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.



The Challenges of Keeping a Chest Tube Free of Clogging after Heart Surgery


Chest tubes are used on every case after heart surgery to drain blood from around the heart and lungs in the early hours of recovery.1,2  If there is any bleeding, or even oozing tissues, the blood must be immediately drained externally by the chest tubes. But chest tubes frequently clot, which can lead to Retained Blood Syndrome (RBS), which includes the need for re-interventions to wash out clot, remove blood or bloody fluid, or long term, even fibrosis around the heart or lungs.3,4  Blood, even in small volumes left around the heart after surgery can cause an inflammatory response, triggering complications such as Post Operative Atrial Fibrillation (POAF).5

Nurses have long recognized the frequent problem of chest tube clogging.2In the absence any reliable and consistent solutions, many will strip or milk the chest tubes, or at times, the chest tube will be opened and suctioned out in the ICU, which breaks the sterile field.   None of these approaches have been shown to work and in fact, it’s published they may be harmful.2,7,8,9

ERAS Cardiac Recommends against Chest Tube Stripping and Milking

In a recently published best evidence review by ERAS Cardiac Surgery, chest tube stripping was found to be ineffective and potentially harmful. The experts at ERAS Cardiac gave this a Class III A.  This is to say they caution against protocols that allow chest tube stripping saying definitively that this practice should be avoided based on high quality, published evidence.10 This has left many heart surgery programs uncertain about what protocols should exist to train ICU nurses to optimally maintain chest tube patency after cardiac surgery. This makes sense as this is a reactive approach that is potentially harmful, and has not been shown to be effective.

ERAS Cardiac Suggests Proactive Chest Tube Patency Management Protocols

Now nurses in the ICU can proactively and routinely keep chest tubes patent at the bedside without the need for milking and stripping or open suction.  This can be done without breaking the sterile seal. PleuraFlow ACT is a FDA approved device to prevent chest tube clogging and retained blood. PleuraFlow has been shown to be clinically efficient, to improve the evacuation of post-surgical blood, and to reduce the volume of blood retained in the surgical spaces.10-12Utilizing PleuraFlow ACT in a defined preventive protocol has been shown to reduce RBS by 43% and POAF by 33%.13With PleuraFlow ACT, a growing number of hospitals are now formally implementing chest tube clearance protocols to proactively maintain chest tube patency in the early hours after surgery in the ICU. By actively and systematically maintaining chest tube patency, top hospitals are working to improve the clinical efficiency of chest tube management process, and decreasing the incidence of RBS and POAF by reducing the volume of retained post-surgical blood.  In the most recent ERAS publication active clearance of chest tubes was given a Level 1 recommendation based on published evidence that it can help reduce retained blood.10

Evidence for PleuraFlow Active Tube Clearance

Numerous studies have shown using PleuraFlow act can reduce reexploration for bleeding, effusions, POAF and other complications.11-18  For example, Sirch and colleagues demonstrated that utilizing PleuraFlow ACT in a defined preventive protocol has been shown to reduce RBS by 43% and POAF by 33%.17This included a significant reduction in the time on the ventilator postoperatively in the ICU.  There have been several studies showing that active clearance of chest tubes reduces the need for take back for re exploration by up 55% to 100%.14, 15 This includes a randomized study from Montreal showing a 75% reduction and one Washington University showing a 100% reduction. Likewise Baribeau and colleagues recently showed not only fewer postoperative bloody pleural effusions, but also less AKI, fewer post op infections and a marked reduction in POAF.  In this clinical trial they also noted a reduced time in the ICU and reduced hospital costs with active clearance of chest tubes using PleuraFlow.18

Addressing the Challenge of Maintaining Chest Tube Patency

Given the growing evidence for active chest tube maintenance of chest tube patency after cardiac surgery, and the mounting expert consensus against chest tube stripping, more and more programs are making the switch to implement PleuraFlow ACT as part of the routine post op care in the ICU with the goal of reducing complications and reducing costs of care.


For more information about how developing chest tube patency protocols and PleuraFlow ACT can help your facility address this common and costly problem, contact us.

  1. Karimov  JH, Gillinov  AM, Schenck  L,  et al.  Incidence of chest tube clogging after cardiac surgery: a single-center prospective observational study. Eur J Cardiothorac Surg. 2013;44(6):1029-1036. doi:1093/ejcts/ezt140
  2. 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(5):503-509. doi:1111/j.1540-8191.2009.00905.x
  3. Balzer  F, von Heymann  C, Boyle  EM, Wernecke  KD, Grubitzsch  H, Sander  M.  Impact of retained blood requiring reintervention on outcomes after cardiac surgery. J Thorac Cardiovasc Surg. 2016;152(2):595-601.e4. doi:1016/j.jtcvs.2016.03.086
  4. Tauriainen  TKE, Morosin  MA, Airaksinen  J, Biancari  F.  Outcome after procedures for retained blood syndrome in coronary surgery. Eur J Cardiothorac Surg. 2017;51(6):1078-1085. doi:1093/ejcts/ezx015
  5. St-Onge  S, Perrault  LP, Demers  P,  et al.  Pericardial blood as a trigger for postoperative atrial fibrillation after cardiac surgery. Ann Thorac Surg. 2018;105(1):321-328. doi:1016/j.athoracsur.2017.07.045
  6. Boyle EM, Jr, Gillinov AM, Cohn WE, et al. Retained blood syndrome after cardiac surgery: a new look at an old problem. Innovations (Phila) 2015;10(5):296–303. doi: 10.1097/IMI.0000000000000200.
  7. Day  TG, Perring  RR, Gofton  K.  Is manipulation of mediastinal chest drains useful or harmful after cardiac surgery? Interact Cardiovasc Thorac Surg. 2008;7(5):888-890. doi:1510/icvts.2008.185413
  8. Halm  MA.  To strip or not to strip? physiological effects of chest tube manipulation. Am J Crit Care. 2007;16(6):609-612.
  9. Boyacıoğlu  K, Kalender  M, Özkaynak  B, Mert  B, Kayalar  N, Erentuğ  V.  A new use of Fogarty catheter: chest tube clearance. Heart Lung Circ. 2014;23(10):e229-e230. doi:1016/j.hlc.2014.04.255
  10. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations. JAMA Surg.2019; 154: 755-766.  doi:10.1001/jamasurg.2019.1153
  11. Shiose A, Takaseya T, Fumoto H, Arakawa Y, Horai T, Boyle EM, Gillinov AM, Fukamachi K. Improved drainage with active chest tube clearance. Interact Cardiovasc Thorac Surg. 2010;10(5):685–8. DOI: 1510/icvts.2009.229393
  12. Arakawa Y, Shiose A, Takaseya T, Fumoto H, Kim HI, Boyle EM, Gillinov AM, Fukamachi K. Superior chest drainage with an active tube clearance system: evaluation of a downsized chest tube. Ann Thorac Surg. 2011;91(2):580–3.DOI: 1016/j.athoracsur.2010.10.018.
  13. Perrault  LP, 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):354-358.  org/10.1097/imi.0b013e31827e2b4d
  14. Grieshaber  P, Heim  N, Herzberg  M, Niemann  B, Roth  P, Boening  A.  Active chest tube clearance after cardiac surgery is associated with reduced reexploration rates. Ann Thorac Surg. 2018;105(6):1771-1777. doi:1016/j.athoracsur.2018.01.002
  15. Maltais  S, Davis  ME, Haglund  NA,  et al.  Active clearance of chest tubes reduces re-exploration for bleeding after ventricular assist device implantation. ASAIO J. 2016;62(6):704-709. doi:1097/MAT.0000000000000437
  16. St-Onge  S, Ben Ali  W, Bouhout  I,  et al.  Examining the impact of active clearance of chest drainage catheters on postoperative atrial fibrillation. J Thorac Cardiovasc Surg. 2017;154(2):501-508. doi:1016/j.jtcvs.2017.03.046
  17. Sirch  J, Ledwon  M, Püski  T, Boyle  EM, Pfeiffer  S, Fischlein  T.  Active clearance of chest drainage catheters reduces retained blood. J Thorac Cardiovasc Surg. 2016;151(3):832-838.e2. doi:1016/j.jtcvs.2015.10.015

Baribeau Y, Westbrook B, Baribeau Y, et al. Active clearance of chest tubes is associated with reduced postoperative complications and costs after cardiac surgery: a propensity matched analysis. J Cardiothorac Surg. 2019;14(1):192.  doi.org/10.1186/s13019-019-0999-3