Drain Placement Flashcards
What is the purpose of drain placement?
Evacuate fluid that would otherwise accumulate due to dead space, inflammation, infection, or necrosis
Why do we want to decrease fluid accumulation in wounds?
Acts as a medium for bacterial growth
Separates tissue plants that need to heal together
Create pressure that can cause pain and decrease local blood flow
T/F: drains are a good alternative to debridement and lavage
False
Drains cannot replace a good debridement/lavage
What are the types of drains?
Passive
-penrose
Active
- commercial closed suction drain (Jackson Pratt)
- red top tue and butterfly catheter
- syringe and safety pin/needle
Where does the fluid drain in a penrose drain?
Along drain, NOT inside
How should a penrose drain be placed?
ASEPTICALLY
Secured in most dorsal non-dependent region, at least 1cm lateral to edge of wound
Exits at most ventral area at an area SEPARATE from the primary incision
-secured near exit site
How would you maintain a penrose drain postop??
Cover with bandage to collect fluid
-frequently change
Remove when amount of drainage has decreased or when exudate has changed to transudate
Generally removed at 3-days
If you are unable to place a PO bandage over your the site where you removed a penrose drain, how would you instruct the owner to manage this site?
Apply warm compress —> promote drainage
T/F: double exit passive drains are used in large wounds
False
NEVER make double exit drains
- promotes ascending infection
- Dr Cavanaugh will never forgive you
Where does the fluid travel in an alive drain?
Inside of drain
How is an active drain placed?
Fenestrated end placed in wound bed
Drain exits DORSAL to wound in non-dependent region
Requires aspetic technique and wound must have compete seal
Secured with purse string and finger strap suture
How are active drains managed post op?
Drain exit site covered with bandage and triple antibiotic ointment
Tacking suture to protect drain from patient and self trauma
Client can quantify fluid production at home
How do you know when it is time to remove your active drain?
Body normally produces 1-2ml/kg/day of fluid as a reaction from the drain
Remove when fluid production is below 5ml/kg/day
Keep drain hole covered for 24hours after drain removal
Why might there be loss of suction with an active drain during wound healing?
Check attachments and that evacuation port is closed
Check external tubing for holes
Dehiscence -> incision is no longer airtight
- immediate re-suturing indicated if the breakdown is due to trauma or excessive tension
What should you do id you can not re-establish negative pressure in your active drain system?
Remove drain and convert to open wound management
Highly contaminated wounds that cannot be primarily closed are managed how?
Open wound management
-> involves covering with appropriate dressing and bandage
What is the first step in open wound management ?
Removing all contaminants, such as foreign material/bacteria and damaged tissue from the wound
What are the types of debridement from most to least selective ?
Autolytic > surgical > mechanical
What are the advantages to bandage therapy for wounds?
Maintain clean environment
Reduce edema, hemorrhage and dead space
Promote acid environment at the wound surface by preventing CO2 loss and absorbing ammonia produced by bacteria
Immobilize injured tissue
Minimize scar tissue
What are the disadvantages of bandage therapy for wound management?
Pressure sores
Increase cost of care
Frequent changes required
Require expertise
What are the layers of a bandage?
Primary (contact) layer (sterile)
-directly touches the wound surface and should remain in contact with it during movement
Intermediate (secondary) layer (non-sterile)
-Common material = loose-weave, absorbent materials
Outer (tertiary) layer (non-sterile)
-contacts secondary layer but not wrapped to limit absorption
What type of contact layer is used for mechanical debridement of necrotic tissue and debris ?
Adherent
-cause pain on removal and serve little purpose in the absence of nonviable tissue
What type of bandage is selected when granulation tissue has formed
Non-adherent
What is the most commonly used badage in veterinary medicine that allows air to penetrate and exudate to escape from a wound surface?
Semi-occlusive
How are contact layers selected?
Phase of wound healing Amount of exudate Wound location and depth Presence/absence of an eschar Amount of necrosis / infection
What type of bandage is commonly used early int he course of wound management and is never indicated once granulation tissue develops?
Wet-to-dry bandage
What is the purpose of wet-to-dry bandage?
Provide wound protection/coverage
Initially maintain a moist environment
Mechanical debridement
Absorb moderate amounts of exudate
Specifically applicable to wounds with viscous exudate and necrotic debris
How often should your wet-to-dry bandage be changed?
Every 24 hours
What technique is used to bandage anatomic sites that would not accept a conventional bandage
Tie over
—> heavy gauge suture loops circumferentially around wound at 2-4cm intervals
—> wound packed with desired material then dry lap sponge as secondary larger
—> water impervious tertiary layer
—> umbilical tape placed in figure 8 fashion through suture loops to secure bandage
What is the purpose of moist wound healing?
Create a wound environment that optimizes the body’s inherent wound-healing abilities using specialized primary layers (moisture retentive dressings)
What makes a moisture retentive dressing?
Process related to moisture vapor transmission rate
Transepidermal water loss is movement of water through skin (4-9 g/msq/hr)
Low MVTR correlates with positive wound healing outcome
Dressing with MVTR <35 g/msq/hr are moisture retentive)
What are the advantages to using a moisture retentive dressing (MRD)?
WBC remain in wound -> selective autolytic debridement
Lower incidence of infection -> barrier to exogenous bacteria and prevention of tissue desiccation and necrosis
Wound maintained a physiological temp, supporting functions of cells, proteases, and growth factors
Maintain proper moisture level > limit expansion of necrosis
Low oxygen tension under occlusive dressings lowers pH —> decrease bacterial growth and favor collagen synthesis
Non-adherent
Water-proof
Longer interval between bandage change
What are the disadvantages to MRD?
More costly to purchase dressings initially
Excess exudate from wound can damage peri-wound skin and the wound bed by way of maceration (softening caused by trapped moisture) or excoriation (damage caused by excessive proteolytic enzymes in chronic wound fluid)
Requires more intellectual planning during wound management to select most appropriate dressing.
What type of MRD should you use in a wound with high level of exudate that requires debridement/granulation?
Calcium alginate
What type of MRD would you use in a wound with moderately high exudate that requires debridement/ granulation?
Polyurethane foam
What type of MRD would you use in a wound with moderate levels of exudate requiring debridement/granulation ?
Hydrocolloid
What type of MRD would you use in a wound with moderately high exudate that requires epithelization/contraction ?
Polyurethane foam
What type of MRD do you use on a wound with moderate levels of exudate that requires epithelization and contraction?
Hydrocolloid
Saline-moistened polyurethane foam
When are hydrocolloid bandages indicated?
Low to moderate exudate
Good for autolytic debridment, granulation, and epithelization
Occlusive cover to dressing
When is hydrogel indicated?
Low to no exudate
Dry wounds requiring autolytic debridement, granulation, or epithelization
May enhance contraction on limb wounds
Cooling effect may decrease pain
When are calcium alginate MRD indicated?
High exudate level
Autolytic debridement
Simulator of granulation tissue
Need hemostasis in oozing wounds
When is polyurethane foam MRD indicated?
Moderate to high exudate
Good for epithelization
Autolytic debridement and granulation
Can wick moisture out of macerated skin
Premoisten with saline for low exudate wounds
How often do you change MRDs?
During inflammatory phase: 2-3days
Once granulation tissue forms: 5-7days
Dressing should be changed before it becomes oversaturated or dries out and should be changed immediately if strike-through or soiling occurs
What are the benefits of manuka honey?
Antimicrobial/ anti-fungal
- high osmolarity —> draws lymph
- creates acidic environment —> deleterious to bacteria and promotes oxygen release and fibroblasts
- glucose oxidase produces hydrogen peroxide
Accelerates the sloughing of necrotic tissue
Provides local nutrition to wound
Abates inflammatory response
Improve epithelialization
What are the benefits of using sugar in open wound management ?
Antimicrobial
High osmolality draws H2O and nutrient rich lymph into wound to promote healing
High osmotic stress interferes with bacterial cell signaling
Enhance superficial debridement
What are the goals of treatment with negative pressure wound therapy?
Remove wound exudate Decrease interstitial edema Draw wound edges together Promote blood supply to the wound Stimulate cells involved with modulating the inflammatory and proliferative response to injury
What is the MOA of negative pressure wound therapy?
Benefits maybe result for cycling of increased blood flow (facilitating oxygenation and nutrient supply) and decreased blood flow (hypoxic stimulation of angiogenesis and fibroplasia)
What pressure is commonly used in NPWT?
125mmHg
What are the indications for NPWT?
Ideal for large open and effusive wounds devoid of granulation tissue
Chronic non-healing wounds
Extremist wounds tx by 2nd intention
Post-op mgt of tissue flaps/grafts
Open abdominal mgt for septic abdomen
When is NPWT contraindicated?
Poor peri-wound skin condition
Necrotic or clearly devitalized tissue
Coagulopathy
Exposed major blood vessels
Open joint
Neoplastic malignancy
Untreated osteomyelitis
Unexplored draining tract
