WEBINAR REPLAY: "Chest Tube Management in Cardiac Surgery" | ERAS Cardiac Society Webinar in collaboration with CTSNet

Key speakers Marc Gillinov, MD, Jurij M. Kalisnik, MD, and Lenard Conradi, MD discuss the clinical implications of retained blood, current strategies in chest tube management, and the benefits of posterior pericardiotomy.
Webinar moderated by Kevin Lobdell, MD, and Marc Gerdisch, MD.



Improving Your Heart Program’s Bottom Line: Seven Simple Steps to Recoup Lost RBC Costs and Reduce Complications After Heart Surgery

sevenBleeding is one of the most common and expensive complications after heart surgery.  When a patient hemorrhages, not only does it impact patient outcomes, the hospital hemorrhages money in un-recouped expenses to manage the ensuing complications.

All patients bleed to some degree after heart surgery. Shed blood is evacuated by drainage systems in the early hours after surgery while the bleeding stops. Retained blood complex (RBC) occurs when the blood evacuation is inadequate in those early hours after heart surgery. A common cause of this is chest tube clogging which  occurs when thrombus obstructs the inside of the drainage catheters placed around the heart and lungs in the early hours after heart surgery.

The following are seven easy steps to help recoup costs and reduce RBC related complications after heart surgery.

1. Understand which patients are at greatest risk of retained blood complex (RBC).

Postoperative bleeding increases the risk for retained post-surgical blood. (1) When chest tubes clog in the early postoperative period, evacuation capacity is impaired and blood and clot can be retained in the pleural and pericardial spaces. In a recent study, Karimov and colleagues found that patients with greater risk for bleeding also had a significantly higher incidence of chest tube clogging and were significantly associated with postoperative complications like atrial fibrillation. (2) Many factors increase the risk for postoperative bleeding, including urgent and emergent procedures, combined procedures, redo operations, and patients on antiplatelet or anticoagulant therapies. (3)

2. Know your institutional RBC incidence.

Postoperative complications associated with chest tube clogging and RBC impact your bottom line and may impact readmissions. Data managers can readily assess your institutional incidence of RBC after heart surgery at your facility by searching existing database elements for tamponade, hemothorax, pleural effusions, and pericardial effusions. In a national ICD-9 analysis of adult heart surgery patients in 2010, 17% of were found to have additional codes indicating RBC. (4) Many institutions find an incidence from 10% to 25%. What is the incidence at your institution?

3.  Understand the cost of RBC at your institution. 

Patients with RBC have longer lengths of stay, doubled mortality rates, and a 55% increase in total cost of care. (4) That translates to an extra $28,000 per patient with RBC. For most programs, this can result in millions of dollars of lost revenue and significantly strains the financial health of the institution. Understanding this source of healthcare dollar loss can help gain consensus to take remedial actions.

4. Develop and implement chest tube management protocols that institute proven protocols to maintain chest tube patency and reduce RBC.

Many institutions don’t have formal policies with regard to managing chest tube patency.(5) Others have very basic guidelines. Often, these prohibit techniques like chest tube stripping, and require periodic monitoring of chest tube output. The only proven method to improve early postoperative drainage, however, is proactive clearance of chest tubes using PleuraFlow Active Clearance Technology. (6, 7) Proactively maintaining chest tube patency significantly decreases the volume of blood and clot retained in the thorax, (6, 7) and is clinically efficient and effective. (8)  Doing this as part of a continuous quality improvement program allows all the key stakeholders to have input, and to adjust real-time to optimize success in your program

5.  Verify active clearance protocol compliance.

Protocols are only effective if they are followed. Periodic compliance verification is an excellent way to ensure that the instituted protocols are being followed. If protocols are not being followed, this is an opportunity for further education or to refine the protocols to fit the needs of your institution.

6.  Participate in programs to allow you to compare your outcomes with others

Formal programs like PROACT offer a way for institutions to compare their outcomes. Learning from the experiences and successes of other institutions can help you determine the most effective way to implement and maintain your protocols.

7.  Measure your success clinically and financially

Reducing the incidence of RBC and chest tube clogging can significantly impact patient outcomes and cost of care. By measuring the baseline incidence of RBC at your institution, you can measure the clinical and financial success of proactive chest tube management protocols after a period of use. Typically, even small reductions in RBC justify any additional costs associated with the program.


Taking steps to reduce RBC is now easier than ever.  Clear Catheter System’s PROACT program offers a simple stepwise approach to measure outcomes after implementing ICU protocols to address this common and expensive complex of complications. Call us and we can help you make it happen.


  1. Dixon, B., Santamaria, J.D., Reid, D., Collins, M., Rechnitzer, T., Newcomb, A.E., Nixon, I., Yii, M., Rosalion, A., and Campbell, D.J. 2012. The association of blood transfusion with mortality after cardiac surgery: cause or confounding? Transfusion.
  2. Karimov JH, Gillinov A M, Schenck L, Cook M, Kosty Sweeney D, Boyle EM, Fukamachi K. Incidence of chest tube clogging after cardiac surgery: a single-centre prospective observational study. Eur J Cardiothorac Surj 2013; 1-8.
  3. Christensen, M.C., Dziewior, F., Kempel, A., and von Heymann, C. 2012. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth 26:46-51.
  4.  Analysis performed by Fletcher Spaght, Inc, using Heart Surgery ICD-9 codes to extract data from the 2010 Nationwide Inpatient Sample (NIS), from the DHHS Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP)
  5. Shalli S, Saeed D, Fukamachi K, Gillinov AM, Cohn WE, Perrault LP 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: 503–9.
  6. Shiose, A.; Takaseya, T.; Fumoto, H.; Arakawa, Y.; Horai, T.; Boyle, E. M.; Gillinov, A. M.; Fukamachi, K. “Improved drainage with active chest tube clearance.” Interactive CardioVascular and Thoracic Surgery 10 (5): 685–688.
  7. Arakawa, Yoko; Shiose, Akira; Takaseya, Tohru; Fumoto, Hideyuki; Kim, Hyun-Il; Boyle, Edward M.; Gillinov, A. Marc; Fukamachi, Kiyotaka. “Superior Chest Drainage With an Active Tube Clearance System: Evaluation of a Downsized Chest Tube.” The Annals of Thoracic Surgery 91 (2): 580–583.
  8. Perrault, Louis, Michel Pellerin, Michel Carrier, Raymond Cartier, Denis Bouchard, Philippe Demers, Edward M. Boyle. The PleuraFlow Active Chest Tube Clearance System: Initial Clinical Experience in Adult Cardiac Surgery. Innovations. 2012;7:354-358.