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Drainology Symposium at ASCVTS 2023 in Busan – Summary

24 July 2023

Drainology Symposium – Summary by Dr Heather L. Mason, Coufetery Comms

Symposium, chaired by Song Wan, MD (Hong Kong, China), at the annual meeting of the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS) in Busan, Korea (May 2023) with contributions from Tohru Asai, MD (Kamakura, Japan), Edward Chen, MD (Duke, USA) and Hirofumi Takemura, MD (Kanazawa,  Japan).

The 31st Annual Meeting of the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS) meeting in Busan, Korea, provided an opportunity to introduce the new science of Drainology to cardiac specialists in this geographic region. In modern cardiothoracic surgery, chest drainage has become ubiquitous and yet characterised by a wide variation in practice. Meanwhile, the evolution of chest drain technology has created knowledge gaps that represent opportunities for new research to support the development of best practices in chest drain management[1].

Acute phase drain management following cardiac surgery

Tohru Asai, MD PhD (Kamakura, Japan) presented an overview of the critical link between surgical outcomes and adequate monitoring and management of chest drains in cardiac surgery. There is currently no consensual evidence for chest drain management, and the new science of Drainology aims to address this knowledge gap.

The type, number, placement of drains, surgical technique, and the clinical state of individual patients all affect clinical outcomes in cardiac surgery. In the 24h-48h post-operative “acute phase,” the major concern is blood drainage. Prolonged blood drainage leads to retained blood syndrome (RBS), extending the drain duration, preventing early mobilisation, increasing the length of hospital stay (LOS), and reducing pulmonary recovery. The most common complications due to RBS are cardiac tamponade, post-operative atrial fibrillation (POAF), and re‑operation due to bleeding.

Influence of drain types

The non-inferiority of flexible silastic drains has been shown in several observational and randomised controlled trials (RCT). A 2003 retrospective case-control study of patients undergoing coronary artery bypass grafting (CABG) found no difference in drainage volumes, pain and narcotic use, operational mortality, or re-operation due to bleeding, but a shorter LOS compared to the traditional polyvinyl chloride (PVC) drain (p=0.01)[2]. In general cardiac surgery, the non-inferiority of one or more 19F silastic drains compared to 28F to 36F PVC drains for drainage volumes, re-operation for bleeding or tamponade, and pleural effusions have also been demonstrated in a retrospective study[3].

These results were supported in an RCT using a 19F silicone rubber drain or a 28F PVC drain for late pericardial effusion[4].

In patients undergoing CABG, an RCT explored the impact of intrapericardial and infracardiac drains on pericardial effusions. A flexible 19F silastic drain or a silicon semi-rigid drain, plus a large-bore rigid silicon drain in the mediastinal space was used. Outcomes were comparable; however, the silastic drain yielded a 71% increase in drainage, a 49% decrease in pericardial effusion volume, and a reduction in POAF (p=0.016)[5]. One or more large-bore PVC drains are usually used to drain blood from the mediastinum and pleura. However, using different sized silastic drains (24F and 32F) or a 32F PVC shows no significant differences in pericardial effusion or tamponade following CABG [6].

In a pig model, introducing an active tube clearance (ATC) system using a guide wire in the lumen of the drain significantly increased drainage and reduced retained blood[7]. Implementation of an ATC system in patients undergoing cardiac surgery has also demonstrated a significant reduction in RBS and POAF[8, 9], reexploration rates due to bleeding[10], and tamponade[11], but not the amount of post-operative bleeding or pericardial effusion[12]. An RCT has also found an 89% reduction in complete chest drain occlusion following ATC[10]. Observational studies have shown that using ACT improves clinical outcomes and reduces time in the intensive care unit (ICU), median LOS, and lowered costs by an average of $2696[13].

Results from a recent first-in-human study using an electronic chest drain system with integrated suction, and an automatic air sweep mechanism to maintain patency, found a comparable drainage profile, and readmission for effusion, compared to conventional drains[14].

Influence of the number of drains

Multiple chest tubes are not associated with any advantages in preventing complications such as re-operation for bleeding or tamponade[15]. A meta-analysis of 19 randomised controlled studies found that posterior pericardial drainage in patients undergoing heart surgery was associated with a significantly reduced odds ratio (OR) for tamponade (90%), early effusion (80%), POAF (58%), cardiac arrest or death (50%). A reduction in LOS by one day was also estimated when comparing overall data[16].

Influence of surgical technique

Surgical technique may also affect post-surgical outcomes. An RCT assigning patients undergoing cardiac surgery to either posterior left pericardiotomy or standard of care found that the incidence of POAF was 17%, compared to 32%, respectively. Equally, the incidence of pericardial effusion was 12% compared to 21%, respectively[17]. The risk of drain blockage is comparable between different drain types. A single institution study from the USA found that nearly 40% of drains blocked [18], raising the question of whether the drain should be ‘milked’. However, a review published in 2008 found that this practice gave no benefit [19], and in fact, breaking the sterile field has the potential to cause tissue damage[20].

 

Preventing Delayed Pericardial Effusion After Cardiac Surgery

Song Wan, MD, FRCS, FACC (Hong Kong, China) presented the role of the inflammatory response following cardiopulmonary surgery, focusing on later onset complications[21]. Between 64% and 85% of patients who undergo cardiac surgery have pleural effusion, with or without pericardial effusion. Guidelines have been published for diagnosing and managing pericardial diseases, including pericardial effusion, chylopericardium, causes of cardiac tamponade, and the analysis of pericardial fluid[22]. The diagnosis of post‑pericardiotomy syndrome (PPS) is made based upon the presence of at least two criteria; fever lasting longer than one week post-surgery without evidence of infection, pleuritic chest pain, friction rub, pleural effusion, or new or worsening pericardial effusion[23].  There remains an unmet need to standardise the diagnostic criteria and early treatment for PPS [24].

Immune-mediated complications show a reduced drainage volume following minimally invasive compared to conventional surgery, which may be due to retained fluid in the pericardial cavity, triggering an immune response[25]. Younger patients generally have a strong immune system and are, therefore, at higher risk of complications following cardiac surgery.

Pharmacological treatment

First-line pharmacological preventative strategies include non-steroidal anti-inflammatories (NSAIDs) with or without colchicine. An early Italian RCT found that the relative risk reduction (RRR) of PPS at 12 months following one month of colchicine treatment was 57.9%. The RRR for secondary endpoints; recurrence, cardiac tamponade, constrictive pericarditis, and PPS-related hospitalisations was 88.9% [23]. The benefits of colchicine have since been reported in acute pericarditis[26, 27]. However, the dosing schedule of colchicine is critical to reduce POAF. Comparing studies published by Imazio et al. found that starting colchicine 48-72 hours before surgery, without a loading dose, did not reduce the risk of POAF, compared to post-surgery initiation of colchicine post-operative pericardial or pleural effusion [28]. This could be attributed to the higher rate of gastrointestinal (GI) complications and a 21.7% discontinuation rate.

Post-pericardiotomy syndrome is not just a benign complication. The increased risk of GI adverse events caused by colchicine should not prevent its use; however, conservative use is recommended to reduce AEs.

 

Discussion

In the experience of Edward Chen, MD, FACS, FAHA (Duke, USA), patients with thick adhesions when attending surgery are likely due to RBS and the inflammatory response. While this response is difficult to control in individual patients, as surgeons, individualising the surgical procedure can reduce these risks. The type and number of drains can reduce the complication risk, but effective drain placement requires prediction of where the bleeding will occur. Post-operative blood drainage is also important, not only for how much but also how little is coming out. Therefore, it is advisable not to take drains out too early, as more drainage can occur once the patient is mobilised. Hirofumi Takemura, MD PhD (Kanazawa,  Japan) added that even if there is no more drainage, it may be a symptom of blockage rather than that drainage has been completed.

The parameters for drain removal among the panel highlighted the complex individual surgeon choice around this subject. Drain removal criteria are generally between  150-200mL / 24h, but some surgeons may keep a smaller drain until day three. The amount of drainage may not be consistent throughout a 24-hour period. For patients with low ejection fraction, or kidney dysfunction, it is not only the amount of drainage that is an important consideration before drain removal. Clinical decisions also need to consider urine output, immunosuppressors index, and bedside ultrasound cannot be relied upon. There was a consensus among the panel that drains should be left in situ longer in these patients. In complex aortic arch operations, the drain duration may not necessarily be longer, but the lumen could be larger.

In response to a question on whether the use of haemostatic adjuncts impacted Drainology, the panel all stated that they considered the surgical technique to be more important and rarely used these products other than for surface oozing.

The use of the Medela Thopaz+ drain was discussed, and the consensus for those who have used it was that it has been very successful in both thoracic and cardiac surgery. The global financial crisis since COVID-19 has unfortunately prevented its use in certain areas.

 

REFERENCES

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