Drains

Question 1

Types of drain

Answer 1

A) OPEN OR CLOSED DRAINS
B) ACTIVE OR PASSIVE DRAINS
C) INSERTION TECHNIQUE - PERCUTEOUS OR SURGICAL
D) ANATOMICAL – THORACIC, ABDOMINO-PELVIC, SUBCUTANEOUS

Question 2

Open Drains examples?

Answer 2

An open system allows drainage of fluids directly to the exterior; either in a drain bag,
stoma bag or on a dressing.

Example – Intra-abdominal drains, biliary drains, corrugated wound drains, etc.

Question 3

Closed Drains examples?

Answer 3

A closed system is where the drain is attached to a closed system, usually to a suction
device.

Example – Chest drains, Redivac drains, etc.

Question 4

Percutaneous drains: examples?

Answer 4

Usually under radiological guidance (CT, Ultrasound, Fluoroscopy, Endoscopy).

• Usually of small calibre
• Less trauma to the patient.
• Usually placed under a local anaesthetic, less commonly GA

Examples - percutaneous chest drains, PTC
tube, Nephrostomy.

Question 5

Surgical drains examples?

Answer 5

Are inserted after a surgical procedure, therefore are technically more traumatic than percutaneous drains.

• Placed either after a small cut-down such as in a large bore chest drain, or after a laparotomy or a thoracotomy.
• Usually of a larger calibre than percutaneous drains.

Examples - Intra-abdominal drains following abdominal surgery, thoracic/chest drains following thoracic surgery or after a surgical cutdown, wound drains.

Question 6

Abdomino-Pelvic drains types?

Answer 6

a) Intra-peritoneal
b) Retro-peritoneal
c) Organ Specific

Question 7

Intra-peritoneal drains examples?

Answer 7

• Drain the peritoneal cavity
  - Seen commonly following abdominal surgery.
  - Usually wide bore in size.
  - Can be percutaneous or surgical.
  - Are almost NEVER on suction as this can damage intra-abdominal organs such as bowel.

Examples include:
o Ascitic drain
o Standard tube drains following laparotomy.
o Peritoneal dialysis catheter.

Question 8

Retro-peritoneal drains examples?

Answer 8

• Drain the retroperitoneal space.
• Usually in peri-pancreatic/peri-nephric collections.
• Always on free drainage into a bag. NOT on suction.
• Can be inserted percutanoeusly or surgically.
• Frequently FLUSHED four times a day with 20-40ml saline each time.
• Small calibre ones usually are pigtail trains and are inserted percutaneously.
• Larger calibre drains are usually inserted surgically in operating theatres.

Example- peri-pancreatic drain following pancreatic necrosectomy, psoas abscess drain.

Question 9

A left retroperitoneal drain in a patient with a pancreatic leak following a distal pancreatectomy - when to check drain amylase?

Answer 9

day 3 post op

if 3x the normal serum amylase level the patient has developed a pancreatic fistula

Question 10

Organ Specific Drains + examples?

Answer 10

• Drain a particular organ
• Never on suction
• Usually require regular washouts.
• Can be inserted percutaneously or surgically

Examples: Liver - Drain into a liver abscess or liver cyst, Bile Duct – For CBD injuries, obstructions and strictures.

Question 11

two types of PTC?

Answer 11

Internal//External PTC: The drain passes through the liver into the bile duct, beyond the blockage and into the duodenum.

External PTC: The drain passes through the liver and into the bile ducts but does not pass through the blockage.

Question 12

T-tube?

Answer 12

inserted surgically into the bile ducts or sometimes directly into the bowel

NOT through the liver

when removed the tract to the skin remains

may be clamped and left in place for 6 weeks then return to hospital for removal

tract = alternative exit point for any bile that does not progress down CBD, for a few days after T-tube removal, limiting the chance of a bile leak

Question 13

Subcutaneous drain?

Answer 13

These drains are closed, active systems (under suction).

Dead space after an operation - prevent a seroma or haematoma.

Can become blocked so if output suddenly stops be wary.

Question 14

what to remember in liver resection drains?

Answer 14

patients need clotting checked daily, observe for blood and bile

Question 15

what to remember pancreatic drains?

Answer 15

patients need drain fluid amylase testing on day 3 and 5 post-op

Question 16

Drain amylase results 3x greater than the upper limit of normal serum value, post-op Whipples/PPPD day 3?

Answer 16

suggests a leak at the pancreatico-jejunostomy anastomosis

Question 17

If a pancreatico-jejunostomy anastomosis leak is confirmed then treatment? (5)

Answer 17

NBM
TPN
octreotide infusion
antibiotics
\+/- CT scan

(in order to control the leak and allow the anastomosis to heal)

Question 18

Fresh bleeding into a pancreatic drain?

Answer 18

emergency, it may be a ‘herald bleed’ before a catastrophic bleed occurs. Clamp the drain and call a registrar or consultant immediately.

Question 19

does absence of blood in a drain rule out internal bleeding?

Answer 19

NO drain may be blocked, e.g. with a large blood clot.

Question 20

if there are any changes to the drain management ?

Answer 20

let the nursing staff looking after the patient know, e.g. drain removal, drain amylases to be sent. Good communication is key

Question 21

No drain under any circumstances….?

Answer 21

should be cut and bagged, due to the risk of accidental internalisation