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Principles of Surgical Drain Management

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Title: Principles of Surgical Drain Management


1
Principles of Surgical Drain Management
  • James H. Paxton, MD MBA
  • Ilan Rubinfeld, MD MBA FACS

2
Viewing This Slideshow
  • At the end of each section, clicking the Back to
    Menu Logo will return you to the Overview slide.
    Click on any title in the Overview slide and it
    will move you directly to that section.
  • Critical Educational Points are highlighted in
    green throughout this presentation

3
Overview
  • Indications for Surgical Drains
  • Types of Surgical Drains
  • Daily Maintenance
  • Drain Removal
  • Timing
  • Preparation
  • Methods
  • Potential Complications
  • Patient Follow-Up / Summary

4
Drain Indications
  • Drains are used to monitor surgical sites and
    remove accumulated bodily fluids (pus, blood,
    lymph, bile etc) or air from a body cavity,
    wound, or potential space
  • Post-Surgical (e.g., Jackson-Pratt)
  • Emergent Decompression (e.g., chest tube)
  • Definitive Therapy (e.g., percutaneous drainage)
  • Medication Delivery (e.g., lavage, antibiotics)
  • The use of post-operative drains is declining,
    but they are still often indicated

5
Technical Considerations
  • Choice of drain depends upon intended use,
    location, and urgency of need
  • Example Jackson-Pratt Drain
  • Can be used to monitor an anastomosis (check for
    leak), drain a known / anticipated fluid
    collection, or prevent fluid accumulation in a
    post-operative bed
  • Tubing may be round or flat
  • May be attached to bulb suction or wall suction
  • May be cut, but should not be cut on side hole
  • Should be cut sharply at an angle, to distinguish
    from fragmented catheter

6
Categories by Position
  • Superficial
  • Soft tissue abscess or seroma
  • Under skin flaps, or over Alloderm
  • Deep
  • Intraperitoneal (e.g., covering anastomosis)
  • Hollow Organ / Duct (e.g., biliary T-tube)
  • Deep Cavity (e.g., abscess or hematoma)
  • Potential Space (e.g., chest tube)
  • Abnormal Channel (e.g., fistula)

7
Types of Surgical Drains
  • Open System
  • Drains into a dressing or bag open to air
  • e.g., Penrose, Sump, Corrugated Rubber
  • Closed System
  • Drains into sterilized airtight tubing and
    container
  • Involves vacuum-generating device
  • Must release vacuum prior to drain removal
  • Generally less prone to infection

8
Types of Surgical Drains
  • CLOSED SYSTEM
  • Davol
  • Jackson-Pratt
  • RediVac / Exudrain
  • HemoVac / BaroVac
  • Pigtail Drain
  • T-tube Drain
  • Blake Drain
  • OPEN SYSTEM
  • Penrose Drain
  • Sump Drain

9
Anatomy of a Closed System
  • Tubing (PVC / Silicon)
  • Radiopaque May be siliconized for free flow
  • Anti-Reflux Valve
  • Rubber valve
  • Water Seal (e.g., Chest Tube)
  • Drainage Reservoir
  • Suction-Generating Device (e.g., bulb or
    spring-loaded device)
  • Drain Plug (Vacuum Release)

10
Penrose Drain
  • Soft, rubber / silicone tube placed in wound to
    prevent closure and facilitate drainage
  • Open system (drains into dressings)

11
Penrose Drain
  • Usually superficial drain
  • Remove with gentle traction, unidirectional
  • End should appear sharply cut
  • If any portion appears torn or degraded, can use
    X-ray of wound to rule out retained drain portion

12
Davol / Jackson-Pratt
  • Portable, closed drainage system
  • Oval-shaped grenade suction device
  • To establish suction, must pull plug, squeeze
    bulb, then replace plug
  • Bulb should initially be concave
  • Suction (100 ml) 80 - 170 mmHg
  • Can be flat or round
  • Round may be more dependable due to less
    transition of material

13
Sump Drains
  • Sump drains contain a large central lumen (for
    drainage), with one or more high-flow sump lumens
    (for irrigation)

14
Suction Drain Removal
  • Release suction prior to removal
  • Remove with gentle traction, unidirectional
  • Tip should appear to have been sharply cut
  • If any portion appears torn or degraded, further
    investigation is warranted to rule out fracture
  • More likely to tear at regions of
    weakness (e.g., side holes)
  • Never cut drainage catheters through
    side holes, as this is more easily
    mistaken for catheter fracture

15
Pigtail Drain
  • Placed percutaneously, rarely cut
  • Tension on central wire causes pigtail form
    (released when wire is broken)
  • Small-caliber drains, with 4-5 holes at end

16
Pigtail Drain - Removal
  • Be sure to unscrew cap and break central wire
    (releasing pigtail) prior to catheter removal
  • Examine end of catheter
  • Should not be cut or torn
  • If in doubt, obtain x-ray of
    area (or CT Scan) to rule out
    retained drain fragment

17
T-Tube Drain
  • Placed for biliary drainage (open vs. lap)
  • Straight when inserted, T-portion released once
    placed in Common Bile Duct (CBD)
  • T-piece is secured in the biliary tree and
    external portion is sutured to the skin
  • Require cholangiogram prior to removal to clear
    biliary tree and confirm duct patency
  • Not generally removed at bedside

18
T-Tube Drain
19
T-Tube Drain Removal
  • Usually clamped 24 hrs before removal
  • Balloon dilatation (in selected units) may be
    performed prior to removal, to separate from
    fibrous sheath
  • Complications of T-tube Removal
  • Bile leak (1-19)
  • Peritonitis
  • Failure to remove with manual traction (lt1)
  • Catheter fracture (breakage)

20
Blake Drain
  • White, radiopaque silicone or Teflon drain with
    four 2-mm channels along the sides, surrounding a
    solid core center
  • Drains fluid by capillary action
  • Does not have side holes, therefore less risk of
    catheter fracture at weak points
  • Apt to clog where the channels converge near the
    tip, known as the choke point

21
Blake Drain
22
Splittable Drain Systems
  • Produced by Jackson-Pratt and other leading
    manufacturers
  • Increased potential for retained drain segments

23
Daily Maintenance
  • Surgical drains should be inspected daily
  • Daily progress notes should document
  • Type of drain (e.g., JP, Penrose etc)
  • Amount of drain output (in milliliters)
  • Quality of drain output (color, consistency etc)
  • Drain problems (e.g., loss of suction, torn
    anchoring suture, drain dislodgement etc)
  • Appearance of wound (e.g., erythema, discharge or
    drainage, maceration etc)

24
Daily Maintenance
  • Drains should be kept clean and dry
  • To prevent stagnation, with associated clogging
    or reflux wound contamination, good flow should
    be promoted by
  • Removing visible clots or tube obstructions, with
    gentle massage or stripping as needed
  • Maintaining adequate suction at all times (e.g.,
    keeping suction bulb compressed)
  • Excess tubing should be taped / secured to the
    patient or patients dressings

25
Drain Stripping
  • Causes a transient elevation in intraluminal
    pressure (20 - 95 mmHg)
  • This elevation in pressure can be dangerous,
    especially with mediastinal chest tubes (risk of
    pneumothorax)
  • Stripping does not significantly increase amount
    of drainage obtained from tubing
  • Gentle massage of clotted areas preferred
  • Fibrinolytics (e.g., urokinase) may be used

26
Daily Maintenance
  • Drainage bulbs (collection reservoirs) should be
    emptied on a regularly scheduled basis (e.g.,
    every shift)
  • When emptying drainage bulb, take care to avoid
    introducing bacteria or foreign materials to the
    closed drainage system (risk infection)
  • Never re-advance a drain that has become
    dislodged (risk infection)

27
Timing of Drain Removal
  • Drains are removed when they are no longer
    needed! (e.g., output lt 50 ml / day for JP drain)
  • Extended duration of drainage may be indicated in
    some patients, up to several weeks!
  • General Guidelines
  • Peri-Op Hematoma / Bleeding 24-48 hrs
  • Serous Collections 3-5 days
  • Infection Prevention 1-5 days
  • Intestinal Anastomosis 5-7 days
  • T-Tube Removal 6-10 days

28
Preparation for Drain Removal
  • Know your drain! (type, placement, length)
  • Review operative notes, talk to surgeon etc
  • Inspect drain externally, look for visible breaks
  • Examine radiographic evidence (x-rays, CT)
  • Know your patient!
  • Examine wound, look for evidence of infection,
    fluid collections / drainage
  • Is it time for the drain to come out?
  • Occlusion? Medically-indicated?

29
Preparation for Drain Removal
  • Gather your tools!
  • Sterile scissors, Skin sterilizing Agent (e.g.,
    DuraPrep)
  • Gloves, Sterile Gauze, Tape
  • Petrolatum Gauze (if indicated)
  • Pick your position!
  • Make patient comfortable (supine / in bed)
  • Clear obstacles to removal (dressings etc)
  • Avoid making a mess keep the nurses happy!
  • Discuss plans for removal with patient and nurse
  • Pain medication is rarely needed

30
Steps in Drain Removal
  • Before attempting drain removal, be sure to
    review the patients operative note
  • Pay particular attention to the number of drains,
    type of drain, location of drain, and indications
    for drain
  • If unsure, ask the surgeon!
  • Inspect the external portion of the drain system
    for breaks or damage
  • Inspect the wound for evidence of infection

31
Steps in Drain Removal
  • Remove all dressings covering insertion site, and
    examine wound / patient for signs of infection

32
Steps in Drain Removal
  • Remove items securing drain in place (e.g.,
    suture, staples, tape), and release suction

33
Steps in Drain Removal
  • Apply unidirectional traction on the catheter,
    while applying counter-traction to patient

34
Steps in Drain Removal
  • Examine tip of drainage catheter for
    irregularities or other evidence of breakage

35
Steps in Drain Removal
  • Cover wound with secure, sterile dressings
  • Always perform serial exams of the insertion site

36
Anesthesia for Drain Removal
  • General anesthesia is seldom indicated
  • I.V. pain medication is required in some
    instances depending on drain depth and location
  • Local anesthesia (e.g., 10-ml 1 Lidocaine) may
    be helpful
  • Pain is due to pressure on nerve fibers in skin
    and underlying innervated structures
  • Always sterilize skin prior to needle puncture to
    reduce risk of infection

37
Complications of Drain Placement
  • Immediate Complications
  • Pain, Bleeding, Perforation or injury to adjacent
    structures
  • Early Complications
  • Occlusion, Leakage around drain, Displacement,
    Infection
  • Late Complications
  • Pressure / Suction necrosis of bowel or blood
    vessels
  • Fistula formation

38
Complications of Drain Removal
  • Pain
  • Drainage from insertion site
  • Infection (e.g., cellulitis, abscess)
  • Fluid collections (e.g., seroma, hematoma)
  • Injury to adjacent structures
  • Retained or fragmented catheter

39
Managing Retained Drains
  • Inform patient and team of the event
  • Confirm device retention with appropriate
    radiographic tests (e.g., x-ray, CT scan)
  • Antibiotics may be needed to prevent infection
    while removal is planned
  • Do not discard portion of device removed
  • Needed for FDA reporting
  • Discuss event with risk management team

40
Patient Follow-Up
  • Serial Exams
  • Examine wound for evidence of infection
  • Examine patient for tachycardia, fever, systemic
    signs of infection
  • Monitor Labs
  • Unexplained leukocytosis / leukopenia
  • Antibiotics used only if signs of infection
  • Monitor pain medication usage

41
Patient Follow-Up
  • Educate patients on signs of infection, with
    instructions to return if they experience
  • Persistent fever gt 100.5 F
  • Sweats, chills, nausea, vomiting, diarrhea
  • Redness, foul-smelling drainage from wound
  • Marked or sudden increase in pain at site
  • Foreign body in wound
  • Let patient know it is normal to have some
    serosanguinous drainage from the wound

42
Summary
  • Drains should be removed by the person who placed
    them or someone familiar with the patients
    operation (i.e., who has read the operative note)
  • Know your patient!
  • Is the insertion site infected? Leaking?
  • Why was the drain placed initially?
  • Is it time to remove it?
  • Know your drain!
  • How many drains are there?
  • What should the tip look like?
  • How long should the drain catheter be?
  • Do I need to disconnect or deflate anything?

43
Summary
  • If indicated, drains should be cut sharply and
    not cut through a side hole
  • Know your complications!
  • Serial examinations are important
  • Identify complications early
  • If you believe that the drainage catheter may
    have fractured, advise your team (senior
    resident, attending) first, and plan your
    investigation (x-ray, CT scan etc) together
  • Talk to your patient (and your team)!
  • Communication is the key to identifying and
    preventing problems with drain removal

44
Acknowledgements
  • Special thanks to the following individuals for
    their assistance in the preparation of this
    educational slideshow
  • Deb Flowers, PA-C
  • Barbara Joyce, PhD
  • Beverly Mihalko, PhD
  • Vinod Narra, MD
  • Karen Ruwoldt, ACSW
  • Ranjodh Singh, MD
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