88/10/2 : 88/4/31 : 1389 /104 / 4 3 2 1 4 5 1 (CT Chest Tube) :.. (CABG Coronary Artery Bypass Graft Surgery) 24 307 : ) 4 40 48 ( ) (. ( ) ( 34/5 40/2). 67/1 59/60 ± 9/24 : ( 85 92/5) ( 2 2/88) ( 36 45/8). P = 0/001 P < 0/001..(P < 0/001) 40/13 ± 3/58 22/803 ± 3/4. 24 (P = 0/047) 24 2/22 ± 2/49) 30 (VAS) Visual Analogue Scale 24 (ICU).(P = 0/016 2/93 ± 2/57 30 14 7..(P = 0/59 5/5 3/7) :.. : Chest Tube).(1) (CT Coronary Artery ) (CABG Bypass Graft Surgery E-mail: gharipour@crc.mui.ac.ir. 2. 3. 4. 5.. : 1 27
.(4-6) CABG. : ( ). (Convenience). CABG. ( ). (n = 200) (n = 107) 24 ( :) :). 48 ( 4 40. 24 40.(2-5) CABG.(6).(4 6 8-11).(7-8 13-14) 50 30 5.(2 4).(4-5) (ICU Intensive Care Unit) 28
. 34.. CABG ). (. ( ).. ICU. ICU Arterial Blood Gas) (I/O) (ABG 4. Visual ) VAS 6 (Analogue Scale VAS. 107.. (re-do operation) CABG CABG :... ICU. :... mg/kg) (0/1-0/15 mg/kg/dose) (2 mg/kg) (0/15 (1 µg/kg/minute)... 29
2/3 39/4 Ejection ). 51/19 ± 10/77 (EF Fraction 49/18 ± 17/59. 78/39 ± 25/12 0/3 87/6. 16 3/9.(1 ). P < 0/001 ) 1.(P = 0/001 CABG ) (.. ( ). 24 48. 3 2 2.. IV 5 3. Chest ) 3 2 (CXR X-Ray. : 24. Excel version 14. SPSS Inc,. ) SPSS 14 (Chicago, IL 2 χ Mann-Whitney-u test student s t-test. Fisher s exact test 0/05 P value %95. CABG 307.. 24. 24 32/9 67/1 36/5. 59/6 ± 9/26. 30
48 24 12. 24 6 VAS.(P = 0/047) 48 42 36 24 18 12 30. P = 0/016 24. 48 24 ICU.. VAS 3/47 40/13 ± 3/58 22/80 ±.(P < 0/001) 24 (2 ) 24 (3 ) 24..(P < 0/001).(P < 0/001) 48 24 12.1 P-value (n = 200) 60/08 ± 9/54 (n = 107) 58/72 ± 8/63 %65 %71 %34/5 %40/2 %36 %45/8 %2 %2/8 %56/0 %44/0 (30 < EF 45) %57/9 %42/1 (EF 30) %85 %92/5 %0/5 %0 %2/8 %4/5 %18 %12/1 < 0/001 83/58 ± 27/27 68/78 ± 16/83 ( ) 0/001 51/58 ± 17/47 44/76 ± 17/04 ( ) : Not Significant EF: Ejection Fraction 31
24.2 P-value < 0/001 < 0/001 0/047 : Not Significant VAS: Visual Analogue Scale (n = 200) 502/40 ± 303/81 68/5 15/95 ± 2/17 16/77 ± 7/28 94/95 ± 3/04 92/31 ± 4/96 4/48 ± 2/14 3/44 ± 2/60 1/76 ± 2/52 2/54 ± 2/71 8/45 ± 5/43 614/07 ± 571/18 (n = 107) 321/07 ± 169/15 43/4 16/21 ± 1/64 16/07 ± 1/52 95/18 ± 3/45 93/37 ± 3/17 4/72 ± 2/16 2/93 ± 2/48 1/88 ± 2/64 2/23 ± 2/78 7/52 ± 57/30 546/95 ± 532/60 ( ) 24 12 ( ) 24 ( ) 12 24 VAS 6 VAS 12 VAS 18 VAS 24 24 ( ) 24 ( ) 24.3 P value (n = 200) (n = 107) - 121/04 ± 120/85 - ( ) 24 16/21 ± 1/17 16/37 ± 1/99 48 ( ) 88/63 ± 11/63 90/72 ± 8/55 48 0/016 2/93 ± 2/57 2/55 ± 2/62 1/87 ± 2/47 1/69 ± 2/42 3/10 ± 3/43 209/04 ± 331/23 43/64 ± 4/65 : Not Significant VAS: Visual Analogue Scale 2/22 ± 2/49 2/38 ± 2/53 1/04 ± 2/32 1/19 ± 2/21 2/79 ± 3/33 157/94 ± 290/56 42/83 ± 3/15 30 VAS 36 VAS 42 VAS 48 VAS ( ) 48 ( ) 48 ( ) ICU 32
Gercekoglu.(6) 2003.(4).(9-11) X CABG.(6) ) (. 30 48.( 5/5 3/7) VAS 30 Mueller. 24 2000 (T) (CABG). 40 CABG.(13-14)..(5).(8). 33
. (6) Abramov (8) Mueller. References. CABG 1. Frazier AA, Qureshi F, Read KM, Gilkeson RC, Poston RS, White CS. Coronary artery bypass grafts: assessment with multidetector CT in the early and late postoperative settings. Radiographics 2005; 25(4): 881-96. 2. Golmohammadi M, Sane SH. Comparison of fentanyl with sufentanil for chest tube removal. Iranian Cardiovascular Research Journal 2008; 2(1): 42-7. 3. Ehrman WJ, Pike NA, Gundry RS. Cardiac surgery without chest tubes and pleurovacs: a new standard of care. Chest meeting 2004; 126(4): 853S-b. 4. Gercekoglu H, Aydin NB, Dagdeviren B, Ozkul V, Sener T, Demirtas M, et al. Effect of timing of chest tube removal on development of pericardial effusion following cardiac surgery. J Card Surg 2003; 18(3): 217-24. 5. Wynne R, Botti M, Copley D, Bailey M. The normative distribution of chest tube drainage volume after coronary artery bypass grafting. Heart Lung 2007; 36(1): 35-42. 6. Abramov D, Yeshaaiahu M, Tsodikov V, Gatot I, Orman S, Gavriel A et al. Timing of chest tube removal after coronary artery bypass surgery. J Card Surg 2005; 20(2): 142-6. 7. Smulders YM, Wiepking ME, Moulijn AC, Koolen JJ, van Wezel HB, Visser CA. How soon should drainage tubes be removed after cardiac operations? Ann Thorac Surg 1989; 48(4): 540-3. 8. Mueller XM, Tinguely F, Tevaearai HT, Ravussin P, Stumpe F, von Segesser LK. Impact of duration 24 48.(8) 48 24 Abramov 36 48 24.(6). 48 ICU of chest tube drainage on pain after cardiac surgery. Eur J Cardiothorac Surg 2000; 18(5): 570-4. 9. Sienel W, Mueller J, Eggeling S, Thetter O, Passlick B. [Early chest tube removal after videoassisted thoracoscopic surgery. Results of a prospective randomized study]. Chirurg 2005; 76(12):1155-1160. 10. Fibla JJ, Molins L, Perez J, Vidal G. Early removal of chest drainage and outpatient program after videothoracoscopic lung biopsy. Eur J Cardiothorac Surg 2006; 29(4): 639-40. 11. Russo L, Wiechmann RJ, Magovern JA, Szydlowski GW, Mack MJ, Naunheim KS, et al. Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung. Ann Thorac Surg 1998; 66(5): 1751-4. 12. Eisenberg E, Pultorak Y, Pud D, Bar-El Y. Prevalence and characteristics of post coronary artery bypass graft surgery pain (PCP). Pain 2001; 92(1-2): 11-7. 13. Light RW, Rogers JT, Moyers JP, Lee YC, Rodriguez RM, Alford WC, Jr., et al. Prevalence and clinical course of pleural effusions at 30 days after coronary artery and cardiac surgery. Am J Respir Crit Care Med 2002; 166(12 Pt 1): 1567-71. 14. Younes RN, Gross JL, Aguiar S, Haddad FJ, Deheinzelin D. When to remove a chest tube? A randomized study with subsequent prospective consecutive validation. J Am Coll Surg 2002; 195(5): 658-62. 34
Journal of Isfahan Medical School Original Article Vol 28, No 104, April 2010 Received: 22.7.2009 Accepted: 23.12.2009 Early Chest Tube Removal after Coronary Artery Bypass Graft Surgery Sayed Mohsen Mirmohammad-Sadeghi MD 1, Ali Etesampour MD 2, Zeinab Shariat 3, Mojgan Gharipour MSc 4, Mahmoud Saeidi MD 1, Peyman Nilforoush MD 5, Fatemeh Mirmohamad Sadeghi MD 3 Abstract Background: Using chest tube (CT) after heart surgeries lead to effective drainage of mediastinal and plural area which is essential for preventing pericardial effusion, hemothorax and pneumothorax. The aim of this study was to assess the effects of time of extracting chest tubes after coronary artery bypass graft surgery (CABG) on clinical outcomes of surgery. Methods: 307 patients who were candidate for coronary artery bypass graft surgery were randomly divided into groups one and two and their chest tubes were extracted respectively 24 and 48 hours after surgery with condition of drainage less than 40 cc in 4 hours. Then their pre-surgery data (age, gender, history of diabetes, myocardial infarction, stroke and left ventricular dysfunction, history of aspirin consumption, plavix, heparin and warfarin), during surgery data (time f aortic pump and klamp) and post-surgery data (number of breathes, rate of oxygen saturation, rate of pain, pain killer consumption, creation of plural effusion and pericardial effusion) were analyzed. Findings: The mean age of patients was 59.60 ± 9.24 years and 67.1% of them were male. There was no significant difference between two groups considering diabetes history (40.2% vs. 34.5%), myocardial infarction (45.8% vs. 36%), stroke (2.88% vs. 2%) and aspirin consumption (92.5% vs. 85%). Time of aortic pump and clamp was significantly higher in the second group (P < 0.001 and P = 0.001, respectively). The mean time of remaining of chest tubes was 22.80 ± 3.4 hours and 40.13 ± 3.58 hours in the first and second groups respectively (P < 0.001). The rate of oxygen saturation was higher in the first group; but this difference became significant in the first 24 hours after surgery (P = 0.047) and it was not significant in the second 24 hours after surgery. The mean pain was measured using Visual Analog Scale (VAS) and only until 30 hours after surgery the difference between two groups was significant (2.22 ± 2.49 vs. 2.93 ± 2.57, P = 0.016). In 7, 14 and 30 days follow-ups, no pericardial effusion was reported and the mean of happening of plural effusion was lower in the first group than the second one (3.7% vs. 5.5%, P = 0.59). Conclusion: Early extracting of chest tubes after coronary artery bypass graft surgery when there is no significant drainage can lead to pain reduction and consuming oxygen is an effective measure after surgery toward healing; it does not increase the risk of creation of plural effusion and pericardial effusion. Keywords: Timing, Chest tube removal, Coronary artery bypass graft surgery. 1 Assistant Professor of Cardiac Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. 2 Assistant Professor of Cardiology, Najafabad Branch, Islamic Azad University, Isfahan, Iran. 3 Intern, Najafabad Branch, Islamic Azad University, Isfahan, Iran. 4 Researcher, Isfahan Cardiovascular Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. 5 General Practitioner, Delasa Heart Center, Sina Hospital, Isfahan, Iran. Corresponding Author: Mojgan Gharipour MSc, E-mail: gharipour@crc.mui.ac.ir 35