Active clearance of chest tubes is associated with reduced postoperative complications and costs after cardiac surgery: a propensity matched analysis

Yvon Baribeau, Benjamin Westbrook, Yanick Baribeau, Simon Maltais, Edward M Boyle, Louis P Perrault, Yvon Baribeau, Benjamin Westbrook, Yanick Baribeau, Simon Maltais, Edward M Boyle, Louis P Perrault

Abstract

Background: Chest tubes are routinely used to evacuate shed mediastinal blood in the critical care setting in the early hours after heart surgery. Inadequate evacuation of shed mediastinal blood due to chest tube clogging may result in retained blood around the heart and lungs after cardiac surgery. The objective of this study was to compare if active chest tube clearance reduces the incidence of retained blood complications and associated hospital resource utilization after cardiac surgery.

Methods: Propensity matched analysis of 697 consecutive patients who underwent cardiac surgery at a single center. 302 patients served as a baseline control (Phase 0), 58 patients in a training and compliance verification period (Phase 1) and 337 were treated prospectively using active tube clearance (Phase 2). The need to drain retained blood, pleural effusions, postoperative atrial fibrillation, ICU resource utilization and hospital costs were assessed.

Results: Propensity matched patients in Phase 2 had a reduced need for drainage procedures for pleural effusions (22% vs. 8.1%, p < 0.001) and reduced postoperative atrial fibrillation (37 to 25%, P = 0.011). This corresponded with fewer hours in the ICU (43.5 [24-79] vs 30 [24-49], p = < 0.001), reduced median postoperative length of stay (6 [4-8] vs 5 [4-6.25], p < 0.001) median costs reduced by $1831.45 (- 3580.52;82.38, p = 0.04) and the mean costs reduced by an average of $2696 (- 6027.59;880.93, 0.116).

Conclusions: This evidence supports the concept that efforts to actively maintain chest tube patency in early recovery is useful in improving outcomes and reducing resource utilization and costs after cardiac surgery.

Trial registration: Clinicaltrial.gov, NCT02145858, Registered: May 23, 2014.

Keywords: Cardiac surgery; Chest tube; Costs; Critical care; Pleural effusion; Postoperative atrial fibrillation.

Conflict of interest statement

YB received partial funding from ClearFlow, Inc., in the form of an unrestricted grant to support data collection for this study. EB is a consultant and equity holder in ClearFlow, Inc. SM is the recipient of a research grant from ClearFlow, Inc., and a Clinical Trial Educator for Medtronic. LPP is a scientific advisor to ClearFlow, Inc. For the remaining of authors, none were declared.

References

    1. Balzer F, von Heymann C, Boyle EM, Wernecke KD, Grubitzsch K, Sander M. Impact of retained blood requiring Reintervention on outcomes after cardiac surgery. J Thorac Cardiovasc Surg. 2016;152(2):595–601. doi: 10.1016/j.jtcvs.2016.03.086.
    1. Karimov JH, Gillinov AM, Schenck L, Cook M, Kosty Sweeney D, Boyle EM, Fukamachi K. Incidence of chest tube clogging after cardiac surgery: a single-center prospective observational study. Eur J Cardiothorac Surg. 2013;44(6):1029–1036. doi: 10.1093/ejcts/ezt140.
    1. Tauriainen TKE, Morosin MA, Airaksinen J. Biancari Fausto: outcome after procedures for retained blood syndrome in coronary surgery. European Journal of Cardiothoracic Surgery. 2017;51(6):1078–1085. doi: 10.1093/ejcts/ezx015.
    1. Boyle E, Gillinov A, Cohn W, Ley S, Fischlein T, Perrault L. Retained blood syndrome after cardiac surgery: a new look at an old problem. Innovations. 2015;10(5):296–303. doi: 10.1097/imi.0000000000000200.
    1. Sirch J, Ledwon M, Püski T, Boyle EM, Pfeiffer S, Fischlein T. Active clearance of chest drainage catheters reduces retained blood. J Thorac Cardiovasc Surg. 2016;151(3):832–838. doi: 10.1016/j.jtcvs.2015.10.015.
    1. Kramer PA, Chacko BK, Ravi S, Johnson MS, Mitchell T, Barnes S, Arabshahi A, Dell'Italia LJ, George DJ, Steele C, et al. Hemoglobin-associated oxidative stress in the pericardial compartment of postoperative cardiac surgery patients. Lab Investig. 2015;95(2):132–141. doi: 10.1038/labinvest.2014.144.
    1. Halm MA. To strip or not to strip? Physiological effects of chest tube manipulation. Am J Crit Care. 2007;16(6):609–612.
    1. Day TG, Perring RR, Gofton K. Is manipulation of mediastinal chest drains useful or harmful after cardiac surgery? Interact Cardiovasc Thorac Surg. 2008;7(5):888–890. doi: 10.1510/icvts.2008.185413.
    1. Shalli S, Boyle EM, Saeed D, Fukamachi K, Cohn WE, Gillinov AM. The active tube clearance system: a novel bedside chest-tube clearance device. Innovations. 2010;5(1):42–47. doi: 10.1097/imi.0b013e3181cf7ce3.
    1. Engelman Daniel T., Ben Ali Walid, Williams Judson B., Perrault Louis P., Reddy V. Seenu, Arora Rakesh C., Roselli Eric E., Khoynezhad Ali, Gerdisch Marc, Levy Jerrold H., Lobdell Kevin, Fletcher Nick, Kirsch Matthias, Nelson Gregg, Engelman Richard M., Gregory Alexander J., Boyle Edward M. Guidelines for Perioperative Care in Cardiac Surgery. JAMA Surgery. 2019;154(8):755. doi: 10.1001/jamasurg.2019.1153.
    1. Maltais S, Davis ME, Haglund NA, Perrault L, Kushwaha SS, Stulak JM, Boyle EM. Active clearance of chest tubes reduces re-exploration for bleeding after ventricular assist device implantation. ASAIO J. 2016;62(6):704–709. doi: 10.1097/MAT.0000000000000437.
    1. St-Onge S, Ben Ali W, Bouhout I, Bouchard D, Lamarche Y, Perrault LP, Demers P. Examining the impact of active clearance of chest drainage catheters on postoperative atrial fibrillation. J Thorac Cardiovasc Surg. 2017;154(2):501–508. doi: 10.1016/j.jtcvs.2017.03.046.
    1. Perrault LP, Pellerin M, Carrier M, Cartier R, Bouchard D, Demers P, Boyle EM. The PleuraFlow active chest tube clearance system: initial clinical experience in adult cardiac surgery. Innovations (Phila) 2012;7(5):354–358. doi: 10.1097/imi.0b013e31827e2b4d.
    1. Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, Zarbock A. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017;43(11):1551–1561. doi: 10.1007/s00134-016-4670-3.
    1. Shalli S, Saeed D, Fukamachi K, Gillinov AM, Cohn WE, Perrault LP, Boyle EM. Chest tube selection in cardiac and thoracic surgery: a survey of chest tube-related complications and their management. J Card Surg. 2009;24(5):503–509. doi: 10.1111/j.1540-8191.2009.00905.x.
    1. Arakawa Y, Shiose A, Takaseya T, Fumoto H, Kim HI, Boyle EM, Gillinov AM, Fukamachi K. Superior chest drainage with an active tube clearance system: evaluation of a downsized chest tube. Ann Thorac Surg. 2011;91(2):580–583. doi: 10.1016/j.athoracsur.2010.10.018.
    1. Shiose A, Takaseya T, Fumoto H, Arakawa Y, Horai T, Boyle EM, Gillinov AM, Fukamachi K. Improved drainage with active chest tube clearance. Interact Cardiovasc Thorac Surg. 2010;10(5):685–688. doi: 10.1510/icvts.2009.229393.
    1. Labidi M, Baillot R, Dionne B, Lacasse Y, Maltais F, Boulet LP. Pleural effusions following cardiac surgery: prevalence, risk factors, and clinical features. Chest. 2009;136(6):1604–1611. doi: 10.1378/chest.09-0689.
    1. Light RW, Rogers JT, Moyers JP, Lee YC, Rodriguez RM, Alford WC, Jr, Ball SK, Burrus GR, Coltharp WH, Glassford DM, Jr, et al. Prevalence and clinical course of pleural effusions at 30 days after coronary artery and cardiac surgery. Am J Respir Crit Care Med. 2002;166(12 Pt 1):1567–1571. doi: 10.1164/rccm.200203-184OC.
    1. Grieshaber P, Heim N, Herzberg M, Niemann B, Roth P, Boening A. Active chest tube clearance after cardiac surgery is associated with reduced Reexploration rates. Ann Thorac Surg. 2018;105(6):1771–1777. doi: 10.1016/j.athoracsur.2018.01.002.
    1. Pelletier MP, Solymoss S, Lee A, Chiu RC. Negative reexploration for cardiac postoperative bleeding: can it be therapeutic? Ann Thorac Surg. 1998;65(4):999–1002. doi: 10.1016/S0003-4975(98)00078-2.
    1. Greenberg JW, Lancaster TS, Schuessler RB, Melby SJ. Postoperative atrial fibrillation following cardiac surgery: a persistent complication. Eur J Cardiothorac Surg. 2017;53(4):655–672.
    1. St-Onge S, Perrault LP, Demers P, Boyle EM, Gillinov AM, Cox J, Melby S. Pericardial blood as a trigger for postoperative atrial fibrillation after cardiac surgery. Ann Thorac Surg. 2018;105(1):321–328. doi: 10.1016/j.athoracsur.2017.07.045.
    1. Gozdek M, Pawliszak W, Hagner W, Zalewski P, Kowalewski J, Paparella D, Carrel T, Anisimowicz L, Kowalewski M. Systematic review and meta-analysis of randomized controlled trials assessing safety and efficacy of posterior pericardial drainage in patients undergoing heart surgery. J Thorac Cardiovasc Surg. 2017;153(4):865–875. doi: 10.1016/j.jtcvs.2016.11.057.
    1. LaPar DJ, Speir AM, Crosby IK, Fonner E, Jr, Brown M, Rich JB, Quader M, Kern JA, Kron IL, Ailawadi G, et al. Postoperative atrial fibrillation significantly increases mortality, hospital readmission, and hospital costs. Ann Thorac Surg. 2014;98(2):527–533. doi: 10.1016/j.athoracsur.2014.03.039.
    1. Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, Arnaoutakis GJ, Ding X, Engelman DT, Gasparovic H, et al. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. Journal of the American Heart Association. 2018;7(11).
    1. Alshaikh HN, Katz NM, Gani F, Nagarajan N, Canner JK, Kacker S, Najjar PA, Higgins RS, Schneider EB. Financial impact of acute kidney injury after cardiac operations in the United States. Ann Thorac Surg. 2018;105(2):469–475. doi: 10.1016/j.athoracsur.2017.10.053.
    1. Engelman DT, Boyle EM, Jr, Benjamin EM. Addressing the imperative to evolve the hospital new product value analysis process. J Thorac Cardiovasc Surg. 2018;155(2):682–685. doi: 10.1016/j.jtcvs.2017.10.057.
    1. Engelman DT. Surgical economics: MACRA, MIPS, and bundles-lessons learned in the first 3 years of a coronary artery bypass grafting alternative payment model. J Thorac Cardiovasc Surg. 2017;153(2):381–384. doi: 10.1016/j.jtcvs.2016.09.052.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner