Surgical Drains

surgical drains

1. Surgical Drains Dr. Shruti Devendra

2. Outline Introduction Ideal drain Classification Indications Types Assessment Removal Complications conclusion

3. Introduction Drains are the devices that acts as a channel to drain established or potential collection of blood, pus, body fluids or air. Drains are available in various types and different sizes. Drains are often inserted after surgery to drain body fluids that may accumulate and may become focus of infection. They are hooked up wall suction, a portable suction device, or they may be left to drain by gravity depending on the location and need. Recording of the quantity of drainage as well as the content is vital to ensure proper healing. Depending on the amount of drainage it may be kept in place from few days to weeks.

4. Ideal drain Firm, not too rigid It should not be too soft as it may twist or kink or become blocked Smooth It should be resistant to decomposition and disintegration Wide and patent enough to prevent easy blockage It should be non electrolytic, non carcinogenic, and non thrombogenic when used in vascular surgery.

5. Classification Open or closed Active or passive

6. Open and Closed drains Open drain: Include corrugated rubber or plastic sheets Drain fluid collects in gauze pad or stoma bag They increase the risk of infection Example, penrose drain, corrugated drain Closed Drain Consists of tubes draining into a bag or bottle They include chest and abdomen drains The risk of infection is low Example, abdominal drain kit (ADK) drain Corrugated drain Penrose drain ADK drain

7. Active and Passive drain Active drain Maintained under suction They can be under low or high pressure Closed e.g., Jackson-Pratt , hemovac drain Open e.g., sump drain Low risk of infection, can be placed anywhere Disadvantage is clogging and tissue injury due to negative pressure Passive drain They have no suction Drains by means of pressure differentials, overflow, and gravity between body cavities and the exterior Closed e.g., NFT, T-Tube , foleys catheter Open e.g., Penrose drain, corrugated drain Low risk of infection, eliminated dead space. Disadvantage is gravity dependent and easily clogged

8. Jackson-Pratt Drain

9. Indications Therapeutic Diagnostic Prophylactic Monitoring Palliative

10. Therapeutic Tension pneumothorax Pleural fluid Abscess cavity Seroma Acute urinary retention Acute supportive arthritis Infected cyst

11. Diagnostic T-tube cholangiogram for retained gall stones in common bile duct Biliary fistula

12. Prophylactic Post thyroidectomy Thoracotomy Splenectomy Pancreatectomy Esophageal resection Cardiothoracic procedures

13. Monitoring and Palliative Monitoring GI bleeding Urethral catheterization Palliative Advanced carcinoma esophagus hydrocephalus

14. Types of drain Examples of different types of drain: Jackson-Pratt drain Hemovac drain Pigtail drain Penrose drain Doval drain T-tube Chest tube Nasogastric tube Urinary catheter

15. Jackson-Pratt drain The JP drain is the bulb shaped device connected to a tube. One end of the tube is inside the body and the other end comes out through the small cut in the skin with which the bulb is connected. This bulb is squeezed and connected to the tube and with negative pressure body fluid is drained. Commonly used in abdominal, breast, and thoracic surgery.

16. Hemovac drain One end of the tube with multiple holes goes into the body and the other end is connected to the hemovac bag which is squeezed before connecting the tube.

17. Pigtail drain Pigtail drains are inserted under strict radiological guidance to ensure correct positioning. The pigtail drain has a locking tip which roles in a pigtail shape. Pigtail drain is commonly used for drainage of liver abscess, as a nephrostomy tube.

18. Penrose drain A penrose drain is soft and flexible. This drain doesn’t have a collection devise. It empties into absorptive dressing material, it promotes drainage passively. With the drainage moving from the area of greater pressure in the wound or surgical site to the area of less pressure.

19. Doval drain This suction device has a rubber bulb on top of the drain that acts as a pump. To inflate the balloon in the drainage bottle rubber bulb is squeezed repeatedly in a pumping motion until the balloon in the drainage bottle is inflated. Then quickly the plug in the drain is replaced before the balloon deflates. The inflated balloon in the bottle creates suction.

20. T-tube T-tube as the name suggests has a stem which connects to a bag and a cross head which goes into the bile duct. It is used as a temporary post-operative drainage of common bile duct. Sometimes used in ureteric problems too.

21. Chest tube (closed drain) Used to drain haemothorax, pneumothorax, pleural effusion, chylothorax, and empyema Size of chest tube Adult male 28-32 Fr Adult female 28 Fr Child 18 Fr New born 12-14 Fr Underwater seal bag

22. Nasogastric tube A tube passes form nostril to stomach Indications Aspiration of gastric juices Lavage: in case of poisoning or drug overdose Feeding Complications Epistaxis Aspiration Erosion in the nasal cavity and nasopharynx For adults 16-18 Fr

23. Urinary catheters Indications Urinary retention Intra and post operative period Incontinence

24. Drain assessment Assess drain insertion site for signs of leakage, redness or signs of ooze Assess the patency of the drain kinks, knots or clogging Monitor the patients signs of sepsis Ensure the suction is maintained in negative pressure drains Drainage documented every 4 hourly and if high output then more frequently Drain should be removed as soon as practicable, the longer the drain remains in situ, higher the risk of infection and granulation tissue formation at the drain site which will increase pain and trauma upon removal

25. Drain removal Once the drainage has stopped or output less than 25 ml/day or when the drain has stopped serving the desired function. In case reactionary body fluid suspected in the drain then intermittent clamping trial is given to see if the daily output has reduced before removing the drain Drain can be shortened by 2 cm per day allowing the site to heal gradually Before the drain is pulled patient is asked to take a deep breath. Once the patient inhales drain is withdrawn steadily and swiftly Once the drain is removed, sterile dry dressing is placed at the site of drain minimum for 24 hours. If the drain site shows discharge beyond 24 hours this means new drain need to be placed

26. Complications Immediate Pain Irritation Bleeding perforation Early Occlusion Leaking around drain Displacement Infection Loss of fluid electrolytes and protein Late Pressure/suction necrosis Fistula Scar hernia Complications during removal Pain Infection (cellulitis/abscess) Injury to adjacent structures Retained or fragmentation of tube

27. Conclusion The use of drains in surgical practice has been contentious over the years The essential questions a surgeon needs to answer when deciding on the value of surgical drain are What purpose would drain serve if placed? What type of drain should be used? How long should the drain be left in place? Once these questions are carefully and adequately answered each time a drain is used, the effectiveness and advantage can be maximized with minimal problems.

28. Thank you!