Leave No Clot Behind Part 2: Preventing Retained Blood Reduces Post Op Atrial Fib (POAF)
Chest tubes are used to prevent retained clot around the heart in patients recovering from heart surgery. Chest tubes often fail by clogging, leading to retained blood syndrome.1, 2 Growing evidence suggests that retained blood is one of the most potent triggers for developing Post Operative Atrial Fibrillation (POAF).3 POAF is the most common complication after Cardiac Surgery, leading to longer and more expensive hospital stays, readmissions and death during early recovery.4, 5 Prevention strategies have long been sought to reduce associated complications, mortality and costs, although none have become universal. Common strategies to prevent POAF have relied on prophylactic drugs, mostly consisting of attempts to block arrhythmias (digoxin, metoprolol, carvedilol, amiodorone) or blunt the inflammatory responses (fish oil, steroids, N-Acetyl Cystine, Colchicine). Various trials have shown modest reductions in POAF with these approaches, but drugs in these categories can have serious side effects.6 Thus current guidelines caution these approaches should be used selectively rather than on all patients to minimize side effects.
One approach that has consistently reduced POAF in randomized trials even better than prophylactic drugs is to limit the amount of blood retained around the heart in the pericardium after cardiac surgery.3, 7 Various pericardiotomy approaches have been tried, all of which rely on shunting blood from the pericardium to pleural spaces.8 There are downsides and risks, including the risk of heart and bypass graft herniation, adhesions and the contribution to the development of pleural effusions that limit recovery since the blood is simply moved from one cavity (pericardial) to another (pleural).3
Active Clearance Technology utilizing PleuraFlow to keep chest tubes clear of clot during the first 24 hours after surgery may offer a best of all worlds, simple, easy to adopt approach to not only reduce the incidence of POAF, but also reduce the need for reinterventions for pericardial and pleural effusions without the risk of adhesions and herniation.9-12 In a peer reviewed study presented at CVT Critical Care Conference and published in the Journal of Thoracic and Cardiovascular Surgery, PleuraFlow reduces retained blood by 43% and POAF by 33% in propensity matched patients.13 This approach shows considerable promise not only to reduce complications and costs from POAF by making a simple change in drainage management technique in the ICU, but also reduce overall healthcare costs.
What’s your ICU protocol to keep chest tubes free of clogging and prevent retained blood during early recovery after heart surgery?
- Boyle, E.M., Jr., Gillinov, A.M., Cohn, W.E., Ley, S.J., Fischlein, T., and Perrault, L.P. 2015. Retained Blood Syndrome After Cardiac Surgery: A New Look at an Old Problem. Innovations (Phila) 10:296-303.
- Karimov, J.H., Gillinov, A. M., Schenck, L., Cook, M., Kosty Sweeney, D., Boyle, E.M., Fukamachi, K. . 2013. Incidence of chest tube clogging after cardiac surgery: A single-center prospective observational study. Eur J Cardiothorac Surg 44:1029-1036.
- Biancari, F., and Mahar, M.A. 2010. Meta-analysis of randomized trials on the efficacy of posterior pericardiotomy in preventing atrial fibrillation after coronary artery bypass surgery. J Thorac Cardiovasc Surg 139:1158-1161.
- Steinberg, B.A., Zhao, Y., He, X., Hernandez, A.F., Fullerton, D.A., Thomas, K.L., Mills, R., Klaskala, W., Peterson, E.D., and Piccini, J.P. 2014. Management of postoperative atrial fibrillation and subsequent outcomes in contemporary patients undergoing cardiac surgery: insights from the Society of Thoracic Surgeons CAPS-Care Atrial Fibrillation Registry. Clin Cardiol 37:7-13.
- LaPar, D.J., Speir, A.M., Crosby, I.K., Fonner, E., Jr., Brown, M., Rich, J.B., Quader, M., Kern, J.A., Kron, I.L., Ailawadi, G., et al. 2014. Postoperative atrial fibrillation significantly increases mortality, hospital readmission, and hospital costs. Ann Thorac Surg 98:527-533; discussion 533.
- Levy, D., and Kannel, W.B. 2004. Postoperative atrial fibrillation and mortality: do the risks merit changes in clinical practice? J Am Coll Cardiol 43:749-751.
- Kaygin, M.A., Dag, O., Gunes, M., Senocak, M., Limandal, H.K., Aslan, U., and Erkut, B. 2011. Posterior pericardiotomy reduces the incidence of atrial fibrillation, pericardial effusion, and length of stay in hospital after coronary artery bypasses surgery. Tohoku J Exp Med 225:103-108.
- Kaleda, V.I., McCormack, D.J., and Shipolini, A.R. 2012. Does posterior pericardiotomy reduce the incidence of atrial fibrillation after coronary artery bypass grafting surgery? Interact Cardiovasc Thorac Surg 14:384-389.
- Arakawa, Y., Shiose, A., Takaseya, T., Fumoto, H., Kim, H.I., Boyle, E.M., Gillinov, A.M., and Fukamachi, K. 2011. Superior chest drainage with an active tube clearance system: evaluation of a downsized chest tube. Ann Thorac Surg 91:580-583.
- 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., Boyle, E.M., Saeed, D., Fukamachi, K., Cohn, W.E., and Gillinov, A.M. 2010. The active tube clearance system: a novel bedside chest-tube clearance device. Innovations (Phila) 5:42-47.
- Shiose, A., Takaseya, T., Fumoto, H., Arakawa, Y., Horai, T., Boyle, E.M., Gillinov, A.M., and Fukamachi, K. 2010. Improved drainage with active chest tube clearance. Interact Cardiovasc Thorac Surg 10:685-688.
- Sirch J, Ledwon M, Puski T, Boyle EM, Pfeiffer S, Fischlein T. Active Clearance of Chest Drainage Catheters Reduces Retained Blood. Journal of Thoracic and Cardiovascular Surgery. 2015 Oct 22. pii: S0022-5223(15)01970-4. doi: 10.1016/j.jtcvs.2015.10.015. [Epub ahead of print].