Guizilini Solange, Bolzan Douglas W, Faresin Sonia M, Ferraz Raquel F, Tavolaro Kelly, Cancio Andrea A, Gomes Walter J
Department of Medicine, Cardiology Discipline, Pirajussara and São Paulo Hospitals, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
J Cardiothorac Surg. 2012 Jan 25;7:11. doi: 10.1186/1749-8090-7-11.
Exacerbation of pulmonary dysfunction has been reported in patients receiving a pleural drain inserted through the intercostal space in comparison to patients with an intact pleura undergoing coronary artery bypass grafting (CABG). Evidence suggests that shifting the site of pleural drain insertion to the subxyphoid position minimizes chest wall trauma and preserves respiratory function in the early postoperative period. The aim of this study was to compare the pulmonary function parameters, clinical outcomes, and pain score between patients undergoing pleurotomy with pleural drain placed in the subxyphoid position and patients with intact pleural cavity after off-pump CABG (OPCAB) using left internal thoracic artery (LITA).
Seventy-one patients were allocated into two groups: I (n = 38 open left pleural cavity and pleural drain inserted in the subxyphoid position); II (n = 33 intact pleural cavity). Pulmonary function tests and clinical parameters were recorded preoperatively and on postoperative days (POD) 1, 3 and 5. Arterial blood gas analysis and shunt fraction were evaluated preoperatively and in POD1. Pain score was assessed on POD1. To monitor pleural effusion and atelectasis chest radiography was performed routinely 1 day before operation and until POD5.
In both groups a significant impairment was found in lung function parameters until on POD5. However, no significant difference in forced vital capacity and forced expiratory volume in 1 second were seen between groups. A significant decrease in partial pressure of arterial oxygen and an increase in shunt fraction values were observed on POD1 in both groups, but no statistical difference was found when the groups were compared. Pleural effusion and atelectasis until on POD5 were similar in both groups. There were no statistical differences in pain score, duration of mechanical ventilation and postoperative hospital stay between groups.
Subxyphoid insertion of pleural drain provides similar effects to preserved pleural integrity in pulmonary function, clinical outcomes, and thoracic pain after OPCAB. Therefore, our results support the hypothesis that once pleural cavities are incidentally or purposely opened during LITA dissection, subxyphoid placement of the pleural drain is recommended.
与接受冠状动脉旁路移植术（CABG）时胸膜完整的患者相比，经肋间间隙插入胸腔引流管的患者已被报道存在肺功能障碍加重的情况。有证据表明，将胸腔引流管插入部位转移至剑突下位置可使胸壁创伤最小化，并在术后早期保留呼吸功能。本研究的目的是比较在非体外循环冠状动脉旁路移植术（OPCAB）中使用左胸廓内动脉（LITA）时，剑突下位置放置胸腔引流管进行胸膜切开术的患者与胸膜腔完整的患者之间的肺功能参数、临床结局和疼痛评分。
71例患者被分为两组：I组（n = 38，打开左胸膜腔并在剑突下位置插入胸腔引流管）；II组（n = 33，胸膜腔完整）。术前以及术后第1、3和5天记录肺功能测试和临床参数。术前和术后第1天评估动脉血气分析和分流分数。在术后第1天评估疼痛评分。为监测胸腔积液和肺不张，在手术前1天常规进行胸部X线检查，直至术后第5天。
两组患者直到术后第5天肺功能参数均有显著损害。然而，两组之间在用力肺活量和1秒用力呼气量方面未见显著差异。两组在术后第1天均观察到动脉血氧分压显著降低和分流分数值增加，但组间比较时未发现统计学差异。两组直到术后第5天的胸腔积液和肺不张情况相似。两组在疼痛评分、机械通气时间和术后住院时间方面无统计学差异。
剑突下插入胸腔引流管在OPCAB后的肺功能、临床结局和胸痛方面与保留胸膜完整性具有相似的效果。因此，我们的结果支持以下假设，即在LITA解剖过程中一旦胸膜腔意外或有意打开，建议将胸腔引流管放置在剑突下位置。
