From the Guidelines
Causes and Management of Pleural Effusion Post-CABG
Pleural effusion is a common complication post-Coronary Artery Bypass Grafting (CABG), occurring in approximately 6.6% of patients 1. The causes of pleural effusion post-CABG are multifactorial and can be attributed to various factors, including the surgical technique, comorbidities, and postoperative care.
Causes of Pleural Effusion Post-CABG
The aetiology of pleural effusion post-CABG can be attributed to:
- Surgical technique: Internal mammary artery harvesting with preservation of the pleura has been shown to reduce the rate of pleural effusion development compared to breaching of the pleura 1
- Comorbidities: Patients with underlying conditions, such as heart failure, may be more prone to developing pleural effusions
- Postoperative care: The use of diuretics, such as furosemide, can help reduce fluid accumulation and prevent pleural effusions 1
Management of Pleural Effusion Post-CABG
The management of pleural effusion post-CABG typically involves:
- Thoracentesis: For diagnostic and therapeutic purposes, to drain the pleural fluid and relieve symptoms 1
- Diuretics: Administration of diuretics, such as furosemide (20-40 mg IV) and spironolactone (25-50 mg PO), to reduce fluid accumulation 1
- Chest tube insertion: In cases of large or recurrent effusions, consideration may be given to insertion of a chest tube to drain the pleural fluid
- Colchicine: Use of colchicine (0.5-1.0 mg PO twice daily) to reduce inflammation, with treatment duration typically ranging from 7-14 days 1
- Ultrasound-guided thoracocentesis: Has replaced the more invasive surgical tube thoracostomy as the initial intervention of choice, and is well tolerated by patients 1
Protocolised Pathway for Intervention
A protocolised pathway for intervention, based on clinical and radiological features, can help reduce the length of hospital stay and improve walking distance in patients with pleural effusion post-CABG 1. However, the optimal treatment of postoperative pleural effusion remains unclear, and further studies are needed to determine the best approach.
From the Research
Causes of Pleural Effusion Post-CABG
- Pleural effusions are a common complication of coronary artery bypass grafting (CABG), with studies suggesting that they occur in 65%-89% of cases 2, 3, 4.
- The causes of pleural effusion post-CABG are not fully understood, but may be related to diaphragm dysfunction, internal mammary artery harvesting, postcardiac injury syndrome, and trapped lung 2, 3, 4.
- Modifiable risk factors for pleural effusion post-CABG may include early removal of chest drains, higher outputs, and removal during or close to mechanical ventilation 5.
Management of Pleural Effusion Post-CABG
- The management of pleural effusion post-CABG depends on the cause and course of the effusion, and may include observation, therapeutic thoracentesis, corticosteroids, or decortication 4.
- Diagnostic thoracentesis should be performed for patients with large symptomatic pleural effusions or fever after CABG surgery 4.
- Video-assisted thoracic surgery (VATS) may play a significant role in the management of pleural effusion developing after CABG, particularly for patients with persistent symptomatic effusions 2.
- Intrapleural injection of sclerosing agents, such as talc, may be effective in managing persistent pleural effusions post-CABG 2, 6.
Clinical Features and Outcomes
- Pleural effusions post-CABG can be associated with significant morbidity and resource utilization, including increased length-of-stay, renal impairment, pericardial effusion, and readmission to ICU or hospital 5.
- Patients with pleural effusion post-CABG may experience dyspnea, and may require repeated thoracenteses or other interventions to manage their symptoms 3, 6.
- The clinical course and outcomes of patients with pleural effusion post-CABG can vary widely, depending on the underlying cause and severity of the effusion, as well as the effectiveness of treatment 5, 2, 3, 4, 6.