Use and abuse of drains in surgery

Akinsulire A.T

Outline

Introduction/definition History behind drains Qualities of an ideal drain Basic mechanism of drain action Classification of drains Principles of drain use Uses of drains Abuse of drain Complications of drains

Introduction/definition

An appliance or piece of material that acts as a channel for the escape (exit) of gases fluids and other material from a cavity, wound, infected area or focus of suppuration.

An important adjunct in a wide variety of surgical procedures

History of drains

Hippocrates –drainage of empyema, ascitic fluid 200AD- Celsius devised means of draining

ascites with conical tubes 1700AD –Johann Schltetus-1st person to use

capillary drainage 1897AD Charles Penrose devised Penrose drain 1932AD Chaffin developed 1st commercially

available suction drain 1959AD silicone rubber discovered and

advantages were reported by Santos

Qualities of a good drain

Soft -Minimal damage to surrounding tissues Smooth -Efficiently evacuate effluent and easy

removal Sterile- not potentiate infection or allow

introduction of infection from external environment Stable- Inert, non allergenic, not degraded by

body Simple to manage by both patient and staff

Mechanism of drain action

Laminar flow through drain Poiseuille’s law

F =dP πr4 /8nL F = flow of fluid thru the drain lumen dP =pressure difference between the two ends n =viscosity L= length of drain

Flow directly prop to suction pressure, radius Indirectly prop to viscosity and length of drain

Double in drain diameter 16 fold increase in flow Halving the length will double the flow

Factors governing effluent movt Gravity Capillary action Tissue pressure Negative pressure

Classification of drains

Open vs. closed drain Passive (non suction) vs. active (suction) Internal vs. external Irritant vs. non irritant

Open drain Empty to the exterior Effluent is directed into overlying dressings High rate of bacterial dissemination with

consequent wound infection E.g. corrugated drain, Penrose,

Yeates drain

Rubber corrugated drain

Penrose drain

Closed drain Drainage tubing is exteriorized and connected to a

closed drainage system Associated with reduced infection

rate/contamination Reduce nursing time esp. if high output Accurate measurement of output Protection of surrounding skin from irritating

discharges Risk of reflux of contaminated reservoir E.g urinary catheter, hemovac ,pigtail catheter

Hemovac drain Jackson–Pratt drain

Foleys catheter Pigtail catheter

Passive drains Work by pressure gradient, gravity effect, capillary

action or combination All open drains are passive drains Closed drains not connected to sunction

Active (suction) Employ suction to facilitate drainage Intermittent /continuous suction Sump-suction vs. closed suction Esp useful in highly viscous, negative pressure

regions

Internal drains Divert retain fluids form a body cavity to

another Useful in neurosurgery,ctsu ,G.I surgery and

urology E.g celestine, southar tubes,V-P shunt,

Pericardio-pleural tube External drains

Channel discharge from cavity to external environment

Celestine tube

Ventriculo- peritoneal shunt

Irritant drains composed of materials irritant to tissues excite fibrous tissue response leading to

fibrosis and tract formation E.g. latex, plastic and rubber drains

Inert drains Non irritant drains Provoke minimal tissue fibrosis E.g. polyvinyl chloride(PVC),polyurethane(PU) silicon elastomer(silastic)

Material Example Properties

Latex rubber Penrose drain Soft, induces tract formation

Red rubber Red rubber tube catheter

Firm, induces tract formation

PVC Chest tube,yeates Firm ,induce some inflammation

Silastic Jackson-Pratt drain Soft, induces minimal inflammation

Heparin coated silastic Jackson pratt drain Aims to inhibit clot formation and achieve greater patency

Hydrogel coating Some foley catheter,image guided percutaneous drain

Produce slippery surface resistant to encrustation

Polytetrafluoro-ethylene(PTFE)

Some foleys catheter Latex + teflon.

Smoother than latex

Silicone elastomer Some foleys catheter latex +silicone –more resistant to encrustation

Polymer hydromer Some foleys catheter Latex bounded with .smoother than latex

Principles of drain use

Should not exit cavity through same surgical incision.

Reach skin by safest shortest route Appropriate size and length A gravity drain must be placed in the safest and

most dependent recess in cavity Must be inserted away from delicate structures Firmly secured at exit wound Appropriate care-dressing,emptying,recharging Must be removed when no longer useful-at once

or by progressive shortening

Choice of drain

What is being drained Consistency,-larger lumen, suction drain

Why is the drain needed Latex, red rubber for tract formation

Where is the drain located Related to delicate structures, Sterile sites-closed drain Negative pressure zones-underwater seal

Waste bin size

Uses of drains

Prophylactic- prevent potential accumulation of fluid in a cavity

Therapeutic- evacuate an existing collection of fluid i.e. lymph, pus, urine saliva, serum

Diagnostic-MCUG,T-tube cholangiogram

Use of drains in cardiothoracic surgery

Intercostal catheter

Mediastinal catheter

Drains in Gastrointestinal surgery

Ryle tubeFine bore NG tube

T-tube(Khers)Salem sump tube

Drains in Neurosurgery

Drains in urology

3-way Coude catheter

Tiemans catheter

Foleys catheter

Drains in plastic surgery

Vacuum assisted closure (VAC) drain

Abuse of drains

A substitute for poor surgical technique or inadequate hemostasis

Wrong indication Delayed removal Untimely removal Wrong selection of appropriate drain Inadequate care of drain Insertion in main surgical wound

Complications of drains

Trauma to tissues during insertion and removal

Fistula formation/perforation –erosion of adjacent tissues

Visceral herniation through tract Anastomotic leak Flap necrosis Bacterial colonization and sepsis

Fluid and electrolyte loss Pain Restricted mobility Drain malfunction-migration,blockage,vacuum

failure Prolonged healing-delayed foreign body

SUMMARY

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