Surgical Tubes used in General Surgery

Surgical Tubes used in General Surgery

1. Hadi Munib Surgical Tubes

2. Introduction Chest Tubes Tracheostomy Endotracheal Tubes Nasogastric and Duodenal Tubes Gastrostomy and jejunostomy Tubes References Outline

3. Surgical drains are used to monitor for: Postoperative leaks or abscesses Collect normal physiologic fluid To minimize dead space. Hospitalists should not manipulate the drains without input from the surgeon who placed them. Introduction

4. Typically, passive drains are open systems Passive drains are made of latex, polypropylene, or silastic rubber. These include Penrose drains, the type most commonly used in veterinary practice. Active drains are closed systems because they rely on negative pressure that is created by the drain. This reservoir prevents saturation of bandage material, decreases the risk for ascending infection, and can limit exposure of hospital staff or other patients to contaminated fluid. Introduction

5. Placed in the pleural space to evacuate air or fluid. They can be as thin as 20 French or as thick as 40 French (for adults). Chest tubes are typically placed between the fourth and fifth intercostal spaces in the anterior axillary or mid-axillary line. Location may vary according to the indication for placement. The tubes can be straight or angled. Indications: Pneumothorax, Hemothorax , or a persistent or large pleural effusion . Pneumothorax and Hemothorax usually require immediate chest tube placement. Also commonly placed at the endo thoracic surgeries, to allow for appropriate re-expansion of the lung tissue. Chest Tubes

6. The tubes are connected to a collecting system with a three-way chamber. The water chamber holds a column of water which prevents air rom being sucked into the pleural space with inhalation. The suction chamber can be attached to continuous wall suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism. The third chamber is the collection chamber for fluid drainage. Chest Tubes

7. A chest x-ray should be obtained after any chest tube insertion to ensure appropriate location. Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on x-ray. Respiratory variation in the fluid in the collecting tube, called “ tidling ,” should also be seen in a correctly placed chest tube, and should be monitored at the bedside to reassure continued appropriate location. If the patient has a pneumothorax, air bubbles will be visible in the water chamber (“air leak”) Often more apparent when the patient coughs. The chest tube should initially be set to continuous suction at –20 mm Hg to evacuate the air. Chest Tubes

8. Once the “air leak” has stopped, the chest tube should be placed on water seal to confirm the pneumothorax is resolved (water seal mimics normal physiology) If the pneumothorax is not resolved  Tube is placed back at continuous suction and a Chest X-Ray is taken If the patient experiences ongoing or worsening pain, or inadequate drainage, a chest computed tomographic (CT) scan may be taken to identify inappropriate positioning or other complications. Chest Tubes

9. If the patient has a pleural effusion, the chest tube can usually be removed when the output is less than 100 to 200 mL per day, and the lung is expanded. The tube should usually be taken to suction and placed on water seal (to rule out pneumothorax) prior to tube removal. Chest Tubes

10. This procedure relieves airway obstruction or protects the airway by fashioning a direct entrance into the trachea through the skin of the neck. Tracheostomy may be carried out as an emergency for acute airway obstruction when the larynx cannot be intubated. The time to do a tracheostomy is when you first think it may be necessary . If time allows, the following should be undertaken: Inspection and palpation of the neck to assess the laryngotracheal anatomy in the individual patient; Indirect or direct laryngoscopy; Assessment of pulmonary function by auscultation. Tracheostomy

11. In patients who have suffered severe head and neck trauma and who may have an unstable cervical spine fracture, cricothyroidotomy may be more suitable.

12. The advantage of an elective surgical procedure is that there is complete airway control at all times, unhurried dissection and careful placement of an appropriate tube. Close cooperation between the surgeon, anaesthetist and scrub nurse is essential, and attention to detail will markedly reduce possible complications and morbidity from the procedure. The patient is positioned with a combination of head extension and placement of an appropriate sandbag under the shoulders. There should be no rotation of the head Tracheostomy

13. A transverse incision may be used in the elective situation. The tracheal isthmus is divided carefully and oversewn and tension sutures placed either side of the tracheal fenestration in children. A Bjork flap may be used in adults Elective Tracheostomy

14. Emergency vs. Elective Tracheostomy Incisions

15. Most modern tracheostomy tubes are made of plastic. Tubes of various sizes with varying curves, angles, cuffs, inner tubes and speaking valves are available. After a newly fashioned tracheostomy is created, a cuffed tube is used initially to protect the airway from secretions or bleeding. This may be changed after 3–4 days to a non-cuffed tube. The pressure within the tube cuff should be carefully monitored and should be low enough so as not to occlude circulation in the mucosal capillaries, which promotes scar tissue formation and subglottic stenosis. When in position, the tube should retained by double tapes threaded through the flanges and passed around the patient’s neck. Tracheostomy Tubes

16. All forms of tracheostomy and cricothyroidotomy bypass the upper airway and have the following advantages: The anatomical dead space is reduced by approximately 50%; The work of breathing is reduced; Alveolar ventilation is increased; The level of sedation needed for patient comfort is decreased and, unlike endotracheal intubation, the patient may be able to talk and eat with a tube in place. Tracheostomy Tubes

17. Several Disadvantages include: Loss of heat and moisture exchange in the upper respiratory tract; Desiccation of tracheal epithelium, loss of ciliated cells and metaplasia; The presence of a foreign body in the trachea stimulates mucous production; where no cilia are present, the mucociliary stream is therefore impeded; The increased mucus is more viscid and thick crusts may form and block the tube; Although many patients with a tracheostomy can feed satisfactorily, there is some splinting of the larynx, which may prevent normal swallowing and lead to aspiration; this aspiration may be silent. Tracheostomy Tubes

18. Nasogastric tubes are often used in the non-operative management of small bowel obstruction or ileus. NGTs should be placed in the most dependent portion of the gastric lumen, and confirmed by chest or abdominal x-ray. NGTs are sump pumps and have a double lumen, which includes an air port to assure flow. The tube may be connected to continuous wall suction or intermittent suction, set to low (<60 mm Hg) to avoid mucosal avulsion Nasogastric and Duodenal Tubes

19. NGT output should decrease during the resolution of obstruction Symptoms of nausea, vomiting, and abdominal distention should concomitantly improve. Persistently high output in a patient with other indicators of bowel function ( eg , flatus) may suggest Post-Pyloric Placement. Nasogastric Tubes

20. Small-bore tubes used when post-pyloric feeding is desired. Small-bore duodenal tubes are placed through the nares. They are very narrow caliber and require a long wire or insertion. The wire should be removed as soon as placement is confirmed by x-ray. Very soft and flexible. The wire used or placement is very stiff, increasing the risk of inadvertent insertion into the airway. In patients who are intubated or who have undergone tracheostomy placement, nasoenteric feeding tubes should be placed under bronchoscopic or uoroscopic guidance to ensure that the tube is properly positioned Duodenal Tubes

21. Gastrostomy tubes are most commonly used for feeding but may also be used or decompression of functional or anatomic gastric outlet obstruction. They are indicated when patients need prolonged enteral access (such as prolonged mechanical ventilation or head and neck pathology that prohibits oral feeding). Rarely used or gastropexy , to tack an atonic or patulous stomach to the abdominal wall or to prevent recurrence of paraesophageal hernias. These tubes can be placed percutaneously by interventional radiologists. Endoscopically by surgeons and gastroenterologists, or via laparoscopy or laparotomy by surgeons [difficult anatomy or who are having laparotomy or another reason] Gastrostomy and Jejunostomy Tubes

22. Due to the stomach’s generous lumen, gastrostomy tubes rarely clog. IF they do get clogged, carbonated liquids, meat tenderizer, or enzymes may help dissolve the obstruction. If a gastrostomy tube is left to drainage, this can result in significant fluid and electrolyte losses; a daily electrolyte panel should be checked and repeated as needed. Gastrostomy Tubes

23. Used exclusively for feeding and are usually placed 10 to 20 cm distal to the ligament of Treitz . These tubes are indicated in patients who require distal feedings, due to gastric dysfunction or following a surgery in which a proximal anastomosis requires time to heal. These tubes are more susceptible to clog and can be more difficult to manage because the lumen of the small bowel is smaller than the stomach. Some prefer not to put pills down the tube to mitigate this risk. Routine flushes (30 mL every 4-6 hours) with water or saline are also helpful in mitigating the risk of clogging. If they get clogged? Similar to Gastrostomy Tubes Jejunostomy Tubes

24. Percutaneous tube sites should be examined frequently for signs of infection. The tubes are typically well secured intra-abdominally, it is possible for them to become dislodged. If a tube has been in place for more than 2 weeks, it can be replaced at the bedside with a tube of comparable caliber. If the tube has been in place less than 2 weeks, it requires replacement with radiographic guidance, as the risk of creating a false lumen is high. Gastrostomy and Jejunostomy Tubes

25. Chapter 46: Surgical Tubes; Principles and Practice of Hospital Medicine CHAPTER 47 Pharynx, larynx and neck; Bailey’s and Love Short Practice of Surgery References

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