• Muhammad Owais Abdul Ghani, Jarrett Foster, Chevis N Shannon, and David P Bichell.
• Division of Pediatric Cardiac Surgery, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tenn; Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tenn.
• J. Thorac. Cardiovasc. Surg. 2021 May 1; 161 (5): 1618-1622.e1.

BackgroundDiaphragm paralysis (DP) complicates the postoperative course of neonates and infants undergoing cardiac surgery. Events causing DP remain poorly understood, and preventive strategies remain elusive. This retrospective cohort analysis aims to test the hypothesis that chest tubes in contact with the phrenic nerve in the pleural apex may cause pressure palsy.MethodsIn late 2018, the chest tube positioning strategy was changed so as to avoid a putative "danger zone" configuration, defined as (1) the chest tube looping apicomedially at the level of the second right intercostal space, and (2) wedging of chest tube tip against pericardium. A preintervention and postintervention analysis of 531 patients from 2012 to 2019 was performed to evaluate any association of chest tube position or duration in place with DP. Univariable and multivariable analyses were carried out, with significance set a priori at P < .05.ResultsThe preintervention group comprised 488 patients, of whom 32 (6.6%) had RDP. The postintervention group comprised 43 patients, none of whom had DP. Multivariable analysis of the entire cohort revealed chest tube positioning in the danger zone as the only significant association with RDP (odds ratio, 4.22; 95% confidence interval, 1.57-11.33; P < .05).ConclusionsChest tubes that occupy the right superior pleural space are associated with increased risk of DP.Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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