Search

OBJECTIVES The goal of this study was to assess the safety and quality of recovery (QOR) after discharge on postoperative day (POD) 1 following subxiphoid thoracoscopic anatomical lung resection within an advanced Enhanced Recovery After Surgery (ERAS) program. METHODS A retrospective analysis of prospectively collected data was conducted. Characteristics, perioperative and outcome data, compliance with ERAS pathways and a home–transition QOR survey were analysed using a multivariable logistic regression model. RESULTS From January 2020 to January 2022, a total of 201 consecutive patients underwent subxiphoid multiportal thoracoscopic anatomical lung resection, comprising 108 lobectomies and 93 sublobar resections (SLRs) (59 complex SLRs and 34 simple SLRs). Among them, 113 patients (56%) were discharged on POD 1, 49% after a lobectomy, 59% after a simple sublobar resection and 68% after a complex sublobar resection. In the multivariable analysis, age > 74 years and duration of the operation were associated with discharge after POD 1, whereas forced expiratory volume in 1 s and complex SLRs were associated with discharge on POD 1. Chest tube removal was achieved on POD 0 in 58 patients (29%), and 138 patients (69%) were free from a chest tube on POD 1. There were 13% with in-hospital morbidity, 10% with 90-day readmission (7% after POD 1 discharge and 14% in patients discharged after POD 1), and 0.5% with 90-day mortality. Patients discharged on POD 1 showed better compliance with the ERAS pathway with early chest tube removal and opioid-free analgesia. The home–transition QOR survey reported a better experience of returning home after discharge on POD 1 and similar pain scores. CONCLUSIONS Postoperative day 1 discharge can be safely achieved in appropriately selected patients after subxiphoid thoracoscopic anatomical lung resection, with excellent outcomes and high quality of recovery, supported by early chest tube removal as a determinant ERAS pathway. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The aim of this study was to assess the safety of early chest tube removal (CTR) protocol on the 1st postoperative day (POD1) of our Enhanced Recovery After Surgery (ERAS) programme by comparing the risk of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. METHODS All consecutive patients undergoing elective coronary revascularization and/or valve surgery between 2015 and 2021 were assessed in terms of their perioperative management pathways: conventional standard of care (control group) versus standardized systematic perioperative ERAS programme including an early CTR on POD1 (ERAS group). A propensity score matching was applied. The primary end-point was a composite of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. RESULTS A total of 3153 patients were included. Propensity score analysis resulted in 2 groups well-matched pairs of 1026 patients. CTR on POD1 was significantly increased from 29.5% in the control group to 70.3% in the ERAS group (P  < 0.001). The incidence of the primary end-point was 6.4% in the control group and 6.9% in the ERAS group (P  = 0.658). Patients in the ERAS group, as compared with control group, had significant lower incidence of bronchopneumonia (9.0% vs 13.5%; P  = 0.001) and higher incidence of mechanical ventilation ≤6 h (84.6% vs 65.2%; P  < 0.001), length of intensive care unit ≤1 day (61.2% vs 50.8%; P  < 0.001) and hospital ≤6 days (67.3% vs.43.2%; P  < 0.001). CONCLUSIONS CTR on POD1 protocol can be safely incorporated into a standardized systematic ERAS programme, enabling early mobilization, and contributing to the improvement of postoperative outcomes. Clinical trial registration number Ethics committee of the French Society of Thoracic and Cardio-Vascular Surgery (CERC-SFCTCV-2022-09-13_23140) [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES To evaluate the safety and feasibility of removing drainage tubes at larger size of air leak in patients with prolonged air leak after pulmonary surgery. METHODS Ninety-five patients who underwent pulmonary surgery with prolonged air leak in our centre were enrolled in this randomized controlled, single-centre, non-inferiority study. The drainage tube was clamped with a stable size of air leak observed over the last 6 h, which was quantified by gas flow rate using the digital drainage system. The control group (n  = 48) and the study group (n  = 46) had their drainage tube clamped at 0–20 ml/min and 60–80 ml/min, respectively. We continuously monitored clinical symptoms, conducted imaging and laboratory examinations, and decided whether to reopen the drainage tube. RESULTS The reopening rate in the study group was not lower than that in the control group (2.08% vs 6.52%, P  > 0.05). The absolute difference in reopening rate was 4.44% (95% confidence interval –0.038 to 0.126), with an upper limit of 12.6% below the non-inferiority margin (15%). There were significant differences in the length of stay [16.5 (13–24.75) vs 13.5 (12–19.25), P  = 0.017] and the duration of drainage [12 (9.25–18.50) vs 10 (8–12.25), P  = 0.007] between the control and study groups. No notable differences were observed in chest X-ray results 14 days after discharge or in the readmission rate. CONCLUSIONS For patients with prolonged air leak, removing drainage tubes at larger size of air leak demonstrated similar safety compared to smaller size of air leak, and can shorten both length of stay and drainage duration. Clinical trial registration number Name of registry: Gas flow threshold for safe removal of chest drainage in patients with alveolar-pleural fistula prolonged air leak after pulmonary surgery. Registration number: ChiCTR2200067120. URL: https://www.chictr.org.cn/ [ABSTRACT FROM AUTHOR]

Objective: Chest tubes cause pain and morbidity. Methods: This is a quality initiative study and review of patients who underwent robotic pulmonary resection by 1 surgeon (R.J.C.). The goal was to remove chest tubes within 4 to 12 hours after robotic segmentectomy and lobectomy. Primary outcome was removal without the need for reinsertion, thoracentesis, or any morbidity due to early removal of the chest tube. Secondary outcomes were symptomatic pneumothorax, pleural effusion, chylothorax, subcutaneous emphysema, and chest tube reinsertion or thoracentesis within 60 days of surgery. Results: Between January 2018 and December 2022, 590 patients underwent robotic lobectomy or segmentectomy. Chest tubes were removed within 4 to 12 hours postoperatively in 63.5% of patients (375/590). In 2022, this was achieved in 91% after lobectomy (119/128) and 94% after segmentectomy (75/80). There were significantly more chest tubes removed within 4 to 12 hours postoperatively from 2020 to 2022 than pre-2020 (P

To assess the effectiveness of cold therapy for pain and anxiety associated with chest tube removal. A Systematic review and meta-analysis of randomized controlled trials. Articles were searched from Cochrane Library, PubMed, Embase, CINAHL, ProQuest, Airiti Library, China National Knowledge Infrastructure, and the National Digital Library of Theses and Dissertations in Taiwan. Eight electronic databases were searched from inception to August 20, 2022. The Cochrane Risk of Bias 2.0 tool was used to assess the quality of the included studies. Using a random-effects model, we calculated Hedges' g and its associated confidence interval to evaluate the effects of cold therapy. Cochrane's Q test and an I 2 test were used to detect heterogeneity, and moderator and meta-regression analyses were conducted to explore possible sources of heterogeneity. Publication bias was assessed using a funnel plot, Egger's test, and trim-and-fill analysis. We examined 24 trials involving 1,821 patients. Cold therapy significantly reduced pain during and after chest tube removal as well as anxiety after chest tube removal (Hedges' g : −1.28, −1.27, and −1.80, respectively). Additionally, the effect size of cold therapy for reducing anxiety after chest tube removal was significantly and positively associated with that of cold therapy for reducing pain after chest tube removal. Cold therapy can reduce pain and anxiety associated with chest tube removal. [ABSTRACT FROM AUTHOR]

Background: The studies that generally investigate the effectiveness of pharmacological and non-pharmacological methods in reducing chest tube removal related pain are remarkable. However, new studies need to expand the use of virtual reality glasses and evaluate its effectiveness. Aim: This study aims to determine the effect of distraction with virtual reality glasses on pain during chest tube removal in patients undergoing tube thoracostomy. Material and methods: This quasi-experimental study with a pre-test post-test control group design was performed with the participation of 40 patients. The patients in the intervention group (n=20) watched the video with virtual reality glasses throughout procedure. Pain measurements were evaluated before, during, and after chest tube removal. The patients in the control group (n=20) received standard care. Results: In the intervention group, it was revealed that the pre-procedure pain score decreased compared to the pain score obtained during the procedure (p=0.002). After the chest tube removal procedure, a statistically significant decrease was observed in pain score in favor of the intervention group. In the intervention group, the pre-procedure pain score was found to decrease statistically significantly in the measurement at the 10th min of the procedure (p=0.000). The pain score of the intervention group 10 min after the chest tube removal procedure was lower than that of the control group (1.80 vs 2.95 and p=0.028). Conclusion: The virtual reality glasses assisted chest tube removal procedure can help reduce pain. Surgical nurses should benefit from the use of virtual reality glasses for pain control.

Aim and Objectives: To conduct a systematic review and meta‐analysis to evaluate the effects of cold application on pain and anxiety reduction after chest tube removal (CTR). Background: The act of removing the chest tube often causes pain among cardiothoracic surgery patients. Most guidelines regarding CTR do not mention pain management. The effects of cold application on reducing pain and anxiety after CTR are inconsistent. Design: Systematic review and meta‐analysis. Methods: We searched six databases, including Embase, Ovid Medline, Cochrane Library, Scopus, the Index to Taiwan Periodical Literature System and Airiti Library, to identify relevant articles up to the end of February 2021. We limited the language to English and Chinese and the design to randomised controlled trials (RCTs). All studies were reviewed by two independent investigators. The Cochrane Collaboration's tool was used to assess the risk of bias, Review Manager 5.4 was used to conduct the meta‐analysis. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology was used for assessing certainty of evidence (CoE). Results: Ten RCTs with 683 participants were included in the meta‐analysis. The use of cold application could effectively reduce pain and anxiety after CTR. The subgroup showed that a skin temperature drops to 13°C of cold application was significantly more effective for the immediate reduction in pain intensity after CTR compared with control group. The GRADE methodology demonstrated that CoE was very low level. Conclusion: Cold application is a safe and easy‐to‐administer nonpharmacological method with immediate and persistent effects on pain and anxiety relief after CTR. Skin temperature drops to 13°C or lasts 20 min of cold application were more effective for immediate reduction of pain intensity following CTR. Relevance to clinical practice: In addition to pharmacological strategy, cold application could be used as evidence for reducing pain intensity and anxiety level after CTR. [ABSTRACT FROM AUTHOR]

Background: Cold gel pad application and deep relaxation exercise are interventions that can be applied to reduce pain during chest tube removal. Aim: The study was conducted to find out the effect of local cold application and relaxation exercise on pain level during chest tube removal in patients undergoing open heart surgery. Methods: It was conducted an experimental study in 90 patients who underwent heart surgery. Local cold gel pad was applied to the patients in cold application group, rytmic breathing exercise was given to the patients in relaxation group, routine procedures were applied in control group during chest tube removal. The patient's pain levels were measured with VAS before, immediately after and 15 minutes after the procedure. Results: It was determined that the mean VAS scores in the cold application group and relaxation exercise group was significantly lower than the control group. Local coldf gel pad application were not found more effective than relaxation group in reducing procedural pain level. Conclusions: Cold gel pack application and relaxation exercise were found to be effective in reducing pain level in our study. Further studies that examine the effectiveness of cold gel pad and deep breathing exercises on the interventional pain should be performed. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the safety and feasibility of early chest tube removal after anatomic pulmonary resection, regardless of the drainage volume. We conducted a multicenter, randomized, controlled, noninferiority trial. Patients with greater than 300 mL drainage volume during postoperative day 1 were randomly assigned to group A (tube removed on postoperative day 2) and group B (tube retained until drainage volume ≤300 mL/24 hours). The primary end point was the frequency of respiratory-related adverse events (grade 2 or higher based on the Clavien–Dindo classification) within 30 days postoperatively. Between April 2019 and October 2021, 175 patients were assigned to group A (N = 88) or group B (N = 87). One patient in group B who experienced chylothorax was excluded from the study. Respiratory-related adverse events were observed in 10 patients (11.4%) in group A and 12 patients (14.0%) in group B (P =.008). The frequencies of thoracentesis or chest tube reinsertion were not significantly different (8.0% and 9.3% in groups A and B, respectively, P =.752). Additionally, the duration of chest tube placement was significantly shorter in group A than in group B (median, 2 vs 3 days; P <.001). No significant difference between groups A and B was found in postoperative hospital stay (median, 6 vs 7 days, P =.231). Early chest tube removal, regardless of drainage volume, was safe and feasible in patients who underwent anatomic pulmonary resection. [Display omitted] [ABSTRACT FROM AUTHOR]

A recent study evaluated the safety and feasibility of removing drainage tubes at larger sizes of air leaks in patients who underwent pulmonary surgery. The study found that the duration of drainage and length of stay were significantly different between the control and study groups, but the safety of removing drainage tubes at larger air leak sizes was comparable to that at smaller air leak sizes. However, the study had limitations such as a small sample size and short-term focus, and more studies with larger sample sizes and cross-center validation are needed. Additionally, the authors suggest the use of a monitor of lung expansion that can detect the loss of pleural apposition based on electrical impedance readings to automatically set the minimal amount of suction necessary to maintain pleural apposition. [Extracted from the article]

Aim of study: We aimed to investigate whether the difference in pleural pressures (ΔP) is wider among patients who develop a residual pneumothorax after chest tube removal following lung resection surgery. Materials and methods: Ninety-eight patients who underwent lung resection were included in the study over a period of 12 months. The ΔP prior to chest tube removal in patients who developed a residual pneumothorax after chest tube removal was compared with that of patients who did not develop this complication. The receiver operating characteristic (ROC) curve analysis was performed to identify cutoff values of ΔP for the prediction of residual pneumothorax. Logistic regression analysis was used to formulate a prediction model for the occurrence of residual pneumothorax based on ΔP. Results: Thirteen patients who developed a residual pneumothorax were compared with 85 patients without this complication. The ΔP in the residual pneumothorax group was significantly higher (10.8 versus 4.2 cm H2O, p

Abstract Background In patients submitted to major pulmonary resection, the postoperative length of stay is mainly influenced by the duration of air leaks and chest tube removal. The measurement of air leaks largely relies on traditional chest drainage systems which are prone to subjective interpretation. Difficulty in differentiating between active air leaks and bubbles due to a pleural space effect may also lead to tentative drain clamping and prolonged time for chest drain removal. New digital systems allow continuous monitoring of air leaks, identifying subtle leakage that may be not visible during daily patient evaluation. Moreover, an objective assessment of air leaks may lead to a reduced interobserver variability and to an optimized timing for chest tube removal. Methods This study is a prospective randomized, interventional, multicenter trial designed to compare an electronic chest drainage system (Drentech™ Palm Evo) with a traditional system (Drentech™ Compact) in a cohort of patients undergoing pulmonary lobectomy through a standard three-port video-assisted thoracic surgery approach for both benign and malignant disease. The study will enroll 382 patients in three Italian centers. The duration of chest drainage and the length of hospital stay will be evaluated in the two groups. Moreover, the study will evaluate whether the use of a digital chest system compared with a traditional system reduces the interobserver variability. Finally, it will evaluate whether the digital drain system may help in distinguishing an active air leak from a pleural space effect, by the digital assessment of intrapleural differential pressure, and in identifying potential predictors of prolonged air leaks. Discussion To date, few studies have been performed to evaluate the clinical impact of digital drainage systems. The proposed prospective randomized trial will provide new knowledge to this research area by investigating and comparing the difference between digital and traditional chest drain systems. In particular, the objectives of this project are to evaluate the feasibility and usefulness of digital chest drainages and to provide new tools to identify patients at higher risk of developing prolonged air leaks. Trial registration ClinicalTrials.gov, NCT03536130. Retrospectively registered on 24 May 2018.

Purpose: The purpose of this study was to determine if routine chest X-rays (CXRs) performed after chest tube (CT) removal in pediatric patients provide additional benefit for clinical management compared to observation of symptoms alone. Methods: A single-center retrospective study was conducted of inpatients, 18 years or younger, who had a CT managed by the pediatric surgery team between July 2017 and May 2019. The study compared two groups: (1) patients who received a post-pull CXR and (2) those who did not. The primary outcome of the study was the need for intervention after CT removal. Results: 102 patients had 116 CTs and met inclusion criteria; 79 post-pull CXRs were performed; the remaining 37 CT pulls did not have a follow-up CXR. No patients required CT replacement or surgery in the absence of symptoms. Three patients exhibited clinical symptoms that would have prompted intervention regardless of post-pull CXR results. One patient had an intervention guided by post-pull CXR results alone. Meanwhile, another patient had delayed onset of symptoms and intervention. No patients required an intervention in the group that did not have a post-pull CXR. Conclusion: Chest X-ray after CT removal had a very low yield for changing clinical management of asymptomatic patients. Clinical symptoms predict the need for an intervention. [ABSTRACT FROM AUTHOR]

Background / objectives. The main treatment option for the first episode of primary spontaneous pneumothorax is chest tube drainage, however, whether delayed chest tube removal might influence the recurrence is unclear. Methods. A prospective study, which included 50 patients, with an initial episode of primary spontaneous pneumothorax was performed. Patients were randomized into two groups according to the chest tube removal time: 1-day and 5-days after the air-leak has stopped. All patients were followed-up for at least six months. Both groups were compared according to the recurrence rate and possible complications. Results. There were 39 (78%) men and the median age was 27 (23–35) years. Successful management with a chest tube was achieved in 43 (86%) patients, others were operated on because of the continuous air-leak or relapse of the pneumothorax after the chest tube was removed. Significant difference was not found comparing groups by age, gender, side, tobacco smoking, alpha-1-antitrypsin level, rate of prolonged air-leak, necessity of surgery, and the mean follow-up time. There was a significant difference between groups in hospitalization time: 1-day group – 6 (4–12), 5-days group – 8 (7–10) days, p = 0.017. Five (20%) patients from 1-day group and 3 (12%) from 5-days group had a recurrence, however the difference was not significant (p = 0.702). There were no significant differences comparing groups by the recurrence time or complications. Conclusions. The recurrence rate of primary spontaneous pneumothorax was higher if the chest tube was removed earlier, however not significantly. More data and longer follow-up are necessary to confirm these findings.

Background and Aims: In patients undergoing open heart surgery, chest tubes are removed postoperatively when patients are well awake and stable. Pain during chest tube removal can be moderate to severe and can be the worst experience of hospitalization. Various modalities of pain relief during chest tube removal have been tried with variable results. We sought to examine the effect of transcutaneous electrical nerve stimulation (TENS) as an intervention for pain relief during chest tube removal after cardiac surgery. Material and Methods: In a tertiary care center, fifty patients undergoing open heart surgery were randomized into two groups. Group TENS (n = 25) received TENS from 30 min before and continued up to 30 min after chest tube removal. Control Group (n = 25) did not receive TENS. In both the groups, additional analgesic medication was provided on demand, besides the standard analgesic regime which was injection ketorolac 30 mg intramuscularly every 8 h. Patients were studied for pain during chest drain removal and pain related nausea, vomiting, and sense of well-being. Results: Mean visual analog pain score assessed for chest tube removal was significantly less 4.1 ± 1.2 (P < 0.05) in TENS Group as compared to 6.1 ± 0.8 in Control Group. Significantly greater number of patients (n = 14) (P < 0.05) in Control Group demanded additional analgesia as compared to TENS Group (n = 5). Feeling of well-being, improvement in appetite, and sleep was better in TENS Group as compared to Control Group. Conclusion: We conclude that TENS might not replace the conventional analgesics but has definite adjuvant role in decreasing pain scores and improves sense of well-being during chest tube removal after cardiac surgery.

Aim of study: We aimed to investigate whether the difference in pleural pressures (ΔP) is wider among patients who develop a residual pneumothorax after chest tube removal following lung resection surgery. Materials and methods: Ninety-eight patients who underwent lung resection were included in the study over a period of 12 months. The ΔP prior to chest tube removal in patients who developed a residual pneumothorax after chest tube removal was compared with that of patients who did not develop this complication. The receiver operating characteristic (ROC) curve analysis was performed to identify cutoff values of ΔP for the prediction of residual pneumothorax. Logistic regression analysis was used to formulate a prediction model for the occurrence of residual pneumothorax based on ΔP. Results: Thirteen patients who developed a residual pneumothorax were compared with 85 patients without this complication. The ΔP in the residual pneumothorax group was significantly higher (10.8 versus 4.2 cm H2O, p < 0.01). The ΔP in patients who required intervention was also significantly higher (14.8 versus 4.2 cm H2O, p < 0.01). A ΔP cutoff value of 8 cm H2O was predictive of the occurrence of residual pneumothorax (sensitivity 85.6%, specificity 84.6%) and a value of 12 cm H2O was predictive of intervention (sensitivity 84%, specificity 85%). Increasing ΔP was an independent predictor of the occurrence of residual pneumothorax (p = 0.008) on the multivariate logistic regression model. Conclusion: Patients with wide ΔP before chest drain removal may be complicated with residual pneumothorax. [ABSTRACT FROM AUTHOR]

Background: In patients submitted to major pulmonary resection, the postoperative length of stay is mainly influenced by the duration of air leaks and chest tube removal. The measurement of air leaks largely relies on traditional chest drainage systems which are prone to subjective interpretation. Difficulty in differentiating between active air leaks and bubbles due to a pleural space effect may also lead to tentative drain clamping and prolonged time for chest drain removal. New digital systems allow continuous monitoring of air leaks, identifying subtle leakage that may be not visible during daily patient evaluation. Moreover, an objective assessment of air leaks may lead to a reduced interobserver variability and to an optimized timing for chest tube removal.Methods: This study is a prospective randomized, interventional, multicenter trial designed to compare an electronic chest drainage system (Drentech™ Palm Evo) with a traditional system (Drentech™ Compact) in a cohort of patients undergoing pulmonary lobectomy through a standard three-port video-assisted thoracic surgery approach for both benign and malignant disease. The study will enroll 382 patients in three Italian centers. The duration of chest drainage and the length of hospital stay will be evaluated in the two groups. Moreover, the study will evaluate whether the use of a digital chest system compared with a traditional system reduces the interobserver variability. Finally, it will evaluate whether the digital drain system may help in distinguishing an active air leak from a pleural space effect, by the digital assessment of intrapleural differential pressure, and in identifying potential predictors of prolonged air leaks.Discussion: To date, few studies have been performed to evaluate the clinical impact of digital drainage systems. The proposed prospective randomized trial will provide new knowledge to this research area by investigating and comparing the difference between digital and traditional chest drain systems. In particular, the objectives of this project are to evaluate the feasibility and usefulness of digital chest drainages and to provide new tools to identify patients at higher risk of developing prolonged air leaks.Trial Registration: ClinicalTrials.gov, NCT03536130. Retrospectively registered on 24 May 2018. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to analyze the safety and validity of early chest tube removal after bullectomy for primary spontaneous pneumothorax (PSP). Methods: Between January 2005 and July 2018, 123 cases of thoracoscopic surgery for PSP were reviewed. The principle procedure was bullectomy accompanied by mechanical and chemical pleurodesis. Approximately 4 h after surgery, we confirmed patients' sufficient recovery from anesthesia and investigated the presence of air leak in a sitting position. Chest tubes were removed on the same day as the surgery if there was no air leak or bloody drainage observed. Postoperative complications and factors that prevented early chest tube removal were analyzed by comparing the early removal group and the remaining tube group. Results: Chest tubes could be removed on the day of the surgery in 105 cases (85.4%). There were 7 cases (5.7%) in which chest tubes could be removed because air leak was not detected after patients' recovery despite intraoperative detection of minor air leak from the resection stump. No patients required chest tube reinsertion during their hospital stay. The mean length of postoperative hospital stay was 1.1 ± 0.5 days. In a logistic regression analysis, surgical history of ipsilateral PSP was independently and significantly associated with the prevention of early chest tube removal. Conclusions: Chest tube removal on the day of surgery for PSP appears to be safe when air leak examination can be performed after sufficient recovery from anesthesia. [ABSTRACT FROM AUTHOR]

Hepatic hydrothorax (HH) is an infrequent but a well-known complication of portal hypertension. Medical management of this condition often fails, and there are no large randomized-controlled trials establishing the best treatment strategies. HH thus represents a formidable entity in the management of end-stage liver disease, and the only definitive treatment is liver transplantation. Despite documented ominous outcome, tube thoracostomy (TT) is still a widely practiced approach to HH mostly by the unaware primary care physician. This communication reports the occurrence of pleurosubcutaneous fistula as a presenting complication of TT in a patient with HH. TT should thus be avoided at all costs in this subset of patients because it is fraught with multiple complications. This report reinforces the importance of clinical education and awareness of these complications and outcomes of TT in a cirrhotic patient with HH.

Objectives: This study aimed to evaluate the safety and feasibility of early chest tube removal after anatomical pulmonary resection, regardless of the drainage volume., Methods: We conducted a multicenter, randomized, controlled, non-inferiority trial. Patients with a >300 mL drainage volume during postoperative day (POD) 1 were randomly assigned to groups A (tube removed on POD 2) and B (tube retained till drainage volume ≤300 mL/24 h). The primary endpoint was the frequency of respiratory-related adverse events (grade 2 or higher based on the Clavien-Dindo classification) within 30 days postoperatively., Results: Between April 2019 and October 2021, 175 patients were assigned to either group A (N = 88) or B (N = 87). One patient in group B who experienced chylothorax was excluded from the study. Respiratory-related adverse events were observed in 10 (11.4%) and 12 (14.0%) patients in groups A and B, respectively (P = 0.008). The frequencies of thoracentesis and/or chest tube re-insertion were not significantly different (8.0% and 9.3% in groups A and B, respectively, P = 0.752). Additionally, the duration of chest tube placement was significantly shorter in group A than in group B (median, 2 vs. 3 days; P < 0.001). No significant difference between groups A and B was found in postoperative hospital stay (median, 6 vs. 7 days, P = 0.231)., Conclusions: Early chest tube removal, regardless of drainage volume, was safe and feasible in patients who underwent anatomical pulmonary resection., (Copyright © 2023. Published by Elsevier Inc.)

Objective: Chest tubes cause pain and morbidity., Methods: This is a quality initiative study and review of patients who underwent robotic pulmonary resection by 1 surgeon (R.J.C.). The goal was to remove chest tubes within 4 to 12 hours after robotic segmentectomy and lobectomy. Primary outcome was removal without the need for reinsertion, thoracentesis, or any morbidity due to early removal of the chest tube. Secondary outcomes were symptomatic pneumothorax, pleural effusion, chylothorax, subcutaneous emphysema, and chest tube reinsertion or thoracentesis within 60 days of surgery., Results: Between January 2018 and December 2022, 590 patients underwent robotic lobectomy or segmentectomy. Chest tubes were removed within 4 to 12 hours postoperatively in 63.5% of patients (375/590). In 2022, this was achieved in 91% after lobectomy (119/128) and 94% after segmentectomy (75/80). There were significantly more chest tubes removed within 4 to 12 hours postoperatively from 2020 to 2022 than pre-2020 ( P  < .001). Forty patients (6.8%) were discharged home on postoperative day 1 with a chest tube. Sixteen patients (2.7%) had post-chest tube removal increasing pneumothorax and subcutaneous emphysema; none required tube reinsertion. There was no 30-day or 90-day mortality. Twelve patients (2%) had an outpatient thoracentesis for effusion within 60 days. Twenty patients (3.3%) were readmitted, none seemingly related to effusions. Nonsmokers ( P  = .04) and segmentectomy ( P  = .001) were associated with chest tube removal within 4 to 12 hours of surgery., Conclusions: Chest tubes can be safely removed within 4 to 12 hours after robotic segmentectomy and lobectomy. Factors associated with successful early chest tube removal are nonsmoking, segmentectomy, and team members becoming comfortable with the process., Competing Interests: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2023 The Author(s).)

Background and Aims: In patients undergoing open heart surgery, chest tubes are removed postoperatively when patients are well awake and stable. Pain during chest tube removal can be moderate to severe and can be the worst experience of hospitalization. Various modalities of pain relief during chest tube removal have been tried with variable results. We sought to examine the effect of transcutaneous electrical nerve stimulation (TENS) as an intervention for pain relief during chest tube removal after cardiac surgery. Material and Methods: In a tertiary care center, fifty patients undergoing open heart surgery were randomized into two groups. Group TENS (n = 25) received TENS from 30 min before and continued up to 30 min after chest tube removal. Control Group (n = 25) did not receive TENS. In both the groups, additional analgesic medication was provided on demand, besides the standard analgesic regime which was injection ketorolac 30 mg intramuscularly every 8 h. Patients were studied for pain during chest drain removal and pain related nausea, vomiting, and sense of well‑being. Results: Mean visual analog pain score assessed for chest tube removal was significantly less 4.1 ± 1.2 (P < 0.05) in TENS Group as compared to 6.1 ± 0.8 in Control Group. Significantly greater number of patients (n = 14) (P < 0.05) in Control Group demanded additional analgesia as compared to TENS Group (n = 5). Feeling of well‑being, improvement in appetite, and sleep was better in TENS Group as compared to Control Group. Conclusion: We conclude that TENS might not replace the conventional analgesics but has definite adjuvant role in decreasing pain scores and improves sense of well‑being during chest tube removal after cardiac surgery. [ABSTRACT FROM AUTHOR]

Our objective was to determine the clinical value of obtaining a chest radiograph after removal of a chest tube. We conducted a retrospective chart review of pediatric general surgical patients with a chest tube in place after a thoracic procedure over a 3-year time period. Postremoval films were considered to be of value if they led to a change in clinical management. Of 468 patients who had a thoracic procedure, 281 patients had a chest tube and a postremoval film. In 263 patients (93.6%) there was no change in the postremoval film result compared with baseline. Only two patients (0.7%) required an intervention based on symptoms, not based on the postremoval film. Eliminating routine postremoval radiographs after chest tube removal in pediatric patients will lessen radiation exposure and provide cost savings with no adverse impact on outcome. [ABSTRACT FROM AUTHOR]

Background: In this meta-analysis, we aimed to investigate the effect of cold application on chest tube removal-related pain compared to conventional analgesic care., Methods: A systematic review and meta-analysis were conducted (PROSPERO, 2021: CRD42020179867). We searched studies in PubMed, Ovid-LWW, Scopus, Taylor & Francis, Science Direct, EBSCO, Google Scholar, Medline Complete, Cochrane Library and ULAKBIM databases and grey literature for this study. We included the articles published from January 2009 to December 2019. We limited the language to Turkish and English and the design to randomized-controlled trials. All studies were reviewed by two independent researchers. Meta-analysis was performed using the Comprehensive Meta-Analysis version 3.3 software. Heterogeneity was investigated by meta-regression., Results: A total of 2,462 records were identified, of which 16 studies were included in a random model meta-analysis. The cold application was used in combination with a pharmacological agent in six studies and alone in 13 studies. All patients were older than 16 years and they had at least one chest tube. Cold application was found to be effective in relieving pain during chest tube removal (d=-1.265)., Conclusion: The use of a non-pharmacological method such as cold application is helpful to reduce pain or reduce painkiller doses during chest tube removal. Its use is recommended, as it is effective, easy to use, and cost-effective without any side effects., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2023, Turkish Society of Cardiovascular Surgery.)

OBJECTIVES: Different opinions exist as to when chest tube removal should be performed following cardiac surgery. The aim of this study was to compare early chest tube removal with removal of the tubes in the morning day 1 postoperatively. Primary combined end point was the risk of postoperative accumulation of fluid in the pericardial and/or pleural cavities requiring invasive treatment. METHODS: A retrospective observational cohort study was performed among patients undergoing coronary artery bypass grafting (CABG) and/or conventional valve surgery between July 2010 and June 2013. Patients in whom chest tube output was <150 ml around midnight during the last 4 h were included in the study. These patients were divided into two groups: Group 1 had their chest tubes removed around midnight on the day of surgery, whereas Group 2 kept their tubes until next morning. Using Poisson regression, we estimated crude and adjusted relative risks (RRs) for developing postoperative pleural and/or pericardial effusion within 14 days requiring interventional treatment. RESULTS: A total of 1232 patients underwent CABG, conventional valve or combined surgery during the study period. Of these, 782 patients fulfilled the criteria for early chest tube removal, which was performed in 385 of the patients. A total of 76 patients in Group 1 (20%) and 51 patients in Group 2 (13%) developed postoperative pleural and/or pericardial effusions requiring invasive treatment (P = 0.011). A positive association between early chest tube removal and the development of pleural and/or pericardial effusions was seen [crude RR: 1.54 (95% CI: 1.11-2.13); adjusted RR: 1.70 (95% CI: 1.24-2.33)]. The association became stronger investigating pleural effusions alone (adjusted RR = 1.77; 95% CI: 1.27-2.46), whereas the association with pericardial effusions was less clear. CONCLUSIONS: Removal of all chest tubes around midnight on the day of surgery is associated with an increased risk of postoperative pleural and/or pericardial effusions requiring invasive treatment even if chest tube output during the last 4 h is <150 ml compared with removal of the tubes next morning. [ABSTRACT FROM AUTHOR]

Background: Several previous studies have investigated the effectiveness of cold applications for pain associated with chest tube removal (CTR). However, the results of these studies are mutually contradictory. Purpose: The aim of this study was to determine the evidence related to the effectiveness of using a cold application to reduce the pain associated with CTR. Methods: This review focused on studies published before June 2014 that were indexed in the following databases: Cochrane Library, PubMed, MEDLINE, CINAHL, ProQuest, Airiti Library, and National Digital Library of Theses and Dissertations in Taiwan. Keywords that were searched included: chest tube removal, cold application, and pain within a search design based on the PICO (patient, intervention, comparion, outcome) structure. Only randomized controlled trials (RCTs) that evaluated the efficacy of cold application in patients before CTR were included in analysis. Study quality was assessed using the Modified Jadad scale. Results: Five RCTs that enrolled a total of 426 patients were included in the analysis. The mean age of participants ranged from 48.7 (SD = 16.5) to 60.2 (SD = 6.2) years. Ice packs were most widely used and applied to an area approximately 5-15 cm in diameter, with the chest tube entry point at the center. The findings of the effectiveness of the cold application were inconsistent among the studies. The researchers terminated the cold application when patients' skin temperature reached 13°C or after 20 min, which showed that the cold application immediately reduced the pain associated with CTR. It was also observed that the cold application prolonged the duration of time between the CTR and the administration of analgesics. Additionally, two studies in which analgesics were administered to participants 60 min before CTR showed that cold application in combination with analgesics administration reduced patient pain due to the enhancement affects of CTR, which obtained results that were better than analgesics administration alone. Conclusion: The results of this study may be used as a reference for reducing pain associated with CTR in clinical practice. However, further studies with larger sample sizes are required to support these results. [ABSTRACT FROM AUTHOR]

Background: Usually the chest tube removal (CTR) has been described as one of the worst experiences by patients in the intensive care unit. Aim: This study aimed to compare the effects of cold therapy and relaxation on pain of CTR among the patients undergoes coronary artery bypass graft surgery. Materials and Methods: This single-blinded clinical trial was done on 80 post-cardiac surgery patients in the heart hospital of Sari-Iran. The patients were assigned to three randomized groups that included cold therapy, relaxation, and control groups. Data analysis was done by T-test, Chi-square, generalized estimating equations and repeated measures analysis variance tests. Results: The groups had no significant differences in pain intensity before CTR (P = 0.84), but immediately after CTR there was a significant difference between the treatment (cold application and relaxation groups) and control groups (P = 0.001). There was no significant difference between relaxation and cold therapy groups. Conclusion: Regarding the relaxation and cold application methods showed relatively equal effects on reducing the pain owing to CTR. Thus, the use of relaxation because of economics, without side effects, easy to use and effective is recommended by the authors to the practitioners. [ABSTRACT FROM AUTHOR]

OBJECTIVE The aim of this study was to assess the immediate influence of chest tube removal on chest pain and forced expiratory volume in 1 s (FEV1) after pulmonary resection. METHODS Prospective longitudinal investigation on 104 consecutive patients (53 wedge/segmentectomies and 51 lobectomies; 69 muscle and nerve-sparing lateral thoracotomy and 35 video-assisted thoracoscopic surgery (VATS)). Post-operative chest pain was controlled in all patients by a standardized combination of oral and intravenous non-opioid analgesics. All patients had one chest tube (24 French). Static and dynamic (after forced expiratory effort) pain and FEV1 were assessed before and 1 h after the chest tube removal by the same operator. No additional analgesics were administered before or after the chest tube removal. The pain level was assessed by the numeric pain scale [range: 0 (no pain)–10 (excruciating pain)]. FEV1 was assessed by a portable spirometer. Bronchodilators were not used in these patients. Pre- and post-removal measurements were compared by the Wilcoxon signed rank test. RESULTS The average pre-removal static and dynamic pain scores were 2.6 and 4.1, respectively. The static and dynamic pain scores decreased by 42 and 41%, respectively, after the tube removal (P < 0.0001). The average FEV1 before the chest tube removal was 1.5 l or 53% of the predicted value and increased by 13% after the tube removal (P = 0.0004). In total, 56 and 78% of patients reported static and dynamic pain scores improvement and 67% showed an FEV1 improvement after the chest tube removal. Similar results were observed in patients operated on through VATS or thoracotomy. Compared with patients whose chest tube was removed later, those who had their chest tube removed before post operative day 3 (POD3), showed a greater reduction in the static pain score (41 vs. 31%, P = 0.05) and greater improvement in FEV1 (18 vs. 0.01%, P = 0.02). CONCLUSIONS The removal of a chest tube reduces pain and improves ventilatory function, independent of surgical access and particularly in the early post-operative phase. A fast track chest tube removal policy may favour patients' recovery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: Background: Definitive practice guidelines regarding the utility of chest x-ray (CXR) following chest tube removal in trauma patients have not been established. The authors hypothesized that the selective use of CXR following chest tube removal is safe and cost effective. Methods: A retrospective review of chest tube insertions performed at a level I trauma center was conducted. Results: Patients who underwent chest tube removal without subsequent CXR had a lower mean Injury Severity Score and were less likely to have suffered penetrating thoracic injuries. These patients received fewer total CXRs and had shorter durations of chest tube therapy and shorter lengths of stay following tube removal. Subsequent reinterventions were performed more frequently in the CXR group. The annual decrease in hospital charges by foregoing a CXR was $16,280. Conclusions: The selective omission of CXR following chest tube removal in less severely injured, nonventilated patients does not adversely affect outcomes or increase reintervention rates. Avoiding unnecessary routine CXR after chest tube removal could provide a significant reduction in total hospital charges. [Copyright &y& Elsevier]

Background: There is no clear data about the optimum time for chest tube removal after coronary artery bypass surgery. Aim: The aim of this study was to assess the impact of the chest tube removal time following coronary artery bypass grafting surgery on the clinical outcome of the patients. Material and Methods: An analysis of data from 307 patients was performed. The patients were randomized into two groups: in group 1 (N=107) chest tubes were removed within the first 24 hours after surgery, whereas in group 2 (N=200), chest tubes were removed in the second 24 hours after surgery. Demographics, lactate and pH at the beginning, during and after the operation, creatinine, left ventricular ejection fraction, inotropic drugs administration, length of ICU stay, and mortality data were collected. Respiratory rate and pain level was assessed. Results: In these surgeries, the mean± standard deviation for the aortic clamping time was 49.18±17.59 minutes and cardiopulmonary bypass time was 78.39±25.12 minutes. The amount of heparin consumed by the second group was higher (P <0.001) which could be considered as an important factor in increasing the drainage time after the surgery (P =0.047). The pain level evaluated 24 hours post-operation was lower in the first group, and the difference in the pain level between the 2 groups evaluated 30 hours post-operation was significant (P=0.016). The mean time of intensive care unit stay was longer in the second group but it was not statistically significant. 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 doesn't increase the risk of creation of plural effusion and pericardial effusion. [ABSTRACT FROM AUTHOR]

Background: Chest tube causes severe pain during removal because it attaches to the endothelium in the chest cavity., Objectives: This study aimed to determine the effectiveness of cold application with ice pack and gel pad in the control of pain experienced during chest tube removal., Methods: The sample of prospective, parallel three-arm (1:1:1), randomized controlled clinical trial consisted of 180 patients in two experimental groups (ice pack/gel pad) and one control group. The primary outcome was effect of cold application materials on severity of pain during chest removal. Secondary outcomes were duration of cold application and analgesic requirements of the patients., Results: The study found that the cold application using either of the materials reduced the severity of pain and the need for analgesics after the removal of chest tube compared to the control group (p<0.05). But cold application with ice pack allowed the skin to drop to the temperature effective in pain control in a shorter time than gel pad application (p<0.05)., Conclusions: Despite entirely covering the area around the chest tube, the gel pad was more disadvantageous than ice pack in pain control due to the longer duration of cold application., (© 2021 Soydan D et al.)

OBJECTIVES Digitalized chest drainage systems allow for quantification of air leak and measurement of intrapleural pressure. Little is known about the value of intrapleural pressure during the postoperative phase and its role in the recovering process after pulmonary resection. The objective of this investigation was to measure the values of pleural pressure immediately before the removal of chest tube after different types of pulmonary lobectomy. METHODS Prospective observational analysis on 203 consecutive patients submitted to pulmonary lobectomy during a 12-month period at two centres. Multiple measurements were recorded in the last hour before the removal of chest tube and averaged for the analysis. All patients were seated in bed in a 45° up-right position or in a chair, had a single chest tube and were not connected to suction during the evaluation period. Analysis of variance (ANOVA) was used to assess the differences in pleural pressure between different types of lobectomies. RESULTS The average maximum, minimum and differential pressures were −6.1, −19.5 and 13.3 cmH2O, respectively. The average pressures were similar in all types of lobectomies (ANOVA, P = 0.2) and ranged from −11 to −13 cmH2O, with the exception of right upper bilobectomy (−20 cmH2O, all P-values vs. other types of lobectomies <0.05). Similar values were also recorded for maximum pressures (range −4.4 to −8.4 cmH2O) and minimum pressures (−31.6 cmH2O vs. ranged from −15.4 to −20.5 cmH2O, all P-values <0.01). The average pleural pressure was not associated with FEV1 (P = 0.9), DLCO (P = 0.2) or FEV1/FVC ratio (P = 0.6), when tested with linear regression. Similarly, the average pleural pressure was similar in patients with and without COPD (−12.1 vs. −13.0 cmH2O, P = 0.4). The ANOVA test was used to assess differences in pressures between different lobectomies. CONCLUSIONS The so-called water seal status may actually correspond to intrapleural pressures ranging from −13 to −20 cmH2O. Modern electronic chest drainage devices allow a stable control of the intrapleural pressure. Thus, the values found in this study may be used as target pressures for different types of lobectomies, in order to favour lung recovery after surgery. [ABSTRACT FROM AUTHOR]

The process of removal of a chest tube can cause pain and anxiety. Spiritual care can be considered as a component of nursing care, especially in the pain and anxiety relating to such procedures. This study was a randomized clinical trial. Eighty patients completed the study. The findings showed significant differences in anxiety and pain between groups ( p  = 0.001). Spiritual care reduced anxiety and pain caused by chest tube removal in patients (Shia and Sunni Islam) undergoing heart surgery.

Background: Several previous studies have investigated the effectiveness of cold applications for pain associated with chest tube removal (CTR). However, the results of these studies are mutually contradictory., Purpose: The aim of this study was to determine the evidence related to the effectiveness of using a cold application to reduce the pain associated with CTR., Methods: This review focused on studies published before June 2014 that were indexed in the following databases: Cochrane Library, PubMed, MEDLINE, CINAHL, ProQuest, Airiti Library, and National Digital Library of Theses and Dissertations in Taiwan. Keywords that were searched included: chest tube removal, cold application, and pain within a search design based on the PICO (patient, intervention, comparion, outcome) structure. Only randomized controlled trials (RCTs) that evaluated the efficacy of cold application in patients before CTR were included in analysis. Study quality was assessed using the Modified Jadad scale., Results: Five RCTs that enrolled a total of 426 patients were included in the analysis. The mean age of participants ranged from 48.7 (SD = 16.5) to 60.2 (SD = 6.2) years. Ice packs were most widely used and applied to an area approximately 5-15 cm in diameter, with the chest tube entry point at the center. The findings of the effectiveness of the cold application were inconsistent among the studies. The researchers terminated the cold application when patients' skin temperature reached 13°C or after 20 min, which showed that the cold application immediately reduced the pain associated with CTR. It was also observed that the cold application prolonged the duration of time between the CTR and the administration of analgesics. Additionally, two studies in which analgesics were administered to participants 60 min before CTR showed that cold application in combination with analgesics administration reduced patient pain due to the enhancement affects of CTR, which obtained results that were better than analgesics administration alone., Conclusions: The results of this study may be used as a reference for reducing pain associated with CTR in clinical practice. However, further studies with larger sample sizes are required to support these results.

Objectives: Owing to the great absorption capability of the pleura for transudates, the protein content of draining pleural fluid may be considered as a more adequate determinant than its daily draining amount in the decision-making for earlier chest tube removal. In an a priori pilot study, we observed that the initially draining protein-rich exudate converts to a transudate quickly in most patients after lobectomies. Thus, chest tubes draining high-volume but low-protein fluids can safely be removed earlier in the absence of an air leak. This randomized study aims to investigate the validity and clinical applicability of this hypothesis as well as its influence on the timing for chest tube removal and earlier discharge after lobectomy., Methods: Seventy-two consecutive patients undergoing straightforward lobectomy were randomized into two groups. Patients with conditions affecting postoperative drainage and with persisting air leaks beyond the third postoperative day were excluded. Drains were removed if the pleural fluid to blood protein ratio (PrRPl/B) was ≤0.5, regardless of its daily draining amount in the study arm (Group S; n = 38), and patients in the control arm (Group C; n = 34) had their tubes removed if daily drainage was ≤250 ml regardless of its protein content. Patients were discharged home immediately or the following morning after removal of the last drain. All cases were followed up regarding the development of symptomatic pleural effusions and hospital readmissions for a redrainage procedure., Results: Demographic and clinical characteristics as well as the pattern of decrease in PrRPl/B were the same between groups. The mean PrRPl/B was 0.65 and 0.67 (95% CI = 0.60-0.69 and 0.62-0.72) on the first postoperative day, and it remarkably dropped down to 0.39 and 0.33 (95% CI = 0.33-0.45 and 0.27-0.39) on the second day in Groups S and C, respectively, and remained below 0.5 on the third day (repeated-measures of ANOVA design, post hoc 'within-group' comparison of the first postoperative day versus second and third days; P < 0.002). Eleven of 38 (29%) and 16 of 27 (59%) patients' chest tubes were, respectively, removed on the first and second postoperative days in Group S, but only two of 34 (6%) and ten of 32 (31%) patients, respectively, had their chest tubes removed in Group C (two-tailed Fisher's exact test, P = 0.02 and 0.005 for the first and the second postoperative days, respectively). On the third postoperative day, daily drainage remained ≥250 ml in 22 (65%) patients, among whom, 17 (77%) would have their chest tubes removed on the PrRPl/B value in Group C. However, drains could not be removed due to the high protein content of draining fluid despite the acceptable volume of daily drainage in only three (27%) of 11 cases in Group S (McNemar's paired proportions test, P = 0.009). The mean chest tube removal time (2.1 ± 0.9 vs 2.9 ± 1.0 days; P < 0.001) and the median hospital stay [3 days (IQR: 1-3) vs 4 days (IQR: 2-4), P < 0.003] were significantly shorter in Group S. None of the patients required a redrainage procedure due to a persistent and symptomatic pleural effusion., Conclusions: Regardless of the daily drainage, chest tubes can safely be removed earlier than anticipated in most patients after lobectomy if the protein content of the draining fluid is low., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Usually the chest tube removal (CTR) has been described as one of the worst experiences by patients in the intensive care unit., Aim: This study aimed to compare the effects of cold therapy and relaxation on pain of CTR among the patients undergoes coronary artery bypass graft surgery., Materials and Methods: This single-blinded clinical trial was done on 80 post-cardiac surgery patients in the heart hospital of Sari-Iran. The patients were assigned to three randomized groups that included cold therapy, relaxation, and control groups. Data analysis was done by T-test, Chi-square, generalized estimating equations and repeated measures analysis variance tests., Results: The groups had no significant differences in pain intensity before CTR (P = 0.84), but immediately after CTR there was a significant difference between the treatment (cold application and relaxation groups) and control groups (P = 0.001). There was no significant difference between relaxation and cold therapy groups., Conclusion: Regarding the relaxation and cold application methods showed relatively equal effects on reducing the pain owing to CTR. Thus, the use of relaxation because of economics, without side effects, easy to use and effective is recommended by the authors to the practitioners.