Timing for Removal of Chest Tubes in Adult Cardiac Surgery

Rationale: Evidence regarding the timing of chest tube removal after cardiac surgery is sparse. The timing of chest tubes removal constitutes a balancing act between risk of retained blood syndrome, infection, patient discomfort and opioid-related side effects. Several studies have shown that chest tubes can safely be removed on the first postoperative day compared to later. A single retrospective study raised concern as chest tube removal on the day of surgery was associated with an increased requirement of drainage of pleural effusions. Primary Objective: To compare the impact of two standard chest tube removal protocols following open-heart surgery on the incidence of pleural and/or pericardial effusion requiring invasive drainage Secondary Objectives To evaluate the impact of chest tube removal on the day of surgery (DAY0) compared to the first postoperative day (DAY1) regarding: Comsumption of analgetic drugs Early postoperative pain Incidence of infection Early postoperative respiratory function Study design: Single-center, open, parallel-group, prospective, cluster-randomized controlled trial Alternate assignment of chest tube removal according to Day 0 versus Day 1 protocol based upon the month of surgery (even versus odd months). Study population: 1300 consecutive patients undergoing elective open heart surgery in full or lower hemisternotomy with or without cardiopulmonary bypass including coronary artery bypass grafting, valve surgery, simple aortic surgery or combinations.

Chest tubes maybe removed ten hours after arrival at the intensive care provided standardized removal criteria are fulfilled: blood loss through chest tubes less than 200 ml during the last four hours no air leak the patient extubated and mobilized It remains at the discretion of the attending cardiac surgeon to postpone chest tube removal in cases of increased bleeding risk, due to circumstances which develop during the perioperative period

Chest tubes are removed in the early morning of the first postoperative day, provided standardized removal criteria are fulfilled: blood loss through chest tubes less than 200 ml during the last four hours no air leak the patient extubated and mobilized It remains at the discretion of both the attending surgeon and anestesiologist to remove chest tubes prematurely in cases of drain-induced, severe analgetic resistant, intractable pain resistant to analgetic treatment.

Daily dose of NSAIDs standardized by using the manufacturers' recommended minimum daily maintenance doses for rheumatoid arthritis as 1 dose unit

Number of: Superficial wound infection (sternal or saphenous vein harvest site) Deep wound infection (sternal or saphenous vein harvest site) Pneumonia Urinary tract infection Antibiotic treatment for fever of unknown origin.

Classified according to the Acute Kidney Injury Network (AKIN) classification: Stage 1: Creatinine × 1.5 - 2.0 from baseline Stage 2: Creatinine × 2.0-3.0 (i.e. doubled or tripled creatinine) Stage 3: Creatinine > 3.0 x baseline level OR initiation of renal replacement therapy

Inclusion Criteria: All consecutive patients undergoing elective open heart surgery in full or lower hemisternotomy with or without cardiopulmonary bypass including coronary artery bypass grafting, valve surgery, simple aortic surgery or combinations. Exclusion Criteria: Cardiac procedures deemed not eligible to chest tube removal on the day of surgery due to increased bleeding risk due to: Procedures in hypothermic circulatory arrest Previous cardiac surgery Procedures performed through upper hemisternotomy Emergent treatment required (< 24 hours) Non-aspirin antiplatelet drugs stopped < 5 days preoperatively (Clopidogrel, Prasugrel, Ticagrelor, Ticlopidine) Current use of vitamin K antagonists or new oral non-vitamin K anticoagulants Platelet count > 450 or <100 x 109/l prior to surgery

Individual-level deidentified patient data that support the findings of this study, and statistical analysis plan are available upon reasonable request.

Data sharing with other researchers requires a methodologically sound proposal (detailed protocol for the proposed study, information about the funding and resources) and approval by the Danish Data Protection Agency.

Andreasen JJ, Sorensen GV, Abrahamsen ER, Hansen-Nord E, Bundgaard K, Bendtsen MD, Troelsen P. Early chest tube removal following cardiac surgery is associated with pleural and/or pericardial effusions requiring invasive treatment. Eur J Cardiothorac Surg. 2016 Jan;49(1):288-92. doi: 10.1093/ejcts/ezv005. Epub 2015 Feb 7.