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* From the Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical School, Worcester, MA.
Correspondence to: Robert Lancey, MD, FCCP, Associate Professor of Surgery, Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655; e-mail: lanceyr{at}ummhc.org
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Abstract |
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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.
Key Words: cardiac tamponade • chest tubes • coronary artery bypass • heart valve prosthesis implantation • pleural effusion • postoperative complications • thoracostomy
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Because of the large diameter of these chest tubes, patients often experience pain at the entry site through the skin and fascia, as well as between the ribs when placed into the pleural space. As a result, deep breathing may be restricted until the drains are removed. Self-ambulation may also be limited due not only to discomfort, but also to bulky fluid-collection devices that are often connected to wall suction, further limiting mobility.
With the advent of less-invasive surgery, efforts have focused on minimizing postoperative pain and hastening recovery. Limited-incision operations have been developed in cardiac surgery for both coronary artery bypass grafting (CABG) and valvular replacement and reconstruction, and have been accompanied by new techniques in patient management to encourage earlier recovery.
We have employed a small, flexible drain for use in patients following open heart surgery in order to limit postoperative pain and encourage earlier ambulation. Although these drains have been used by others on a limited basis to drain the pericardium following limited-access valvular surgery, little information exists as to their safety and efficacy.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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In procedures performed with the use of cardiopulmonary bypass (CPB), patients were given IV heparin, 3 to 4 mg/kg, before establishing flow in the circuit, and activated clotting times (ACT) were maintained at > 400 s during CPB. Heparin was then reversed with protamine sulfate to obtain ACT values of < 120 s. In procedures without the use of CPB (off-pump operations), IV heparin was administered at 1 to 2 mg/kg and a continuous heparin infusion was initiated to maintain ACT values of > 400 s. Protamine was also used in these cases for reversal of anticoagulation in similar fashion. All patients were given enteric-coated aspirin, 325 mg po qd, beginning on the first postoperative day.
One drainage tube was placed in the pericardium through a small incision several centimeters inferior to the lower pole of the median sternotomy wound. This tube was placed in the oblique sinus in a longitudinal position, anterior to the left superior and inferior pulmonary veins and to the left of the main pulmonary artery and ascending aorta, with the distal tip placed at approximately at the level of the ascending aorta. An additional tube was placed in any opened pleural space (one per side). These were inserted through small incisions in the anterolateral chest wall and passed through the sixth or seventh intercostal space, to lie in the posterior costovertebral area. If neither pleural space was opened, a second tube was placed in the pericardial space, lying longitudinally and anterior to the heart.
Drainage fluid was collected in compressed suction bulbs with antireflux valves (100 mL Jackson-Pratt Suction Reservoirs; Allegiance Healthcare; McGaw Park, IL) [Fig 1 ]. The bulbs were emptied hourly or when full. If excessive bleeding (> 200 mL/h) occurred and persisted for > 1 h, the drains were connected instead to a three-chambered closed suction apparatus (Water Seal Chest Drain; Atrium Medical; Hudson, NH). Tubes were removed when total drainage was < 100 mL over an 8-h period. The total amount of drainage, number of days of drainage, length of postoperative stay, and the need for further drainage from either the pleural or pericardial spaces were recorded.
In-hospital chest radiographs were routinely performed on the first and second postoperative days and subsequently if dictated by individual patient’s symptoms. Late follow-up radiographs (posteroanterior and lateral views) were also obtained at an outpatient clinic visit 6 weeks after discharge from the hospital (or earlier if clinically indicated). All radiographs were assessed for the presence and size of residual pleural effusions, and were generally classified as "none" if there was no blunting of the costophrenic angle; "minimal" if blunting was present but did not obscure the diaphragm; "moderate" if the diaphragm was obscured but the pleural space was not opacified > 3 cm above the diaphragm; and "large" if the opacification extended > 3 cm above the diaphragm.
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Results |
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Tubes were left in for an average of 2.4 days (range, 1 to 5 days), and mean postoperative length of stay was 6.7 days (range, 3 to 103 days), with a median length of stay of 5 days. The average amount of drainage was 826.7 mL. Conversion to use of a three-chambered collection system was necessary in four patients because of excessive bleeding, two of whom required reexploration for bleeding. Before or at a 6-week follow-up visit, chest radiographs revealed minimal or no pleural effusions in 179 patients (88.6%), and 23 patients (11.4%) had moderate or large effusions. Of this latter group, 16 patients had an effusion only on the left side, and all of these patients had undergone harvesting of the left internal mammary artery (IMA) with pleurotomy. Two patients had an effusion only on the right side, and in five patients the effusions were bilateral. In 4 of these 23 patients, the pleural space affected had not been opened at the time of surgery.
Eleven of the patients who presented at 6-week follow-up with greater-than-small effusions did not require drainage (nine on the left side, one bilateral, and one on the right). Twelve patients (5.9%) required additional postoperative procedures for pleural drainage in the first 6 weeks following surgery. Eight patients (4.0%) required a left thoracentesis, and in seven of these patients, the left IMA was harvested with opening of the pleural space. In the remaining patient, the left pleural space had been neither entered nor drained at the original operation. Four patients (2.0%) required late pleural drainage with a tube, with two requiring only left pleural tubes, and one each requiring a right-sided tube and bilateral tubes. In neither of these latter two patients had either pleural space been opened at the time of surgery. Two of the patients who required late tubes were receiving anticoagulation with warfarin after their operations.
Ten patients in all (5.0%) required reexploration of the pericardium, of which four were for tamponade (2.0%). Of these four patients, all were reexplored 6 or more days after their original operation, and three patients were receiving oral anticoagulants (warfarin) at the time of reexploration. There were two additional cases (1.0%) of mediastinitis. In all, 21 patients (10.4%) required an additional intervention (thoracentesis, chest tube placement, or reexploration). There was no difference in average drainage amount between those who required a subsequent intervention (732.4 mL) vs those who did not (835.4 mL; p = 0.40 by Student’s t test).
There were four deaths (2.0%) in the series, two from biventricular failure and two from sepsis. None of these patients suffered from tamponade or mediastinitis, and none required an additional drainage procedure of the pleural or pericardial spaces.
An analysis of costs demonstrated little difference between the two standard chest tubes connected to a single, three-chambered collection apparatus ($43.32) vs two Blake drains each connected to a bulb reservoir ($48.20).
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Discussion |
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Pleural effusions following CABG are believed to be due to numerous factors: decreased lymphatic drainage, inflammation of the pericardium, postpericardiotomy syndrome,1 presence of the chest tubes,2 and trauma to the pleura.3 Although atelectasis has been associated with pleural effusions after abdominal surgery, studies have shown no relationship between the presence of atelectasis and subsequent effusions after CABG.2 4
Varying degrees of residual pleural effusions are common following coronary artery bypass surgery. Rolla et al1 noted a 74% incidence of pleural effusions on the second postoperative day in CABG patients in whom the pleural space had been entered, with 48% still present on postoperative day 6. Significant effusions have also been detected by chest ultrasonography in 89% of patients on the seventh day after open heart surgery, with a decline to 57% on the 30th postoperative day.2 Landymore and Howell,5 in examining chest radiographs just prior to discharge from the hospital in patients who had undergone CABG, found 43% with moderate-sized effusions, whereas only 14% had small effusions. Interestingly, effusions were found in one third of patients in whom the pleura had not been opened.
The occurrence of residual postoperative effusions has been noted in some series to be more common if the left IMA is harvested during the operation,2 5 even up to 8 to 28 months after surgery.6 Hurlbut et al7 found a higher incidence of pleural effusions on chest radiographs performed on the sixth postoperative day in patients who had IMA harvesting (84%) vs those without (47% with effusions), as well as significantly more chest tube drainage in this group (1,413 mL vs 1,028 mL). Peng et al3 noted little difference in the occurrence of pleural effusions on the sixth postoperative day whether or not an IMA was used, though the incidence of a greater-than-small effusions was different (7.4% in the IMA patients and 1.9% in the non-IMA group).
Although the rate of moderate or large effusions (11.4%) in the present study appears small compared with data from other series, it is difficult to compare these values, as the degree of effusion is often not reported. The need for late postoperative pleural space drainage procedures in our patients (5.9%), which we performed for symptomatic patients with moderate or large effusions, is consistent with rates reported in other studies, as well as the rate at our institution for patients drained postoperatively with rigid tubes over the same time period (5.38%). Riebman and colleagues8 found 28% of patients after CABG were left with residual pleural effusions following removal of chest drains, and 6% of their total patients who had undergone a left pleurotomy for IMA harvesting required a subsequent drainage procedure on that side. Hurlbut et al7 also demonstrated a greater need for a subsequent thoracoscopy or thoracentesis when the internal mammary artery is harvested (4%) than when it is not (0%). Of note, although 12 patients in our series required a subsequent procedure for pleural drainage, in 3 patients the pleural space had not been originally drained. Thus, only 9 of the original 202 patients (4.5%) required either a thoracentesis or tube drainage of a pleural space that had been drained with a Blake drain at the time of open heart surgery.
The incidence of reexploration for tamponade (2.0%) is within the range (0.5 to 5.8%) noted in the literature,9 10 11 and is consistent with that found in all our open heart surgery patients (1.7%) treated with standard drains over the same time period. Evidence of tamponade appeared at least 6 days after the operation in all four patients, consistent with a study in which the diagnosis of tamponade was made on the average of 8.5 days following open heart surgery.9 Three of the four patients with tamponade in our study were receiving anticoagulants at the time of presentation, which is known to increase the risk of developing this condition.12
Rigid chest tubes of polyvinyl chloride are used routinely in open heart surgery to decompress the mediastinal and pleural spaces of fluid and air to prevent hemodynamic compromise from cardiac tamponade or tension pneumothorax, to prevent incomplete expansion of the lung from air or fluid, and to monitor the bleeding rate postoperatively. Although their use is routine and associated complications are rare, they do possess several undesirable features.
Because of their rigidity, there is the potential for compression of intrathoracic structures, most notably a coronary vein graft with resultant myocardial ischemia.13 Grafts may also be drawn in to the large side holes of the tubes, causing ischemia.14 Cardiogenic shock due to compression of the right ventricle by a rigid chest drain has also been reported.15 Thrombus formation within the drain may hinder further drainage and promote residual collections of blood within the pericardial space and/or pleural spaces which often have significant acute or chronic consequences. Although some advocate stripping of the tubes when thrombus formation develops, this practice may generate negative pressures of up to 1,500 mm Hg and lead to injury to adjacent tissues.16
Because of their size and rigidity, standard chest tubes may also hinder postoperative recovery by limiting ambulation and deep breathing. Pain associated with their presence as well as with their removal has come under scrutiny with efforts to encourage early ambulation and discharge,17 18 and they have been cited by nurses as a major problem following cardiac surgery.19 They have also been found to impair pulmonary function especially when placed through an intercostal space.20 As it is routine and necessary to connect the tubes to a specialized collection apparatus (which in turn is usually connected to wall suction),21 ambulation becomes cumbersome and is difficult for the patient to undertake without assistance.
Blake silicone drains are small-bore (19F), round, flexible fluted drains that exert constant suction over the entire length of the fluted portion of the drain. With noncollapsible tubing and long channels for drainage, they are theoretically resistant to occlusion with thrombus. Fluid may be collected in a small, closed suction drainage system (such as a suction bulb) that can be secured to the sternal wound dressing. Because of their size and flexibility as well as lacking the requirement of connection to a large, wall-connected drainage system, they theoretically are less painful for patients and allow earlier ambulation and potentially faster recovery. In our study, however, the average length of stay for this patient subpopulation (6.7 days) did not differ significantly from the average length of stay for either the author’s patients in whom standard chest tubes were placed nor from the length of stay following coronary bypass surgery for the institution. The average time of tube removal (2.4 days following surgery) was slightly longer than for rigid tubes (which are routinely removed at our institution on the second postoperative day).
The use of Blake drains has been found at our institution to be a safe, effective form of decompression of the pleural and/or mediastinal spaces following open heart surgery, without significantly greater incidences of either clinically significant pleural effusions or of cardiac tamponade when compared to historical rates using larger chest drains. Although most patients had no or only a minimal pleural effusion at 6-week follow-up, 12.4% in this series had a greater-than-small effusion, with just over a third of these requiring an intervention for symptomatic relief. We found adequate drainage of the chest cavities even in patients with excessive bleeding (three patients), as well as complete evacuation of air from the pleural space when an unsuspected air leak was detected (two patients). In patients with either excessive bleeding or an air leak, our practice is to connect the Blake drains to a three-chambered drainage system for more accurate assessment of drainage amount over time in order to determine a need for reexploration, and to allow more continuous evacuation of pleural air, respectively. Although in our series, they were initially used for uncomplicated coronary artery bypass patients, their use eventually became routine for most all patients undergoing open heart surgery for one surgeon.
Anecdotally, patients seemed to experience less pain with the smaller drains and appeared to have greater freedom with ambulation. However, these conclusions are observational only and can only be confirmed by a well-controlled study comparing patients with large tube vs those with small tubes using specific quantitative parameters (for instance, a pain scale and time and distance of early efforts at ambulation). By securing the bulb drains to the chest dressings, the need for assistance in carrying large suction containers was eliminated. These conclusions are merely observational and can only be confirmed by a controlled study comparing the two types of chest drainage tubes utilizing quantitative measurements (such as a Visual Pain Analog Scale, and time and distance of first ambulation).
Though the use of these drains appears to have a role for patients undergoing open heart surgery, a randomized, prospective trial comparing their use to standard large-bore tubes would be valuable to determine if there are true advantages. Degree of pain at the tube sites, time to first independent ambulation, postoperative length of stay, and need for intervention for residual collections would be important parameters to evaluate.
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Footnotes |
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Received for publication November 24, 1999. Accepted for publication June 2, 2000.
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This article has been cited by other articles:
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