Use And Abuse Of Drains In Surgery1

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, 

Penrose drain

Rubber corrugated drain

Yeates 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 

Foleys catheter

Hemovac drain

Pigtail catheter

Jackson–Pratt drain

 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

Ventriculoperitoneal 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

Polytetrafluoroethylene(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

Fine bore NG tube

Ryle tube

Salem sump tube

T-tube(Khers)

Drains in Neurosurgery

Drains in urology

Foleys catheter

3-way Coude catheter

Tiemans 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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