Khan Tanveer, Chawla Girish, Daniel Romany, Swamy Mallikarjuna, Dimitri Wade R
Department of Cardiothoracic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Warwickshire, UK.
Eur J Cardiothorac Surg. 2008 Sep;34(3):542-4. doi: 10.1016/j.ejcts.2008.05.002. Epub 2008 Jun 9.
Mediastinal and pleural drains are routinely employed following open-heart surgery to prevent accumulation of blood and fluids in the mediastinum or the pleural cavities. Chest radiographs are obtained after removal of these drains to search for a pneumothorax. We hypothesised that clinical signs and symptoms are sensitive indicators of the presence of significant pneumothorax and routine use of radiographs in these patients is unnecessary.
A prospective study of 151 consecutive patients undergoing various cardiac surgical procedures over a 10-week period was undertaken. Chest X-rays were performed in all patients within 4h of drain removal. Patients were clinically monitored for development of any respiratory difficulties and the X-rays were evaluated for presence of a pneumothorax or any other abnormality necessitating intervention. The cost of a portable chest X-ray was calculated by taking into consideration the radiographer's time and the cost of an X-ray film.
There were 113 males and 38 females with a mean age of 67.5 years. Fourteen patients (9%) had obstructive airway disease. The left and right pleurae were opened in 62% and 11% of patients respectively and a chest drain was inserted in all of them intraoperatively. Three patients (2%) developed pneumothorax following drain removal. Two of these patients had clinical signs and symptoms, which would have warranted a chest X-ray. One patient had a moderate pneumothorax but was not clinically compromised. Two patients needed chest drain reinsertion that was subsequently removed after 3 and 4 days. The third patient was monitored clinically and the pneumothorax resolved spontaneously on subsequent chest X-ray. In the remaining 148 patients, postdrain removal chest X-ray did not provide any additional information to alter the management. The cost saving of omitting an additional chest X-ray was calculated to be about pound10,000 per year.
Incidence of pneumothorax following mediastinal drain removal is very low. Clinical signs and symptoms almost always identify those few patients requiring intervention and the decision to obtain an X-ray could be based on clinical judgement alone. In addition, this approach may result in cost savings without compromising patient safety.
心脏直视手术后常规使用纵隔引流管和胸腔引流管，以防止血液和液体在纵隔或胸腔内积聚。拔除这些引流管后进行胸部X线检查以寻找气胸。我们假设临床体征和症状是大量气胸存在的敏感指标，在这些患者中常规使用X线检查是不必要的。
对连续151例在10周内接受各种心脏手术的患者进行前瞻性研究。所有患者在拔除引流管后4小时内进行胸部X线检查。对患者进行临床监测，观察是否出现任何呼吸困难，并对X线片进行评估，以确定是否存在气胸或任何其他需要干预的异常情况。通过考虑放射技师的时间和X线胶片的成本来计算便携式胸部X线检查的费用。
患者中男性113例，女性38例，平均年龄67.5岁。14例（9%）患者患有阻塞性气道疾病。分别有62%和11%的患者左侧和右侧胸膜被打开，所有患者术中均插入了胸腔引流管。3例（2%）患者在拔除引流管后发生气胸。其中2例患者有临床体征和症状，本应进行胸部X线检查。1例患者有中度气胸，但临床上无不适。2例患者需要重新插入胸腔引流管，随后在3天和4天后拔除。第3例患者进行临床监测，气胸在随后的胸部X线检查中自行吸收。在其余148例患者中，拔除引流管后的胸部X线检查未提供任何额外信息以改变治疗方案。省略额外胸部X线检查每年可节省约10,000英镑的费用。
拔除纵隔引流管后气胸的发生率非常低。临床体征和症状几乎总能识别出少数需要干预的患者，是否进行X线检查的决定可以仅基于临床判断。此外，这种方法可能在不影响患者安全的情况下节省成本。
