Chest Tube Patency in Cardiac Surgery
Chest Tube Patency
Immediately after Cardiac Surgery (CS), most patients have some degree of bleeding. If left unevacuated, retained blood can cause tamponade or hemothorax. Thus, a pericardial drain is always necessary after CS to evacuate shed mediastinal blood. Drains used to evacuate shed mediastinal blood are prone to clogging with clotted blood in up to 36% of patients. When these tubes clog, shed mediastinal blood can pool around the heart or lungs, necessitating reinterventions for tamponade or hemothorax. Retained shed mediastinal blood hemolyzes and promotes an oxidative inflammatory process that may further cause pleural and pericardial effusions and trigger postoperative atrial fibrillation.
Chest tube manipulation strategies that are commonly used in an attempt to maintain tube patency after CS are of questionable efficacy and safety. One example is chest-tube stripping or milking, in which the practitioner strips the tubes toward the drainage canister to break up visible clots or create short periods of high negative pressure to remove clots. In meta-analyses of randomized clinical trials, chest-tube stripping has been shown to be ineffective and potentially harmful. Another technique used to maintain patency is to break the sterile field to access the inside of chest tubes and use a smaller tube to suction the clot out. This technique may be dangerous, because it can increase infection risk and potentially damage internal structures.
To address the unmet need to prevent chest-tube clogging, active chest-tube clearance methods can be used to prevent occlusion without breaking the sterile field. This has been demonstrated to reduce the subsequent need for interventions to treat retained blood compared with conventional chest tube drainage in 5 nonrandomized clinical trials of CS. Active chest-tube clearance has also been shown to reduce postoperative atrial fibrillation, suggesting that retained blood may be a trigger for this common problem.
While there are no standard criteria for the timing of mediastinal drain removal, evidence suggests that they can be safely removed as soon as the drainage becomes macroscopically serous. Based on these clinical trials, maintenance of chest tube patency without breaking the sterile field is recommended to prevent retained blood complications (class I, level B-NR). Stripping or breaking the sterile field of chest tubes to remove clot is not recommended (class IIIA, level B-R).
Source: JAMA
