Postoperative Chest-Tube Management in Paediatric Cardiac Surgery: A Systematic Review for Nursing Practice

Background/Objectives: Chest tubes are inserted in almost all children undergoing cardiac surgery and managed at the bedside until removal. Management spans the drainage system, tube patency, and the criteria and timing used to judge readiness for removal. This review assessed the effectiveness and safety of these strategies, as well as their implications for nursing practice. Methods: Five databases and two trial registries were searched up to 20 May 2026. Eligible studies compared a chest-tube management intervention with an alternative, usual care, or a pre-intervention baseline. Two reviewers independently undertook selection, extraction, and risk-of-bias assessment (RoB 2, ROBINS-I). Randomised and non-randomised evidence were synthesised separately without pooling; certainty was assessed using GRADE. The review was prospectively registered in PROSPERO (CRD420261397281) and received no external funding. Results: Eight studies including up to 6567 children were included; seven, four of them randomised trials, contributed to the comparative synthesis, and one surveillance cohort was synthesised descriptively. Shorter duration was reported with more frequent assessment of an unchanged removal threshold, a smaller-calibre silicone drain, and protocol-driven removal pathways. A high-vacuum drainage system combined with smaller-calibre chest tubes (12 Ch versus 16 Ch) was associated with fewer residual pleural effusions requiring drainage than a conventional underwater-seal system with larger-calibre tubes (risk ratio 0.23, 95% CI 0.08 to 0.66); however, the independent effects of suction configuration and tube calibre could not be distinguished. Apart from that reduction, post-removal events were uncommon, and available studies did not demonstrate a clear increase or decrease in clinically important complications; however, the remaining safety estimates were imprecise and did not exclude clinically important benefit or harm. Certainty was low or very low for all outcomes. Conclusions: Interventions acting at different points of the management pathway were associated with shorter chest-tube duration, though their mechanisms and magnitudes varied. Structured removal criteria and more frequent assessment are potentially modifiable, but their effects cannot be separated from those of drain and drainage-system characteristics. Safety after removal could not be established in either direction, and complication rates varied with outcome definition and surveillance method. For nursing practice, the findings are consistent with an explicit, documented removal decision reviewed at defined intervals, with defined post-removal observation given the uncertain safety of earlier removal.