL), and adverse events. A probability of <0.05 was considered significant.

RESULTS

No incidence of sternal dehiscence or postoperative complications was witnessed. Time to hemostasis, bone wax properties, number of dressing changes, sternal stability, pain, blood and blood products used, duration of ICU/hospital stay, reoperations, time taken to return back to normal day-to-day activities and to work, and subject satisfaction and QoL were comparable between Truwax® and Ethicon® bone wax groups.

CONCLUSION

Truwax® and Ethicon® bone waxes are safe and effective and provide sternal wound hemostasis in people undergoing sternotomy.

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.

Does Active Chest Tube Clearance After Cardiac Surgery Provide Any Clear Benefits?

BACKGROUND

Retained blood syndrome (RBS) encompasses complications, acute and chronic, related to inflammation created by retained intrathoracic blood after cardiac surgery. Reports suggest that active chest tube clearance devices reduce RBS and may lower the rates of reoperation for bleeding and postoperative atrial fibrillation.

METHODS

In a prospective study (April 2015-October 2017), 1367 patients meeting the study inclusion criteria (1113 control subjects with conventional chest tubes and 254 patients with active chest tube clearance devices [the ATC group]) underwent cardiac surgery through primary sternotomy.

RESULTS

Groups were similar in their preoperative and intraoperative characteristics. No differences were found in overall RBS occurrence (4.3% in the ATC group vs 5.3% in the control group; P = .527), including the components of reexploration for bleeding (2.0% [5/254] for the ATC group and 2.4% [27/1113] for the control group; P = .664) and pleural effusion requiring intervention (3.1% [8/254] vs 3.6% [40/1113]; P = .729). Postoperative atrial fibrillation (20.8% [52/254] vs 20.2 % [221/1113]; P = .837) and 30-day mortality were also similar (3.5% vs 2.2%; P = .231). Postoperative blood product use was 31.9% (81/254) in the ATC group and 28.7% (319/1113) in the control group (P = .308). Some complications were more common in the ATC group, including septicemia (2.4% [6/254] vs 0.7% [8/1113]; P = .019) and renal failure (3.9% [10/254] vs 1.7% [19/1113]; P = .026). Median postoperative length of stay was shorter in the ATC group (5 days vs 6 days; P = .025).

CONCLUSIONS

Active chest tube clearance devices were not associated with improved postoperative outcomes related to RBS at the study institution (Northwestern Medicine, Chicago, IL). Given the additional cost, the nursing effort to maintain the active chest tube clearance devices, and the lack of apparent benefit, this study did not demonstrate the value of using such devices in cardiac surgery.