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J Thorac Cardiovasc Surg 2007;133:1124-1125
© 2007 The American Association for Thoracic Surgery
Letter to the Editor |
a Department of Cardiac Surgery, Northern General Hospital, Sheffield, United Kingdom
b Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
We thank Dr Mair and colleagues for their interest in our study1
and for their comments to which we would like to reply.
First, we agree that homogenous patient groups avoid confounding variables; the influence of complex valve procedures is one that was mentioned. However, we do not agree that it was the heterogeneity of the patient groups that prevented us from demonstrating an advantage of the Blake system (Ethicon Inc, Somerville, NJ). Our study was powered on the statistical basis of testing noninferiority, which allows statistical comparison with a predefined level of difference between groups. Had the study hypothesis been that Blake drains were superior to Portex drains (Portex, Inc, Keene, NH), the power calculation of the study would have been entirely different and the patient number much higher. This would have effectively made the study impossible to perform because of the logistic difficulty of arranging postoperative echocardiography in a defined time period after drain removal.
Second, we agree that Akowuah and colleagues2 clearly demonstrated less pain associated with Blake drains when compared with Portex drains. In fact, the differences between the groups were dramatic; thus, their conclusions about the benefit of Blake drains on postoperative pain were valid even with the small patient numbers. Before initiating our study we performed an assessment of pain scores between the 2 drain systems in patients with patient-controlled analgesia postoperatively to avoid the bias of unequal analgesic regimens. By using a 0 to 100 visual analogue pain score, we documented a similar baseline in 20 patients (21 ± 25 Blake vs 34 ± 26 Portex, P = .28) but a lower drain removal score (40 ± 21 Blake vs 69 ± 21 Portex, P = .006) in favor of Blake drains. We believed the benefit of Blake drains in terms of pain reduction to be undoubted and performed our study because it could be argued that Akowuah and colleagues’ conclusions of equivalence of drainage efficacy were based on an underpowered sample.
Finally, we apologize if we misquoted Mair and colleagues’ correspondence by summarizing "the only way to reduce patient discomfort is to use smaller and softer drains." The exact quote in relation to Barnard and colleagues’ article3 was "the authors focus on analgesia for chest drain removal. But in our opinion it is more important to use modern drainage techniques for pain reduction while removing drains after thoracic and cardiac surgery." In this aspect we agree with Mair and colleagues that modern drainage techniques are most important for pain reduction after cardiothoracic surgery. We are pleased that our randomized control trial data confirm their clinical observations that Blake drains are as effective as conventional drains, and we also advocate their use.
References
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