RE-EXPLORATION AND ECONOMIC JUSTIFICATION OF A CHEST DRAINAGE PROTOCOL IMPLEMENTING ACTIVE TUBE CLEARANCE AFTER CARDIAC SURGERY
CCC ePoster Library. St-Onge S. 10/26/19; 280542; 307
Samuel St-Onge
Samuel St-Onge
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Abstract
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BACKGROUND: Appropriate evacuation of shed blood with chest tubes is a critical component of patient care after cardiac surgery as re-exploration for bleeding or tamponade is a morbid, lethal and costly complication. Drainage protocols involving extended drainage duration, specific placement of silastic drains or prevention of intraluminal clogging have all exhibited the potential to reduce the need for re-exploration. This sub-study from a larger randomized investigation is aimed towards exploring the risk factors and impacts of re-exploration, while also determining whether the implementation of active chest tube clearing devices is economically justified.

METHODS AND RESULTS: Data from the 490 patients included in the analysis by intention-to-treat of our pragmatic, single-blinded, parallel randomized control trial comparing a chest drainage strategy using active tube clearance (ATC) at the bedside to standard management after cardiac surgery in two centers affiliated to the Université de Montréal School of Medicine, were used. The 18 patients who required re-exploration for bleeding or tamponade were compared with the ones who did not experience such complication through univariate analysis (chi-square, Fischer exact, t-test and Mann-Whitney U tests were used appropriately). A cost-benefit analysis was also conducted. Patients who required re-exploration presented more preoperative pulmonary hypertension (33% vs 9%, P = 0.01) and higher EuroScore II (3.54 ± 3.55% vs 2.30 ± 2.28%, P = 0.03). Mitral valve replacements or repairs (11% vs 2%, P = 0.02) and aortic surgeries (11% vs 1%, P = 0.02) were more frequent in the re-exploration group. The incidence of POAF (83% vs 34%, P < 0.001) and allogenic blood products transfusion (89% vs 32%, P < 0.001) were higher in the re-exploration group. Re-exploration was associated with significantly greater in-hospital mortality (22% vs 1%, P < 0.001), increased rate of acute renal failure and cardiac arrest, and longer ventilation time, intensive care unit time and hospital length of stay. In our randomized controlled trial, ATC was associated with a significant reduction in re-exploration, with a Number Needed to Treat of 25. The cost-benefit analysis, based on mean local incremental costs per major complication, which includes re-exploration, revealed savings of ~240$ per patients by systematically using ATC.

CONCLUSION: Re-exploration after cardiac surgery is associated with significantly worse outcomes and potentially lethal complications. While determining which patient will require re-exploration after cardiac surgery may be delicate, the implementation of a drainage strategy using ATC could represent an efficient and cost-effective preventative strategy.
BACKGROUND: Appropriate evacuation of shed blood with chest tubes is a critical component of patient care after cardiac surgery as re-exploration for bleeding or tamponade is a morbid, lethal and costly complication. Drainage protocols involving extended drainage duration, specific placement of silastic drains or prevention of intraluminal clogging have all exhibited the potential to reduce the need for re-exploration. This sub-study from a larger randomized investigation is aimed towards exploring the risk factors and impacts of re-exploration, while also determining whether the implementation of active chest tube clearing devices is economically justified.

METHODS AND RESULTS: Data from the 490 patients included in the analysis by intention-to-treat of our pragmatic, single-blinded, parallel randomized control trial comparing a chest drainage strategy using active tube clearance (ATC) at the bedside to standard management after cardiac surgery in two centers affiliated to the Université de Montréal School of Medicine, were used. The 18 patients who required re-exploration for bleeding or tamponade were compared with the ones who did not experience such complication through univariate analysis (chi-square, Fischer exact, t-test and Mann-Whitney U tests were used appropriately). A cost-benefit analysis was also conducted. Patients who required re-exploration presented more preoperative pulmonary hypertension (33% vs 9%, P = 0.01) and higher EuroScore II (3.54 ± 3.55% vs 2.30 ± 2.28%, P = 0.03). Mitral valve replacements or repairs (11% vs 2%, P = 0.02) and aortic surgeries (11% vs 1%, P = 0.02) were more frequent in the re-exploration group. The incidence of POAF (83% vs 34%, P < 0.001) and allogenic blood products transfusion (89% vs 32%, P < 0.001) were higher in the re-exploration group. Re-exploration was associated with significantly greater in-hospital mortality (22% vs 1%, P < 0.001), increased rate of acute renal failure and cardiac arrest, and longer ventilation time, intensive care unit time and hospital length of stay. In our randomized controlled trial, ATC was associated with a significant reduction in re-exploration, with a Number Needed to Treat of 25. The cost-benefit analysis, based on mean local incremental costs per major complication, which includes re-exploration, revealed savings of ~240$ per patients by systematically using ATC.

CONCLUSION: Re-exploration after cardiac surgery is associated with significantly worse outcomes and potentially lethal complications. While determining which patient will require re-exploration after cardiac surgery may be delicate, the implementation of a drainage strategy using ATC could represent an efficient and cost-effective preventative strategy.
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