Preliminary report of a prospective, randomized trial of underwater seal for spontaneous and iatrogenic pneumothorax

BACKGROUND: Management of pneumothorax has traditionally been tube thoracostomy and -20 cm H2O suction. The purpose of our study was to determine if underwater seal in iatrogenic and spontaneous pneumothoraces is safe and efficacious and if small-caliber chest tubes are appropriate for routine use in pneumothorax. STUDY DESIGN: From April 2001 through October 2003 patients with iatrogenic or spontaneous pneumothorax were enrolled in this prospective, randomized trial. Small-bore catheters were inserted. Initial management was 1 hour -20 cm H2O suction, chest radiography, and randomization into -20 cm H2O suction, -10 cm H2O suction, or underwater seal. Tubes were discontinued at 48 hours if there were no pneumothoraces and no air leaks. Those with air leaks and recurrent pneumothoraces persisting 5 days underwent pleurodesis. The primary end point was successful chest tube removal at 48 hours. The secondary end point was need for pleurodesis. RESULTS: Twenty-nine patients were analyzed. Seven were randomized to -20 cm H2O suction, 11 to -10 cm H2O suction, and 11 to underwater seal. Most (59%, 17 of 29) chest tubes were successfully removed 48 hours after placement: 57% (4 of 7) after -20 cm H2O suction, 73% (8 of 11) after -10 cm H2O suction, and 45% (5 of 11) after underwater seal (p = 0.48). Seven (24%) required pleurodesis: 29% (2 of 7) after -20 cm H2O suction, 27% (3 of 11) after -10 cm H2O suction, and 18% (2 of 11) after underwater seal (p = 0.70). CONCLUSIONS: Early underwater seal appears to be safe for treating iatrogenic and spontaneous pneumothoraces. It can achieve comparable frequencies of early chest tube removal and avoidance of operation compared with traditional management. A larger, multi-institutional study should be performed to demonstrate that pneumothorax treatment can effectively incorporate small-caliber tubes and underwater seal.     

早期拔除胸腔引流管在胸腔镜肺部手术后的应用

目的探讨胸腔镜肺部手术后早期拔除胸腔引流管的可行性和安全性,探索胸腔引流管的拔除指征。 方法选择2019年11月至2020年4月在南京大学医学院附属鼓楼医院行胸腔镜肺部手术,并于术后早期(48 h内)拔除胸腔引流管患者117例作为观察组;另外选择2018年11月至2019年4月在南京大学医学院附属鼓楼医院行胸腔镜肺部手术,但术后非早期拔除胸腔引流管患者114例作为对照组。两组在年龄(P＝0.476)、性别(P＝0.216)、术式(P＝0.715)、是否行纵隔淋巴结清扫或采样(P＝0.200)、目标肺叶(P＝0.925)、病变性质(P＝0.957)方面均差异无统计学意义。回顾性分析两组患者术后临床结果、拔除引流管后并发症及再次行胸腔引流情况。 结果观察组和对照组拔管前24 h引流量[(245.7±98.1)ml比(120.8±46.8)ml,P<0.001]、术后引流时间[(43.9±2.6)h比(84.5±10.5)h,P<0.001]、术后住院时间[(2.2±0.4)d比(4.2±1.1)d,P<0.001]、住院费用[(5.3±0.4)万元比(5.6±0.3)万元,P<0.001]、拔管后疼痛视觉模拟评分(visionl analogue scale, VAS) [(4.4±1.2)分比(3.3±1.2)分,P<0.001]、拔管后总体并发症发生率(20.5%比10.5%,P＝0.036)差异有统计学意义,观察组拔管前后VAS [(5.9±0.8)分比(4.4±1.2)分,P<0.001]和对照组拔管前后VAS [(6.0±0.9)分比(3.3±1.2)分,P<0.001]差异有统计学意义。观察组和对照组拔管前VAS [(5.9±0.8)分比(6.0±0.9)分,P＝0.464]、拔管后气胸(1.7%比0.9%,P>0.999)、胸腔积液(12.8%比6.1%,P＝0.084)、皮下气肿(2.6%比1.8%,P>0.999)、发热(3.4%比1.8%,P＝0.703)、再次行胸腔引流(2.6%比1.8%,P>0.999)发生率差异无统计学意义。 结论虽然术后早期拔除引流管可能会增加拔除引流管后胸腔积液的发生率,但早期拔除引流管可以明显减轻患者术后疼痛,并且不会增加气胸、皮下气肿、发热的发生率,也不会增加再次行胸腔引流的风险。因此,胸腔镜肺部手术后早期拔除胸腔引流管是安全、可行的,有利于减轻患者经济负担,缩短住院时间,促进患者加速康复。     

Efficacy of Blake drains for mediastinal and pleural drainage following cardiac operations

BACKGROUND: Mediastinal and pleural drainage following cardiac operations has traditionally been achieved with large bore, semirigid chest tubes. The purpose of this study was to evaluate the safety and efficacy of drainage by means of small, soft, and flexible 19 F Blake drains. METHODS: This is a review of all patients who underwent heart surgery over a 3-year period at a single institution. Chest tubes and Blake drains were removed on postoperative day 1 to 5 depending on patient's condition, amount of drainage, and surgeon's preference. The criteria for drain removal did not vary with type of drain. RESULTS: There was no significant difference in the amount of drainage between both groups. Postoperative mediastinal exploration occurred in 3.47% of patients (12/346) in the chest tube group and in 2.08% of patients (8/385) in the Blake group (p = 0.27). Significant pleural effusions requiring a subsequent drainage procedure occurred in 9.54% of patients (33/346) in the chest tube group and in 9.87% of patients (38/385) in the Blake group. CONCLUSIONS: No significant differences were noted in the number of mediastinal explorations in patients drained with conventional chest tubes as compared to Blake drains during cardiac operations. Though not statistically significant, there may actually be an advantage of Blake drains over conventional chest tubes in this regard. There was also no significant difference in the incidence of postoperative pleural effusions. Blake drains appear to be at least as effective and safe as conventional chest tubes in draining the mediastinum and pleural spaces following cardiac surgery.     

Recent improvements in outcome with the Novacor left ventricular assist device.

BACKGROUND: The Novacor implantable, electrically powered, wearable, left ventricular assist device (LVAD) has been used as a bridge to transplantation at our institution since 1994. Recent changes in protocol have resulted in a decreased incidence of infections, thromboembolism, and mortality. METHODS: We reviewed the medical records of all 43 patients who received implantable LVADs at the Mount Sinai Medical Center. After 1998, a number of protocol modifications were instituted. Vascular grafts were changed from a low-porosity, woven polyester (Cooley) to a gelatin-sealed, knitted polyester graft (Vascutek), the devices were implanted pre-peritoneally rather than in the posterior rectus sheath, and extensive drainage of the chest and pre-peritoneal pocket was used. The following anti-coagulation regimen was used: low-molecular-weight Dextran for 1 day, initiated after chest tube drainage <50 cc/hour; then IV heparin for 10 to 14 days, beginning at 500 U/hour, slowly increasing partial thromboplastin time to 1.5 to 2 x control; and finally Coumadin, maintaining the international normalized ratio at 2.5 to 3.5. Daily aspirin, 325 mg, was begun on post-operative Day 7. We compared 22 patients who electively underwent surgery before the changes, Group I, with 18 patients treated thereafter, Group II. RESULTS: Groups I and II were well matched with regard to age (47 vs 44 years); cause of heart failure (idiopathic, 50% vs 44%; ischemic, 50% vs 56%), and duration of support (79 vs 76 days). The incidence of thromboembolic cerebrovascular events was significantly less in Group II (6%) than in Group I (23%), p = 0.025. The incidence of bleeding increased mildly in Group I. Pocket infections occurred in 27% of Group I patients vs 11% of Group II patients, p = 0.018. Only 2 patients (11%) in Group II died while receiving device support, vs 7 (32%) in Group I, p = 0.019. CONCLUSIONS: Our results indicate that pre-peritoneal implantation, use of a new generation of vascular grafts, extensive drainage, and a more restricted anti-coagulation regimen improve outcome after Novacor LVAD implantation for advanced heart failure.     

No panacea for drainage after percutaneous nephrolithotomy

BACKGROUND AND PURPOSE: The optimal postoperative drainage system for patients undergoing percutaneous nephrolithotomy (PCNL) has not yet been determined. Each of the different tubes available has theoretical advantages and disadvantages. The objective of this study was to determine if any one system of post-PCNL drainage has any significant advantage over the others. PATIENTS AND METHODS: Sixty patients were randomized to either a 24F Re-entry tube (Group 1), an 8F pigtail catheter (Group 2), or a double-J stent (Group 3) (N = 20 for all groups). The double-J stent patients also had an 18F Councill catheter as a nephrostomy tube, which was removed on the morning of postoperative day 1. The three groups were well-matched for age, stone size, operative time, and mean number of percutaneous tracts (P > 0.05 for all). Data collected included intraoperative findings, postoperative analog pain scores and narcotic usage, presence of extravasation on postoperative nephrostogram, presence of perinephric fluid on postoperative ultrasound scans, length of stay, and whether leakage from the nephrostomy site persisted more than 48 hours after tube removal. RESULTS: There were no statistically significant differences among the three groups in terms of change in hematocrit or number of patients requiring blood transfusion; in the incidence of tube blockage, extravasation, or presence of perinephritic fluid; or in complication rates, length of hospital stay, or persistent leakage after tube removal. There was a strong trend to less postoperative leakage with the 8F pigtail than the Reentry tube (P = 0.05). Postoperative analog pain scores and narcotic usage were equivalent for all three groups. Patients Groups 1 and 2 were free of all tubes sooner than patients in Group 3 (P < 0.001). CONCLUSIONS: This study did not demonstrate an overwhelming advantage of any one drainage system over the others. All three systems were equally tolerated by patients. There may be less chance of prolonged nephrostomy-site leakage with an 8F pigtail catheter.     

Should We Give Prophylactic “Renal‐Dose” Dopamine After Coronary Artery Bypass Surgery?

OBJECTIVE: A prospective double-blind randomized study undertaken to assess the effect of postoperative prophylactic "renal-dose" dopamine on post-coronary artery bypass grafting surgery's clinical outcome. METHODS: Eighty-five consecutive patients undergoing CABG operation were randomized to receive either 3-5 microg/kg/min dopamine (group D, n = 41) or saline as placebo (group P, n = 45) for 48 postoperative hours. Clinical outcome parameters were collected for four postoperative days. RESULTS: Preoperative and operative parameters were similar in both groups. Four patients from group P and none from group D reached an end-point of the study (oliguria, renal dysfunction) and received dopamine. Two patients from group P and none from group D needed an additional inotropic support. Mean arterial pressure values were similar during the first 24 hours after operation, but left atrial pressure values tended to be higher in group P (10 +/- 4 vs 7 +/- 3 mmH2O, p = 0.18). The mean pH was higher in group D at 8 hours after operation (7.38 +/- 0.2 vs 7.36 +/- 0.3, p = NS), due to higher bicarbonate levels (23 +/- 2 mmol/l vs 21 +/- 2, p = 0.49). The incidence of lung congestion in chest X-rays and CT scans was significantly higher in group P (50% vs 29%, p = 0.073 at 48 hours postoperatively). Room air blood O2 saturation and maximal expiratory volume tended to be higher in group D (at 72 hours after operation- 92 +/- 4 vs 90%+/- 5, p = 0.29 and 646 +/- 276 vs 485 ml +/- 206, p = 0.16, respectively). There was no statistical difference in urine output but the amount of furosemide given to patients in group P was significantly higher (during the first 8 hours 2.5 +/- 0.5 vs. 0.3 mg +/- 1.6, p = 0.07). Plasma creatinine levels were significantly lower in group D (at 24 hours 0.93 +/- 0.02 vs 1.05 mg/dL +/- 0.02, p = 0.02). Mobilization after surgery was faster in group D. CONCLUSIONS: Prophylactic dopamine administration after coronary artery bypass grafting surgery improves patient hemodynamic and renal status, reduces the need for additional medical support (inotropes and furosemide) and thus, provides stable postoperative course.     

Initial chest tube management after pulmonary resection

Tube thoracostomy management with suction or water seal after anatomical pulmonary resection remains somewhat controversial. Initial chest tube management may influence the duration of pleural fluid drainage, duration of tube thoracostomy, and/or hospital length of stay following pulmonary resection. We hypothesized that initial chest tube management with water seal decreases time for chest tube removal and decreases time of hospital stay. A retrospective chart review was performed on 109 consecutive patients who underwent lobectomy or segmentectomy in Western Pennsylvania Hospital between December 1999 and December 2003. Comparison was made between chest tube management of water seal or suction in patients with and without air leak. Of the 109 patients, 78 (72%) had no air leak at the completion of surgery, and 31 (28%) had air leak. In the group without air leak (n = 78), water seal was used in 32 (41%) patients and suction in 46 (59%). In patients placed to water seal initially after surgery (n = 32), removal of chest tubes was on postoperative day (POD) 3.19 +/- 0.24 and hospital discharge was on POD 5.13 +/- 0.61. In patients placed to suction initially (n = 46), chest tubes were removed on POD 4.52 +/- 0.40. Hospital discharge was on POD 6.74 +/- 0.5. Both duration of chest tube (P < 0.007) and length of hospital stay (P < 0.04) were significantly lower in the water seal group. In the air leak group (n = 31), 7 (23%) patients were managed with water seal and 24 (77%) patients with suction. Both duration of chest tube (P = 0.001) and length of hospital stay (P < 0.05) were significantly lower in the water seal group. In patients without air leak, chest tubes should be managed with water seal following anatomical pulmonary resection, resulting in significantly shorter chest tube duration and hospital length of stay.     

使用硝酸甘油控制性降压对食管癌开胸术后胸腔引流量的影响

目的观察食管癌根治术后应用硝酸甘油控制性降压对术后胸腔引流量及胸腔引流管拔除时间的影响。 方法将甘肃省人民医院胸外科2015年3月—2017年4月行经左胸食管癌根治术的128例患者随机分为两组。试验组(n＝64)：术后48 h内以0.01%的硝酸甘油溶液微量泵泵入行控制性降压,血压严格控制在90～100 mmHg/60～70 mmHg范围内;对照组(n＝64)：术后48 h内未行硝酸甘油控制性降压,血压波动在110～148 mmHg/70～102 mmHg。比较两组患者的术前临床资料,以及术后第1、3、5、7、9天的胸腔引流量及胸腔引流总量、术后胸腔引流管拔除时间。 结果两组患者的年龄、性别、病变部位、病理类型及TNM分期等临床资料比较差异均无统计学意义(P>0.05)。试验组患者的术后胸腔引流总量、胸腔引流管拔除时间和住院时间均显著少于对照组,差异有统计学意义[(939±134)ml vs (1 203±146)ml,P<0.01;(8.7±1.1)d vs (10.6±1.3)d,P<0.01;(9.5±1.2)d vs(11.2±2.4)d]。 结论经左胸食管癌根治术后应用硝酸甘油控制性降压可有效减少胸腔引流总量,能在一定程度上缩短胸腔引流管的拔除时间和住院时间。     

Steroid use is associated with pneumonia in pediatric chest trauma.

A review of pediatric trauma focused on pediatric chest injuries was performed at a trauma center specializing in neurologic trauma. Eighty of 342 (23%) pediatric trauma patients admitted to the center had chest injuries. Age, gender, mechanism of injury, magnitude of injury, incidence of pulmonary infection, chest tube usage, endotracheal intubation, steroid or antibiotic usage, morbidity, and mortality data were reviewed. Sixteen of 78 children (20%) with chest injuries developed pulmonary infections and were compared with the noninfected group. Patients with pneumonia had a higher morbidity with significantly longer mean hospital stay (43.0 vs. 12.7 days; p = 0.001), duration of intubation (8.4 vs. 1.5 days; p = 0.001), and total days with chest tubes, (2.2 vs. 1.4 days; p = 0.02). Pneumonia was significantly associated with longer mean duration of steroid usage (6.4 vs. 0.8 days; p = 0.0001). Duration of steroid administration for the treatment of concomitant brain injury was a significant independent risk factor for the occurrence of pneumonia.     

Effect of timing of chest tube removal on development of pericardial effusion following cardiac surgery

BACKGROUND: There are no standard criteria for the timing of drain removal. The objective of this study was to determine whether the macroscopic appearance of chest tube drainage fluid to serosanguineous may be used as a criteria for drain removal. METHODS: 2,359 patients were assessed retrospectively and 80 randomized patients were followed prospectively who underwent cardiac surgery. In both parts of the study, patients were divided into two groups according to the timing of drain removal. Group I consisted of patients whose chest tubes were removed as soon as the macroscopic appearance of the drainage fluid turned to serosanguineous. Group II consisted of patients whose chest tubes were removed at the second postoperative day when the drainage output declined to less than 50 mL in a five-hour period. In the retrospective part, cases of hemodynamically significant pericardial effusion observed within seven days postoperatively were reviewed. In the prospective part, just before the drain removal, the fluid sample hematocrit obtained from the drain lines and patients' blood hematocrit were measured and recorded. Patients were evaluated with echocardiography for pericardial effusion. RESULTS: No statistically significant difference was detected in the frequency of hemodynamically significant pericardial effusion and incidence or amount of pericardial effusion between the two study groups. The drain hematocrit to blood hematocrit ratios before drain removal showed a significant correlation with pericardial effusion.The strength of correlation between the drain hematocrit to blood hematocrit ratios before drain removal and pericardial effusion was also studied using receiver operating characteristic curve, which suggests that a drain hematocrit to blood hematocrit ratio of < or = 0.3 is strongly predictive that pericardial effusion would be absent or mild between the fifth and seventh postoperative days. CONCLUSIONS: It is safe to remove the chest tubes as soon as the macroscopic appearance of the drainage fluid turns to serosanguineous since this practically indicates cessation of active bleeding.     

The effect of autologous fibrin sealant (Vivostat) on morbidity after pulmonary lobectomy: a prospective randomised, blinded study

Objective: Postoperative air leakage is the most frequent complication after pulmonary surgery. The development of modern surgical techniques has been influenced strongly by the need to manage air leakage effectively during pulmonary resection. This study evaluated the effect of using an autologous fibrin sealant (Vivostat^®) during lobectomy on morbidity following surgery. Methods: This was a prospective, blinded, randomised clinical study. Patients undergoing lobectomy were enrolled into two groups (Vivostat or non-treatment control, 20 per group). Air leakage was measured over a 1-h period (using a mechanical suction pump) on the day of operation, and both air leakage and bleeding/exudation (drainage volume) were recorded every morning postoperatively until the chest tubes were removed. Personnel recording these parameters were blinded to the intervention received. Results: Compared with the control group, mean bleeding/exudate volumes were significantly reduced in the Vivostat group (day 1, 370 vs. 525 ml; total, 424 vs. 782 ml; both P<0.001), and drains were inserted for a shorter time (medians, 1 vs. 2 days, P=0.07). Significantly fewer patients had air leakage at any time in the Vivostat group (40 vs. 80%, P=0.02), and air leakage volumes were significantly lower compared with the control group (median differences: day of surgery: 0.6 l/min, P=0.01; total 0.8 l/min, P=0.03). Postoperative hospitalisation time was shorter in the Vivostat group than in the control group but the difference was not significant (0.5 days, P=0.12). Conclusions: Vivostat fibrin sealant significantly reduces post-surgical air leakage and drainage volumes following lobectomy in pulmonary surgery and is suitable for routine use in this procedure.     

Frühe Drainagenentfernung nach videoassistierten thorakoskopischen Operationen

BACKGROUND: Chest tubes frequently cause postoperative patient discomfort after video-assisted thoracoscopic surgery (VATS). Therefore, a prospective randomized study was conducted to analyze whether early chest tube removal within 2 h postoperatively is justified in VATS. METHODS: Ninety-three patients fulfilled the inclusion criteria (VATS including wedge resection, complete lung extension on postoperative chest roentgenogram) and showed no exclusion criteria (lung volume reduction surgery, extensive pulmonary fibrosis, pneumothorax, pleural effusion, air fistula). Randomization resulted in early chest tube removal in 48 patients and in conventional chest tube management in 45 patients. RESULTS: Pain intensity was significantly reduced after early chest tube removal (P=0.03, t-test). In consequence, the mean analgesic requirement was significantly reduced (P=0.0001, t-test). The number of postoperative chest roentgenograms was significantly reduced after early chest tube removal (P=0.0001, t-test). The mean postoperative length of hospital stay was 5.4 vs 6.7 days (P=0.11, t-test). No postoperative complication occurred after early chest tube removal, while postoperative complications were observed in six patients with conventional chest tube management (P=0.01, Fisher's test). CONCLUSION: Early chest tube removal after video-assisted thoracoscopic wedge resection is recommended. The inclusion and exclusion criteria of this study should be considered for future early chest tube removal. Long-term follow-up will clarify if early chest tube removal also leads to a reduction in chronic pain.     

Role of early thoracoscopy for management of penetrating wounds of the chest

Most nonlife-threatening penetrating wounds of the chest (PWC) are treated with a chest tube alone. This may be inadequate because missed injuries, retained hemothorax, or foreign material may be difficult to address later. Early thoracoscopy should improve outcome. We conducted a retrospective review of 88 stable patients with PWC initially treated with a chest tube and had retained a hemothorax beyond 48 hours. Twenty-seven underwent an early video-assisted thoracoscopy (VATS). Fifty-five were observed, chest tubes were manipulated, or an additional one placed. The outcome was compared with the National Trauma Data Bank and controlled for Injury Severity Score. Early VATS reduced length of stay (4.3 vs 9.4 days), days in the intensive care unit (1.3 vs 3.2), and open thoracotomy (0 vs 7). A chest tube undertreats a nonlife-threatening PWC correctable by timely VATs.     

Thoracoscopic application of a topical sealant for the management of persistent posttraumatic pneumothorax

BACKGROUND: Persistent posttraumatic pneumothorax (PPP) is an uncommon complication of blunt or penetrating chest trauma. Currently, most patients are managed with pleural chest tube(s) and suction drainage. Prolonged hospital stay and added cost of care are not uncommon. METHODS: Over a 2-year period, 13 patients with PPP, nonresponsive to conventional management, underwent video-assisted thoracoscopic surgery (VATS). As part of our protocol for PPP, routine preoperative computed tomography of the chest and bronchoscopy to determine the presence of associated injuries were performed in all of the patients. During the VATS procedure, all of the patients underwent drainage of any retained hemothorax, and a topical surgical sealant was applied to the source of the air leak as definitive treatment. RESULTS: A persistent pneumothorax with an air leak was identified in all 13 of the patients. There were 10 patients with blunt and 3 patients with penetrating injuries, respectively. The mean age for the patients was 34 years (range, 13 to 64 years). Parenchymal lacerations were identified in all of the patients ranging in size from 0.5 to 3 cm. After the VATS procedure and application of the surgical sealant, 11 patients had the chest tubes removed within 24 hours of the procedure. In the other two patients, the chest tubes were removed within 48 hours. There was no recurrence of the pneumothorax in any of these patients. The mean length of hospital stay before VATS and the application of the surgical sealant was 6 days (range, 2-14 days). CONCLUSION: Early VATS and the use of a topical sealant in patients with PPP is a safe and effective alternative to the conventional management with prolonged thoracostomy chest tubes or an open thoracostomy. This alternative management, when used early in the appropriate patient, will decrease the length of hospital stay, cost of care, and unnecessary procedures.     

When to remove a chest tube? A randomized study with subsequent prospective consecutive validation

BACKGROUND: Operative procedures on the pleural space are usually managed by chest tube drainage. Timing for removing the tube is empirically established, with wide variation among surgeons. Our objective was to evaluate the effectiveness and safety of establishing a volume of 200 mL/d of uninfected drainage as a threshold for removal of chest tube, as compared with more frequently used volumes of 100 and 150 mL/d. STUDY DESIGN: A prospective randomized study was performed in a single institution. Patients (n = 139) submitting to pleural drainage after surgical procedures were randomized to one of three groups, defined by the planned timing of chest tube removal (depending on the threshold volume per day of pleural fluid drained): G-100 (< or = 100 mL/d, n = 44); G-150 (< or =150 mL/d, n = 58); and G-200 (< or = 200 mL/d, n = 37). Subsequently, another 91 consecutive patients had chest tubes removed when drainage was less than 200 mL/d (G-val, prospective validation group). All patients had similar discharge and 60-day followup. Drainage time, hospital stay, and reaccumulation rate were registered. RESULTS: Drainage time (median days: 3.5 for G-100, 3 for G-150, 3 for G-200, 3 for G-val) and hospital stay (median days: 4 for G-100, 3 for G-150, 3 for G-200, 3 for G-val) were not statistically different among groups. Radiologic reaccumulation rates were 9.1% for G-100, 13.1% for G-150, 5.4% for G-200, and 10.9% for G-val, and the thoracenteses rates were 2.3%, 0.8%, 2.7%, and 3.3%, respectively, with no major differences among groups (G-100 versus G-150 versus G-200; G-200 versus G-val). CONCLUSIONS: Increasing the threshold of daily drainage to 200 mL before removing the chest tube did not markedly affect drainage, hospitalization time, or overall costs, nor did it increase the likelihood of major pleural fluid reaccumulation. This volume (200 mL/d) could be recommended for chest tube withdrawal decision for uninfected pleural fluid with no evidence of air leaks.     

Renal function changes after elective cardiac surgery with cardiopulmonary bypass

Cardiac surgery can either induce acute renal failure or improve GFR by improving the cardiac performance. In order to study renal function changes after elective cardiac surgery (CS) with cardiopulmonary bypass (CPBP), 21 patients undergoing valvular CS (VCS) or coronary artery bypass (CAB) were prospectively evaluated in three time periods: before, 24 hours after surgery and 48 hours after surgery. Patients were divided in 2 groups according to the GFR percent change in comparison to the baseline value found 24 hours after CS (deltaGFR24): Group 1, deltaGFR24 decrease higher than 20% (n = 11) and Group 2, deltaGFR24 decrease < or = 20% or deltaGFR24 increase (n = 10). In Group 1, 73% of the patients underwent VCS (p = 0.05 vs. Group 2) and all of them had previous VCS in sharp contrast with Group 2, where none of the patients had previous CS (p = 0.006). Patients in Group I required more volume replacement than Group 2 during the first 24 hours after CS: 2,699+/-704 mL versus 217+/-603 mL respectively, p = 0.019. Despite similar baseline GFR, Group 1 presented lower GFR 24 hours after CS when compared to Group 2 (39+/-5 versus 75+/-8 mL/(min x 1.73m2), p = 0.001) and a significantly different deltaGFR 48 hours after CS as compared to Group 2 (-21+/-11 versus +88+/-36%, p<0.01). Baseline sodium fractional excretion (FENa) in Group 1 was lower than in Group 2 (0.27+/-0.04 versus 0.70+/-0.12%, p = 0.01). No changes were observed after CS in urinary osmolality (Uosm) and urinary pH (UpH) in both groups. The deltaGFR24 showed positive correlation with baseline FENa (r = 0.44 p = 0.04) and negative correlation with volume balance during the first 24h after CS (r = -0.63, p = 0.007). More patients in Group 1 required nitroprusside than in Group 2 (66% vs. 14%, p = 0.04). Anesthesia time was shorter in Group 1 as compared to Group 2: 323+/-21 vs. 395+/-26 min, p = 0.04. No significant hemolysis occurred during CS in either group. There were no differences in age, gender, CPBP time, need for dopamine and/or dobutamine between the two groups. In conclusion, patients who presented GFR decrease after CS underwent VCS more frequently, had more prevalence of previous CS, presented lower baseline FENa, required more volume infusion and more nitroprusside use. On the other hand, no tubular dysfunction was detected in the early follow-up of CS. These results suggest that the observed renal function changes should be the result of an appropriated renal response to a low effective blood volume. In fact, a low baseline FENa anticipated a GFR decrease in these patients. Consistently, CAB patients that usually improve their cardiac output after surgery showed a clear GFR improvement.     

Intraoperative chest tube removal following thoracoscopic lung biopsy results in improved outcomes

BackgroundTraditionally, chest tubes are left following video assisted thoracoscopic surgery (VATS) to treat a potential air leak or significant drainage. Recognizing the potential complications, our aim was to determine if intraoperative chest tube removal in children undergoing VATS lung biopsy is safe and if outcomes differ from when a chest tube is left in place.MethodsWe identified all children who underwent VATS lung biopsies from 2009 to 2013 and performed a retrospective review of the medical records. Pulmonary resection patients were excluded as were those with an air leak present in the operating room.ResultsA total of 90 VATS lung biopsies were performed. 41 children had a postoperative chest tube left in place (Group A), and 49 children had it removed intraoperatively (Group B). Mean age was 9 ± 6.4 years. One child in Group A and 2 children in Group B required replacement of a chest tube (p = NS). Group B patients had a lower postoperative pain score on day one, fewer postoperative chest X-rays, and a shorter length of postoperative stay.ConclusionsThese data suggest that intraoperative chest tube removal is safe and may be associated with improved outcomes following lung biopsy in children.     

Plateletworks platelet function test compared to the thromboelastograph for prediction of postoperative outcomes

Approximately 3.5 million units of platelets are transfused in the United States each year to patients undergoing open-heart surgery with cardiopulmonary bypass (CPB). CPB is a known contributor to platelet loss and platelet dysfunction leading to disruption of hemostasis. Impaired hemostasis results in excess bleeding in 5-25% of all patients undergoing CPB. For this reason, it may be beneficial to measure platelet number and function in these patients. The purpose of this study was to compare the Plateletworks platelet function analyzer to the thromboelastograph (TEG) in predicting postoperatiave hemostatic outcomes as measured by blood product use and chest tube (CT) drainage. This study consisted of 35 adult patients undergoing cardiac surgery with cardiopulmonary bypass at Rush-Presbyterian-Saint Luke's Medical Center (RPSLMC). The Plateletworks and TEG tests were performed preoperatively, after protamine was given, and 24 hours postoperatively on all patients. Plateletworks demonstrated a statistically significant change in platelet function as shown by the adenosine diphosphate (ADP) reagent tube from the preoperative period to the removal of the aortic cross clamp (p = .011). The TEG did not demonstrate a significant change in the k-time and maximum amplitude (MA), but did show a significant change in the alpha-angle from the pre-operative to postoperatiave sample (p = .035). A correlation was found between Plateletworks collagen reagent tubes preoperatively and CT drainage (p = .048, r -0.324). No statistical correlation was established between TEG parameters and CT drainage at any time interval. TEG preoperative MA showed a correlation to receipt of blood products (p = .016). When comparing the Plateletworks to the TEG in this study, the Plateletworks system was a more useful predictor of blood product use and chest tube drainage.     

Clinical implications of blood gas analysis of chest tube drainage

Blood gas analysis of chest tube drainage following thoracostomy for experimental and clinical penetrating chest injuries was evaluated to determine its usefulness in predicting the etiology of the injury. Twenty dogs were divided into four groups and sustained right chest injury as follows: Group I--closed chest lung laceration; Group II--open chest lung laceration; Group IIII-gunshot wounds; Group IV--thoracotomy and injection of autologous, mixed venous blood. All animals and 14 patients who sustained penetrating chest injury were made simultaneously from chest tube draininage, systemic artery, and central vein in all dogs and patients. Eight patients (Group A) had pneumothorax; six patients (Group B) did not. Mean control canine aortic PO2 and pulmonary arterial PO2 values in Group I did not differ significantly from those in the other three canine groups, nor from the two human groups. Group II dogs exhibited chest tube PO2 which was significantly (p less than 0.01) above aortic PO2. In Group IV, chest tube PO2 was increased significantly above pulmonary arterial blood. Patients without pneumothorax had values for PO2 in chest tube drainage and aorta which were not significantly different, whereas when pneumothorax was present, PO2 of chest tube drainage was significantly higher than that of aortic PO2. Thus blood gas determinations on chest tube drainage may reflect the nature of the injury; however, the presence of air in the pleural space can result in oxygenation of contained blood well above systemic arterial levels.     

Does more than a single chest tube for mediastinal drainage affect outcomes after cardiac surgery?

Background

The use of 1 or more mediastinal chest tubes has traditionally been routine for all cardiac surgery procedures to deal with bleeding. However, it remains unproven whether multiple chest tubes offer a benefit over a single chest tube.

Methods

All consecutive patients undergoing cardiac surgery (2005–2010) received at least 1 chest tube at the time of surgery based on surgeon preference. Patients were grouped into those receiving a single chest tube (SCT) and those receiving multiple chest tubes (MCT). The primary outcome was return to the operating room for bleeding or tamponade.

Results

A total of 5698 consecutive patients were assigned to 2 groups: 3045 to the SCT and 2653 to the MCT group. Patients in the SCT group were older, more often female and less likely to undergo isolated coronary artery bypass graft than those in the MCT group. Unadjusted outcomes for SCT and MCT, respectively, were return to the operating room for bleeding or tamponade (4.7% v. 5.0%; p = 0.50), intensive care unit stay longer than 48 hours (25.5% v. 27.9%; p = 0.041, postoperative stay > 9 days (31.5% v. 33.1%; p = 0.20) and mortality (3.8% v. 4.6%; p = 0.16). Logistic regression analysis, adjusted for clinical differences between groups, showed that the number of chest tubes was not associated with return to the operating room for bleeding or tamponade.

Conclusion

The use of multiple mediastinal chest tubes after cardiac surgery confers no advantage over a single chest tube in preventing return to the operating room for bleeding or tamponade.