Usage of Various types of Drains in Surgery .pdf

Drains

1. DRAIN USE IN SURGERY
LOVI

2. outline
•Introduction
•Classification of drains
•Indications for drain use
•Placement, assessment and removal
•Complications
•Conclusion

3. introduction
•Drains are appliances that act as a deliberate channel through
which established or potential collection of pus, blood or body fluid
egress to allow a gradual collapse and apposition of tissue
•Their use dates back to Hippocrates where metal tubes, glass tubes
as well as bone were used as passive drains. Prophylactic placement
postoperatively has been widely practised since the mid-1800s,
with the dictum of Lawson Tait, the 19th century British surgeon,
“When in doubt, drain”.
•Heaton (1889) discovered air-vent suction or active drains
•Advances in the technique of modern surgery have reduced
indications for the use of drains to just a handful- where, placement
is invaluable in preventing catastrophes

4. Mechanism of Drains

A drain removes
1.Contents of body organs e.g.catheterisation of
urinary bladder, nasogastric tube aspiration
2.Excess secretions of body cavities such as in
peritoneal and pleural cavities
3. Tissue fluids such as blood, serum, lymph and
other body fluids that accumulate in the wound
bed after a surgical procedure

5. Classification of drains
1.Mechanism – Active vs Passive
2.Nature - Tube vs sheet/flat
3.Disposition – Open or closed
4.Location – internal vs external
5.Property – inert vs irritant
( latex,rubber,pvc,silicon,PTFE)

The ideal drain:
Firm, smooth,resistant to degeneration,not easily
blocked,non-electrolytic,non-carcinogenic, non-
thrombogenic

6. Passive drains
These are drains that act by the mechanism of
capillary action, gravity or the fluctuation of intra-
cavity pressure.
Based on the principle of natural pressure gradients
Examples :
-Corrugated rubber drain
-Penrose drain
-sump drain

7. Active drains
These are tube drains that are aided by suction
which could be continuous or intermittent
Based on the principle of negative pressure gradient
Examples:
-Jackson-Pratt drains
-Surgivac® drain
-Redivac® drain
regular activation of reservoir is often required

8. passive vs active drains
passive active
function Pressure differential dependent Works by active suction
Pressure gradient Positive pressure Negative pressure
Drain exit site Dependent position necessary for
best function
Dependent position not
necessary
Site dressing Bulky to absorb fluid output Minimal or not required
Effluent measure Difficult to quantify Reliable and accurate
Recollection Likely because of limited effect on
the dead space
Unlikely because negative
pressure improves tissue
apposition
Retrograde infection High incidence especially with
open system
Lower incidence especially with
close suction system
Drain obstruction Less common More common due to smaller
caliber
Radiographic studies Difficult except in special
circumstances like T-tube and
Nasogastric tube
Easy to perform
Pressure necrosis Low incidence High incidence

9. Open Drains
These drains empty directly to the exterior into the
overlying wound dressings or stoma bag which can easily
be changed
They are mostly used in superficial wounds and cavities
Examples:
-Corrugated rubber drain
-Penrose
-Gauze wick drain
-Glove finger drain

10. Closed Drains
An airtight circuit system which prevents interaction between
the environment and the anatomic site of drainage
Used for deep body cavities
Effluent can easily be collected and measured
The risk of skin excoriations and surgical wound infection is
less
Example:
-Under water seal drainage system
-Urinary catheter/NG tube and bag
-Negative pressure wound therapy system

11. External Drains
These are drains that are brought out through the body
wall to the exterior
The fluid discharge is channeled from the deepest part of
the cavity to the exterior
Internal Drains
These are drains that are placed internally within luminal
organs to create a route or to connect two luminal organs
-Diversion
-stenting

16. BLAKE
JACKSON-PRATT
NEGATIVE PRESSURE WOUND
THERAPY SYSTEM

17. INDICATIONS FOR DRAINS
Drains are used across all surgical specialties

The purpose of a drain may be:
1.Prophylactic (post-procedural)
2.Diagnostic(characteristics of effluent/adjunct)
3.Therapeutic(definitive/supportive or adjunctive)
-Drainage,splinting and bridging,stenting
4.Palliative
5. Monitoring
6.Access route

18. Diagnostic
•T-tube cholangiogram for
retained gall stones in
common bile duct
•G.O.O/ GI Bleeding

Prophylactic
•Cardiothoracic procedures
•Extensive skin flap
•Post thyroidectomy
•Thoracotomy
•Hepatobiliary procedures
•Patient on PPV post chest
trauma

Therapeutic
•Tension pneumothorax
•Abscess cavity
•Seroma
•Acute urinary retention
•Acute suppurative arthritis
•NPWT

Palliative
•Advanced Ca esophagus
•Hydrocephalus

Monitoring
• Gastrointestinal bleeding
• Urethral catheterizations

19. Principles of placement of surgical
drains
•Drains should be placed such that they take the safest, shortest
route possible .
•They should reach the deepest, most dependent part of the cavity
or wound.
•Bring out external drains through a stab wound, and not from the
main wound so as to minimize the incidence of wound infection .
•Tubing should remain free of kinks, debris and clots so as to
enhance free drainage.
•The drain should be secured well so as to avoid falling off or its
migration into the cavity or erosion of surrounding tissue:
-Roman Garter technique, use of nylon suture, safety pin, drain clip,
adhesives, Tie-lok
• Drain should be lower than the incision at all times
•Confirmation of proper placement for certain drains is mandatory

20. Prophylactic drainage sites:
Subhepatic (1)
Right subphrenic(2)
Left subphrenic (3)
Parapancreatic (4)
Therapeutic drainage for UGI surgery
Anastomotic drain
Placement of wound drain

22. Post operative care of a surgical drain
1.Aseptic technique
2.Skin care
3.Monitoring(function/output/secure/complicatio
ns)
4.Replacement of losses
5.Empty reservoir
6.Regular activation of the reservoir of active
drains
7.PATIENT EDUCATION

23. Drain discontinuation
1.When it has stopped serving its function
-Drainage has stopped
-Output is less than 25 to 50mls
2. When it has served its purpose i.e desired result has
been achieved
-Delay removal until desired tract is formed eg.
suprapubic

-urethral catheter removal (deflate balloon)
-Chest tube removal (full inspiration/expiration)
-Open drain removal (inch out gradually)

24. Misuse of drains
The abuse of a drain may be in the following
ways
1.Indication
2.Type- material,consistency,size,cost
3.Technique- placement(site,route,means-
invasiveness), security
4.Duration- prematurity,post-datism
5.Care- the drain, the patient

25. Complications of drain use
1.Drain failure
-poor selection, placement and post-op management
2. Effects as a foreign body
-chemical and mechanical effects/potential for infection
3. Mechanical problems
-displacement/migration/fragmentation
4. Physiologic derangements
-pain/fluid and electrolytes
5. Placement and removal
-haemorrhage/injury to viscera

26. controversies
•No consensus on indication and duration for
drain use
•Arguments for drain vs no drain use
Increased hospital stay
Delay tissue healing
Anastomotic breakdown
•The issue of prophylactic antibiotics

27. conclusion
Three questions are essential and serve as a basic
frame work which must be considered when
deciding on the value of surgical drains.
1. What purpose would a drain serve if placed?
2. What type of drains should be used?
3. 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 advantages can be maximized
with minimal problems.

28. references
•Memon MA, Memon B, Memon MI, Donohue JH.
The uses and abuses of drains in abdominal
surgery. Hospital medicine 2002; 63: 282-287
•Postgraduate Surgery: The candidate's guide 2 ed.
M. A. R. AlFallouji
•Surgical Drains: What the Resident Needs To
Know Makama J G MBBS, Ameh E A FWACS, FACS
Department Of Surgery, A B U Teaching Hospital,
Shika-Zaria