CARDIOVASCULAR SURGERY COMPLICATIONS A LOOK AT THE ROOT CAUSE OF COMMON COMPLICATIONS AND A NOVEL NEW TECHNOLOGY TO PROACTIVELY MAINTAIN CHEST TUBE PATENCY x

ML064-A

WHY CHEST TUBES ARE USED

•  Bleeding is common after cardiac surgery

•  Chest tubes are used to drain the blood until coagulation is restored

•  Adequate drainage is imperative to prevent retained blood in the pleural and pericardial spaces postoperatively

•  Typically 2-4 large tubes are used as tubes are prone to clogging

Typical  occluded  chest  drainage  tube  é  

CHEST TUBES COMMONLY CLOG

TUBES BEGIN TO CLOT IMMEDIATELY

Fluid evacuates without impairment

Blood begins to coagulate as it comes in contact with foreign chest tubes. Obstructions begin to form inside chest tubes

Flow slows and blood begins to pool around the chest tubes

As phase change occurs and stagnate collections of blood begin to clot around the chest tube

Skin-­‐Line  

Day, Interactive CardioVascular and Thoracic Surgery. 2008 Wallen, The Cochrane Library, 2008

MILKING & STRIPPING DON’T WORK

Makeshift techniques are often employed despite policies that prohibit them Stripping, milking, and open suction are reactive methods to unclog tubes but do not prevent clogging

CLASS III EVIDENCE RECOMMENDATION AGAINST MILKING AND STRIPPING

”…stripping chest tubes may significantly increase negative intrathoracic pressures that could cause harm (eg, tissue entrapment, increased bleeding, left ventricular dysfunction), thereby further impairing patients’ postoperative recovery.”

Halm, American Journal of Critcal Care, 2007  

INCIDENCE OF CHEST TUBE CLOGGING

In Patients Following Cardiac Surgery: •  36% of tubes become

completely clogged

•  In 86% of these cases, clogging is in the chest where it cannot be seen by the nursing staff

Karimov, Eur J Cardiothoracic Surg. 2013

Retained Blood Syndrome (RBS):

Any re-operation or intervention to remove blood, blood clot or bloody fluid from the pericardial or pleural spaces after cardiac surgery.

RBS Can Occur In Any Of The Following Stages of Recovery:

-  Acute (Pericardial tamponade or hemothorax) -  Sub Acute (Bloody pleural or pericardial effusions) -  Chronic (Fibrothorax, constrictive pericarditis)

CHEST TUBE CLOGGING IS A ROOT CAUSE IN THE DEVELOPMENT OF RBS

REVIEW OF LITERATURE SHOWS RBS IN ~1:5 PATIENTS

Blocked chest tubes lead to complications requiring additional re-operation and intervention.

References Available Upon Request

NATIONWIDE RBS INCIDENCE EVALUATED IN THE US

Based on over 313,000 US adult heart surgery patients. Data extracted using ICD-9 codes from the 2010 Nationwide Inpatient Sample (NIS), from the DHHS Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP).

of adult cardiac surgery patients have one or more complications that require re-operation or intervention due to retained blood

17%

CONSEQUENCES OF RETAINED BLOOD

Patients with retained blood experience: •  Significantly longer ICU time •  Significantly higher rates of post operative atrial fibrillation (POAF) •  Significantly higher rates of postoperative renal failure •  Significantly longer ventilator time •  Trends to more postoperative strokes and cardiac arrest

Dixon, Transfusion. 2012

SYSTEMIC INFLAMMATORY RESPONSE

The body has to deal with the clot from around the chest tube that is left behind after removal. This is what may trigger many of the complications that are seen after surgery.        

COMPLICATIONS ARE SERIOUS AND COSTLY

Retained Blood Syndrome affects patient outcomes and significantly increase healthcare costs.

Based on over 313,000 US adult heart surgery patients. Data extracted using ICD-9 codes from the 2010 Nationwide Inpatient Sample (NIS), from the DHHS Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP).

per RBS

PLEURAFLOW WITH ACTIVE CLEARANCE TECHNOLOGY (ACT)

•  ACT is an easy to use System that proactively clears chest tubes and prevents the retention of blood in the chest cavity

Perrault, Innovations. 2012; Shiose, Interactive CV and Thorac Surg. 2010; Arakawa, Ann Thorac Surg. 2011

SUMMARY

•  Interventions for Retained Blood Syndrome (RBS) are needed in ~1:5 cardiovascular surgery patients

•  RBS patients cannot be predicted preoperatively

•  Patients with RBS are associated with increased costs and complications

•  The first clinical study with prospective evaluation of the PleuraFlow ACT System showed a reduced need for re-operations and interventions by 42%

•  PleuraFlow ACT also showed a reduction in other complications, including a 30% reduction in Post-Operative Atrial Fibrillation (POAF)

Arakawa, Y., Shiose, A., Takaseya, T. et al. Superior Chest Drainage With an Active Tube Clearance System: Evaluation of a Downsized Chest Tube. Ann Thorac Surg. 2011;91:580-583. doi: 10.1016/j.athoracsur.2010.10.018.

Christensen, M., Krapf, S., Kempel, A. et al. Costs of excessive postoperative hemorrhage in cardiac surgery. J Thorac Cardioasc Surg. 2009;138(3):687-93. PMID: 19698857.

Day, T., Perring. R., Gofton, T., Is manipulation of mediastinal chest drains useful or harmful after cardiac surgery? Interact CardioVasc Thorac Surg. 2008;7:888-890.

Dixon, B., Santamaria, J.D., Reid, D., et al. The association of blood transfusion with mortality after cardiac surgery: cause or confounding? Transfusion. 2013;53(1):19-27. doi: 10.1111/j.1537-2995.2012.03697.x.

Halm, MA. To Strip or Not to Strip? Physiological Effects of Chest Tube Manipulation. Amer J of Critical Care. 2007, Vol. 16, No. 6 609:612.

Hannan, E., Zhong, Y., Lahey, S., et al. 30-day readmissions after coronary artery bypass graft surgery in New York State. J Am Coll Cardiol Intv. 2011;4(5):569-576. doi:10.1016.jcin 2011.01.010.

Karimov, J.H., Gillinov, A.M., Schenck, L., et al. Incidence of chest tube clogging after cardiac surgery: a single-centre prospective observational study. Eur J Cardiothorac Surg. 2013;44(6):1029-1036. doi:10.1093/ejcts/ezt140.

Lee, Y.C., Vaz, M.A., Ely, K.A., McDonald, E.C., Thompson, P.J., Nesbitt, J.C., and Light, R.W. 2001. Symptomatic persistent post-coronary artery bypass graft pleural effusions requiring operative treatment : clinical and histologic features. Chest 119:795-800.

Light, R.W., Rogers, J.T., Moyers, J.P., et al. Prevalence and Clinical Course of Pleural Effusions at 30 Days after Coronary Artery and Cardiac Surgery. Am J Respir Crit Care Med. 2002;166:1567-1571. doi: 10.1164/rccm.200203-184OC.

Mangus, P.C., et al. Causes of 30-Day Readmission After Cardiac Surgery in Northern New England, Abstract 13474. Circulation. 2011;124-134.

Perrault, L.P., Pellerin, M., Carrier, M., et al. The PleuraFlow Active Chest Tube Clearance System: Initial Clinical Experience in Adult Cardiac Surgery. Innovations (Phila). 2012;7(5):354-8. doi: 10.1097/IMI.0b013e31827e2b4d.

Shalli, S., Saeed, D., Fukamachi, K., et al. Chest Tube Selection in Cardiac and Thoracic Surgery: A Survey of Chest Tube-Related Complications and Their Management. J Card Surg. 2009;24:503-509. doi: 10.1111/j.1540-8191.2009.00905.x.

Shiose, A., Takaseya, T., Fumoto, H., et al. Improved drainage with active chest tube clearance. Interact Cardiovasc Thorac Surg. 2010;10:685-688. doi: 10.1510/icvts.2009.229393.

Wallen, M.M., Morrison, A.L., Gillies D, et al. Mediastinal chest drain clearance for cardiac surgery (Review). The Cochrane Library. 2008, Issue 3.

Wheatcroft, M., Shrivastava, V., Nyawo, B., Rostron, A., and Dunning, J. 2005. Does pleurotomy during internal mammary artery harvest increase post-operative pulmonary complications? Interact Cardiovasc Thorac Surg 4:143-146.

Based on over 313,000 US adult heart surgery patients. Data extracted using ICD-9 codes from the 2010 Nationwide Inpatient Sample (NIS), from the DHHS Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP).

CLINICAL REFERENCES