A look at the root case of common complications and a novel new technology to proactively maintain chest tube patency.

1. CARDIOVASCULAR SURGERY
COMPLICATIONS
A LOOK AT THE ROOT CAUSE OF COMMON COMPLICATIONS
AND A NOVEL NEW TECHNOLOGY TO PROACTIVELY
MAINTAIN CHEST TUBE PATENCY
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ML064-A

2. 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

3. CHEST TUBES COMMONLY CLOG

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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%

11. 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

12. 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.

13. 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

14. 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

15. 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)

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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.
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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.
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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.
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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