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

Samuel St-Onge, Vincent Chauvette, Raphael Hamad, Denis Bouchard, Hugues Jeanmart, Yoan Lamarche, Louis P Perrault, Philippe Demers, Samuel St-Onge, Vincent Chauvette, Raphael Hamad, Denis Bouchard, Hugues Jeanmart, Yoan Lamarche, Louis P Perrault, Philippe Demers

Abstract

Background: Chest tubes are routinely used after cardiac surgery to evacuate shed mediastinal blood. Incomplete chest drainage due to chest tube clogging can lead to retained blood after cardiac surgery. This can include cardiac tamponade, hemothorax, bloody effusions and postoperative atrial fibrillation (POAF). Prior published non randomized studies have demonstrated that active tube clearance (ATC) of chest tubes can reduce retained blood complications prompting the ERAS Cardiac Society guidelines to recommend this modality.

Objective: A randomized prospective trial to evaluate whether an ATC protocol aimed at improving chest tube patency without breaking the sterile field could efficiently reduce complications related to retained blood after cardiac surgery.

Methods: This was a pragmatic, single-blinded, parallel randomized control trial held from November 2015 to June 2017 including a 30-day post index surgery follow-up. The setting was two academic centers affiliated with the Université de Montréal School of Medicine; the Montreal Heart Institute and the Hôpital du Sacré-Coeur de Montréal. Adult patients admitted for non-emergent coronary bypass grafting and/or valvular heart surgery through median sternotomy, in sinus rhythm for a minimum of 30 days prior to the surgical intervention were eligible for inclusion. In the active tube clearance group (ATC), a 28F PleuraFlow device was positioned within the mediastinum. In the standard drainage group, a conventional chest tube (Teleflex Inc.) was used. Other chest tubes were left at the discretion of the operating surgeon.

Results: A total of 520 adult patients undergoing cardiac surgery were randomized to receive either ATC (n = 257) or standard drainage (n = 263). ATC was associated with a 72% reduction in re-exploration for bleeding (5.7% vs 1.6%, p = .01) and an 89% reduction in complete chest tube occlusion (2% vs 19%, p = .01). There was an 18% reduction in POAF between the ATC and control group that was not statistically significant (31% vs 38%, p = .08).

Conclusions and relevance: In this RCT, the implementation of active clearance of chest tubes reduced re-exploration and chest tube clogging in patients after cardiac surgery further supporting recommendations to consider this modality postoperatively.

Trial registration: Clinical Trials NCT02808897 . Retrospectively registered 22 June 2016.

Keywords: Bleeding; Cardiac surgery; Chest tube; Complications; Critical care; ICU; Postoperative atrial fibrillation; Reexploration; Retained blood.

Conflict of interest statement

This trial was not externally funded. LPP serves as a ClearFlow Inc. Scientific Advisor and both LPP and PD have received honorarium for scientific presentations. During the duration of the trial, ClearFlow Inc. offered a volume discount on PleuraFlow chest tubes but provided no direct funding for the clinical trial or data analysis. The investigators had full unrestricted scientific control of the design of the trial, data analysis and publication of the written report.

Figures

Fig. 1
Fig. 1
CONSORT Flow Diagram. A total of 520 patients consented to participate in this study before surgery and were randomized to receive either active tube clearance (n = 257) or standard chest drainage (n = 263). Of these patients, 11 did not receive the allocated intervention, for a cross-over rate of 2.1%. Thirty patients were included in the study despite being screening failures, mostly because of undergoing a minimally invasive procedure (n = 14) or presenting a history of atrial fibrillation (n = 10). Twenty-seven patients did not complete the 30-day follow-up period, for a completion rate of 95%. Of the 100 patients included in the visual inspection of chest tubes patency, 57 were allocated to ATC and 43, to standard drainage.OR, operating room; TAVR, transcatheter aortic valve replacement
Fig. 2
Fig. 2
Active clearance of chest tubes decreased the incidence of postoperative atrial fibrillation by 18% (31% vs 38%, p = 0.08) and significantly reduced the rate of re-exploration for bleeding or tamponade by 72% (1.6% vs 5.7%, p = 0.01) when compared to standard drainage. ATC, active tube clearance; POAF, postoperative atrial fibrillation
Fig. 3
Fig. 3
Graphical abstract. Chest tube clogging is common and can lead to retained blood around the heart and lungs. This study sought to evaluate the impact of a chest drainage protocol aimed at actively maintaining chest tube patency after cardiac surgery. Patients undergoing non-emergent cardiac surgery through median sternotomy were randomly allocated according to a 1:1 ratio to either ATC or standard drainage protocol. ATC was associated with non-significant reduction in POAF, lowered need for re-exploration for bleeding or tamponade and improved chest tube patency. This randomized controlled trial demonstrated that maintaining chest tube patency is paramount after cardiac surgery and may improve patient outcomes. ATC, active tube clearance; POAF, postoperative atrial fibrillation

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Source: PubMed

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