Draft:Continuous Postoperative Pericardial Flushing

Continuous Postoperative Pericardial Flushing (CPPF) is a medical technique developed for cardiac surgery with the objective to minimize postoperative complications, such as excessive bleeding and even tamponades. This technique involves continuous irrigation of the pericardial space with a saline solution after surgery starting towards the end of surgery just before sternal closure.

CPPF involves both the irrigation and drainage of the pericardial space post-cardiac surgery.

This approach is in line with emerging research that underscores the importance of efficient chest tube management and patency in reducing postoperative complications and improving patient outcome. .Dr David R Koolbergen, congenital cardio-thoracic surgeon at Amsterdam UMC and LUMC, is considered as the inventor of the CPPF technology. The technology was originally patented by the Amsterdam UMC.

Procedure
The procedure includes:

Irrigation: An inflow drain is inserted into the pericardial space. This drain delivers a continuous flow of a saline solution to the area. This continuous irrigation helps to clear blood, prevent clot formation, and minimize inflammation.

Drainage: Simultaneously, the CPPF procedure facilitates the effective drainage of fluids with chest tubes from the pericardial space. This aspect of the procedure is crucial for removing accumulated blood and clots, thereby reducing the risk of complications like cardiac tamponade.

The combination of these two mechanisms – irrigation and drainage – plays a vital role in enhancing the recovery process and improving patient outcomes following cardiac surgery.

Research
Manshanden et al (2015): This study found CPPF to be safe and feasible. It involved 20 patients, with 95.2% completing the treatment successfully and no complications related to the method. The study observed a significant 30% reduction in blood loss 12 hours post-surgery.

Diephuis et al (2020): This trial included 170 patients, divided into a study group receiving CPPF and a control group receiving standard care. The study found a significant 41% reduction in blood loss after 12 hours in the ICU for the CPPF group. Additionally, instances of cardiac tamponade and reoperations for bleeding were lower in the CPPF group, and patients were less likely to have pleural effusion at discharge.

Diephuis et al (2021): In this study, 169 patients were assigned to either CPPF or standard care. The CPPF group showed a substantial reduction in postoperative blood loss (76%), though the results were somewhat overestimated due to a measurement error. There were no cases of reoperation for non-surgical bleeding or cardiac tamponade in the CPPF group. The study also assessed cost-effectiveness.

Kara et al (2019): This study successfully completed CPPF in 40 patients (95.24%) without any method-related complications. It reported lower blood loss in the CPPF group compared to a non-CPPF group, demonstrating the method's effectiveness and feasibility.

An article, by Lobdell et al, explaining the past, present and future of chest tube management, mentions continuous postoperative pericardial flushing (CPPF) as a technique involving the continuous irrigation of the pericardial space with warm saline solution. This method has been evaluated in small investigations, suggesting its feasibility, safety, and potential efficacy in reducing postoperative blood loss.

A recent article by, Lobdell et al, focusing on leveraging research in chest-drain management, mentions CPPF as a novel technique that is worth addressing in future guidelines. The strategy to reduce retained blood seems promising, but also mentions that the current studies are small

Future directions
Larger trials are anticipated to validate the effectiveness of CPPF on clinically relevant outcomes, such as reducing complications related to bleeding, improving overall patient recovery, and enhancing the effectiveness of postoperative care. These future studies could lead to broader adoption of CPPF in clinical practice if they confirm its benefits and safety profile. Additionally, as more data become available, CPPF could potentially be refined and optimized, further enhancing its effectiveness and applicability to a wider range of cardiac surgeries.