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Three Part Question

In [patients undergoing CABG with a LIMA graft] does [a Pleural drain] reduce [incidence of Pleural Effusion]?

Clinical Scenario

You are telephoned by your Cardiac Nurse Specialist who has visited a 65 year old gentleman who was discharged 2 days ago after CABG with LIMA grafting. She reports that he is still Short of Breath and Examination reveals Stony dull percussion notes and no Breath sounds on the Left side of the Chest. As you arrange readmisison, you wonder whether if you had inserted a pleural drain intraoperatively you could have avoided this annoying complication.

Search Strategy

Medline 1966-09/02 using the OVID interface.
[exp Pleural effusion OR pleural effusion.mp] AND [exp cardiac surgery OR CABG.mp] LIMIT to human AND English.

Search Outcome

56 papers were found, of which 1 was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Payne et al, 2002, USA	Controls: 345 patients who had standard chest drainage, removed at day 1 Cases: 115 had a supplemental flexible plastic pleural drain left for 3 to 5 days (Blake drain, Ethicon) Inclusion criteria: Non emergency operation including use of LIMA. 46 CABG + valve patients included	Prospective non randomised case-control study	Symptomatic effusion over 6 weeks defined as one that required thoracentesis, tube thoracostomy, or readmission for treatment	11.9% (41 of 345) controls had a symptomatic pleural effusion 3.5% (4 of 115) of the cases had an effusion when a supplemental drain was placed. This difference was significant (F ratio 7.583, p < 0.005)	Non- randomised Decision to use the supplemental drain was surgeon determined as some surgeons always used the drain, others never used the drain Functional outcome measure: symptomatic pleural effusion is open to the interpretation of the clinician No comments regarding any complications from the drains or excess pain scores.

Comment(s)

Only one study has been done on this topic but it shows a significant reduction in the incidence of Pleural Effusion after CABG with LIMA grafting. The incidence of symptomatic Pleural Effusion in the control group of 12% does seem high, and therefore if UK practise sees fewer symptomatic effusions then the reported ability to reduce the incidence to 3.5% would lose its significance. Calculated from the reported figures the Absolute risk reduction is 8.4% so the Number needed to treat is 12 patients per Pleural Effusion avoided.

Clinical Bottom Line

Intercostal drainage reduces the incidence of Pleural Effusion after CABG with LIMA grafting.

References

1. Payne M, Magovern GJ Jr, Benckart DH, et al. Left pleural effusion after coronary artery bypass decreases with a supplemental pleural drain. Annals of Thoracic Surgery 2002;73(1):149-52.