Ghani MOA, Foster J, Shannon CN, Bichell DP. Association of chest tube position with phrenic nerve palsy after neonatal and infant cardiac surgery. J Thorac Cardiovas Surg. 2021 May;161(5):1618-1622.e1.
Commentary from Dr. Frederic Jacques (Quebec City, QC, Canada), chief section editor of Congenital Heart Surgery Journal Watch:
Screening Journals to create May 2021’s selection of congenital cardiac surgery papers, I found numerous interesting papers on ultra-specific topics. The reader is encouraged to look at this month’s list of abstracts as it contains insightful papers on the management of single ventricle patients, atrioventricular ventricular septal defect, tetralogy of Fallot, etc. Nevertheless, the topic I decided to feature is far less attractive, but so important: phrenic nerve palsy. This complication is relatively frequent (4%), has a major impact on patient’s clinical outcome, and is quite frustrating for the meticulous surgeons we all expect to be. Direct trauma to the phrenic nerves by both anesthetic and surgical manipulations are well recognized risk factors. Bichell and colleagues (Vanderbilt University, Nashville) postulated that pressure nerve damage could occur by indwelling chest tubes. The authors evaluated the effect of a strategy of avoiding chest tube positioning in proximity to the nerve within the apex of the right apical portion of the right pleural cavity.
This paper is of great interest as diaphragm paralysis may affect all the spectrum of pediatric cardiac surgery. Having diaphragm paralysis may have catastrophic consequences on the management of single ventricle patients on whom stage 1 palliative strategies were recently performed. Secondary increased pulmonary vascular resistance in these patients may lead to instability and may require early diaphragmatic plication. On the other end of the spectrum, there is not much complication as frustrating as having a diaphragm paralysis after simpler surgeon such as isolated ventricular septal defect closure, to give an example. For all type of patients such complications seem avoidable and realizing that factors other than the intraoperative management may impact on diaphragmatic function is important. With the findings of this paper, every surgeon should beware the placement of chest tube within the right apical portion of the chest (and likely the left by extrapolation). Avoiding preventable complications is the goal for all surgeries and placing chest tubes in the apical portions of pleural cavities should likely be considered an error from now on.