Effectiveness and safety of indomethacin for decreasing chest tube duration after coronary artery bypass graft surgery

Purpose: Early removal of chest tubes in coronary artery bypass graft (CABG) patients is a factor that positively affects length of hospital stay. Indomethacin is sometimes used in one community hospital to reduce chest tube output via reduction in inflammation in an attempt to shorten chest tube duration. Nonsteroidal anti-inflammatory drugs, including indomethacin, are contraindicated in the setting of CABG due to a boxed warning regarding increased risk of cardiovascular thrombotic events. The aim of this study was to determine if the use of indomethacin in CABG patients is safe and effective in shortening the duration of chest tube placement. Methods: This was a retrospective chart review of patients in a 348 bed community hospital receiving indomethacin therapy after CABG surgery. The records of all adult patients receiving CABG surgery between 2010 and 2015 were systematically screened for receipt of at least one dose of indomethacin while chest tubes remained inserted. Charts with admit diagnoses of cardiac arrest or stroke were omitted from review. Identified subjects were individually matched based on demographics, medical history, and concomitant cardiac surgeries. Data collected included patient comorbidities, daily chest tube output, duration of chest tube placement, and concomitant medications. The primary outcome measure was change in time from first dose of indomethacin until removal of chest tubes compared with duration of insertion of chest tubes in control patients. The secondary outcome measure was total duration of chest tube insertion. Safety endpoints included occurrence of thrombotic events, TIMI bleeding in the setting of CABG, or death. Descriptive statistics were utilized. This study was approved by the institutional review board. Results: Sixteen patients received indomethacin and were eligible for inclusion. They were matched 1:1 to 16 patients not receiving indomethacin. Two of the patients in the indomethacin group received heart valve replacement at time of CABG and were able to be matched only on sex and type of valve replaced. The median age was 55 years in the indomethacin group and 56 years in the control group. Twenty-four subjects were male. Indomethacin was associated with a shorter duration of chest tube insertion when comparing time from first dose of indomethacin to chest tube discontinuation with duration of insertion in control. The median decrease in duration of chest tube insertion in the indomethacin group was 14.5 hours. The median total duration of chest tube insertion in indomethacin and control patients was 214.3 and 91.2 hours, respectively. No patients experienced thrombotic events, bleeding, or death during admission. Conclusions: Indomethacin decreased chest tube insertion times, however the clinical impact of this reduction is uncertain. Although it has shown to be safe in this cohort study, more studies are needed to determine if indomethacin has a place in the setting of CABG surgery.