8 – Dead Space and Drainage

Question 1

What is dead space?

Answer 1

• Abnormal space or potential space within a wound
• Contains fluid or gas

Question 2

What are some causes of dead space?

Answer 2

• Extensive dissection
• Injury resulting in tissue loss (ex. accident or bullet wound)
• Removal of large masses
• Reconstruction with flaps and grafts

Question 3

What happens when fluid accumulates within a wound?

Answer 3

• *reduces healing and favours infection if bugs are present
  o Ab opsonic activity lost
  o Disrupts phagocyte-bacteria interaction
  o Substrate for bacterial growth
  o Compromises blood supply
  o Interferes with graft appearance

Question 4

How can you avoid creating dead space?

Answer 4

• Meticulous and minimalist technique
• Avoid undermining when you make incision
• Mayo dissection
  o Take Metzenbaum scissors and keep them closed and create a tunnel
• Don’t remove tissue unless there’s a very good reason for it to go

Question 5

What are some ways to deal with dead space?

Answer 5

• Tacking sutures
• Pressure wraps
  o Need to consider anatomic location of problem before you place one (ex. don’t do it around neck)
• *if can’t eliminate then you can try continuous or intermittent fluid (or gas) removal (DRAINAGE)

Question 6

Passive drains

Answer 6

• Work by capillary action and gravity
• Efficacy dependent upon surface area
• Ex. penrose drains (latex)

Question 7

Passive drains: location and important points

Answer 7

• Make exit point ventral to wound (ex. need to work with gravity)
• Avoid exiting through the incision itself
• Aseptic post-op care needed
• *but if you actually need drainage=use another strategy

Question 8

Active drains (closed suction drains)

Answer 8

• Work by attaching tubing withing the wound to a suction device outside of the wound
• *more efficient than passive suction and NOT dependent on gravity
• Ex. Jackson-Pratt drain attached to a grenade suction device
• Ex. can make a rebel suction device (ex. vacuum tubes, plunger)

Question 9

Physiologic drainage

Answer 9

• Omentalization
  o Good at sticking to everything and has lots of blood supply
  o Ex. pancreatic access=stick omentum to it

Question 10

Treatment as an open wound

Answer 10

• *most effective way to provide drainage
• Almost always the right answer when there is significant contamination present

Question 11

Negative pressure wound therapy (NPWT) (vacuum-assisted closure, VAC)

Answer 11

• Vacuum applied to wound through open cell foam covered by occlusive layer
• *Encourages granulation tissue formation and eases wound care (can leave in place for 3-4 days)
• Ex. stoma past, speaker foam and ‘sticky’ plastic on top (occlusive layer)

Question 12

When do you use drainage?

Answer 12

• If fluid will remain or be produced post-op AND is likely to be a problem
• If contamination is present and can’t be completely resolved surgically (if this is the case, best bet is to leave the wound open)

Question 13

When do you NOT use drainage?

Answer 13

• Most postoperative seromas and hematomas

Question 14

When do you remove a drain?

Answer 14

• 1-7d after surgery (case dependent)
• When it stops working (ex. clogs, kinks)
• Dependent on fluid quality and quantity
  o Decreased amount
  o Serosanguinous rather than cloudy
  o If fluid <0.2ml/kg/hr

Question 15

How do you remove a drain?

Answer 15

• Doesn’t usually require sedation
• Remove sutures and pull
• Ensure the ENTIRE drain has been removed
• Cover wound for 24-48hrs