Drains and Tubes, Chapter16 P93-103 Flashcards
What is the purpose of drains?
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- Withdrawal of fluids
2. Apposition of tissues to remove a potential space by suction
What is a Jackson-Pratt (JP) drain?
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Closed drainage system attached to a suction bulb (“grenade”)
What are the “three S’s” of Jackson-Pratt drain removal?
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- Stitch removal
- Suction discontinuation
- Slow, steady pull
What is a Penrose drain?
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Open drainage system composed of a thin rubber hose; associated with increased infection rate in clean wounds
Define the following terms: G-tube
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Gastrostomy tube; used for drainage or feeding
J-tube
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Jejunostomy tube; used for feeding; may be a small-needle catheter (remember to flush after use or it will clog) or a large, red rubber catheter
Cholecystostomy tube
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Tube placed surgically or percutaneously with ultrasound guidance to drain the gallbladder
T-tube
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- Tube placed in the common bile duct with an ascending and descending limb that forms a “T”
- Drains percutaneously; placed after common bile duct exploration
CHEST TUBES
1. What is a thoracostomy tube?
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Chest tube
- What is the purpose of a chest tube?
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To appose the parietal and visceral pleura by draining blood, pus, fluid, chyle, or air
- How is a chest tube inserted?
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- Administer local anesthetic
- Incise skin in the fourth or fifth intercostal space between the mid- and anterior-axillary lines
- Perform blunt Kelly-clamp dissection over the rib into the pleural space
- Perform finger exploration to confirm intrapleural placement
- Place tube posteriorly and superiorly
- Is the chest tube placed under or over the rib?
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Over to avoid the vessels and nerves
- What are the goals of chest tube insertion?
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- Drain the pleural cavity
- Appose parietal and visceral pleura to seal any visceral pleural holes
- In most cases, where should the chest tube be positioned?
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Posteriorly into the apex
- How can you tell on CXR if the last hole on the chest
tube is in the pleural cavity?
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Last hole is cut through the radiopaque line in the chest tube and is seen on CXR as a break in the line, which should be within the pleural cavity
- What are the cm measurements on a chest tube?
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Centimeters from the last hole on the chest tube
- What is the chest tube connected to?
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Suction, waterseal, collection system
three-chambered box, e.g., Pleuravac®
- What are the three chambers of the Pleuravac®?
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- Collection chamber
- Water seal
- Suction control
Describe how each chamber of the Pleuravac® box works
as the old three-bottle system:
1. Collection chamber
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Collects fluid, pus, blood, or chyle and measures the amount; connects to the water seal bottle and to the chest tube
- Water-seal chamber
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One-way valve—allows air to be removed from the pleural space; does not allow air to enter pleural cavity; connects to the suction control bottle and to the collection chamber
- Suction-control chamber
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Controls the amount of suction by the height of the water column; sucking in room air releases excessive suction;
connects to wall suction and to the water seal bottle
Give a good example of a water seal.
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Place a straw in a cup of water—you can blow air out but if you suck in, the straw fills with water and thus forms a one-way valve for air just like the chest tube water seal
How is a chest tube placed on water seal?
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By removing the suction; a tension pneumothorax (PTX) cannot form because the one-way valve (water seal) allows release of air buildup
Should a chest tube ever be clamped off?
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No, except to “run the system” momentarily
What does it mean to “run the system” of a chest tube?
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- To see if the air leak is from a leak in the pleural cavity (e.g., hole in lung) or from a leak in the tubing
- Momentarily occlude the chest tube and if the air leak is still present, it is from the tubing or tubing connection,
not from the chest
How can you tell if the chest tube is “tidling”?
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Take the Pleuravac® off of suction and look at the water seal chamber: Fluid should move with respiration/ventilation (called “tidling”); this decreases and ceases if the pleura seals off the chest tube
How can you check for an air leak?
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Look at the water seal chamber on suction:
- If bubbles pass through the water seal fluid, a large air leak (i.e., air leaking into chest tube) is present; if no air leak is evident on suction, remove suction and ask the patient to cough
- If air bubbles through the water seal, a small air leak is present
What is the usual course for removing a chest tube
placed for a PTX?
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- Suction until the PTX resolves and the air leak is gone
- Water seal for 24 hours
- Remove the chest tube if no PTX or air leak is present after 24 hours of water seal
How fast is a small, stable PTX absorbed?
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≈1% daily; therefore, a 10% PTX by
volume will absorb in ≈10 days
How should a chest tube be removed?
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- Cut the stitch
- Ask the patient to exhale or inhale maximally
- Rapidly remove the tube (split second) and at same time, place petroleum jelly gauze covered by 4 4’s and then tape
- Obtain a CXR
What is a Heimlich valve?
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One-way flutter valve for a chest tube
NASOGASTRIC TUBES (NGT)
1. How should an NGT be placed?
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- Use lubrication and have suction up on the bed
- Use anesthetic to numb nose
- Place head in flexion
- Ask patient to drink a small amount of water when the tube is in the back of the throat and to swallow the tube; if
the patient can talk without difficulty and succus returns, the tube should be in the stomach (Get an x-ray if there is
any question about position)
- How should an NGT be removed?
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Give patient a tissue, discontinue suction, untape nose, remove quickly, and tell patient to blow nose
- What test should be performed before feeding via any tube?
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High abdominal x-ray to confirm placement into the GI tract and NOT the lung!
- How does an NGT work?
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Sump pump, dual lumen tube—the large clear tube is hooked to suction and the small blue tube allows for air sump (i.e., circuit sump pump with air in the blue tube and air and succus sucked out through the large clear lumen)
- How can you check to see if the NGT is working?
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Blue port will make a sucking noise; always keep the blue port opening above the stomach
- Should an NGT be placed on continuous or intermittent suction?
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Continuous low suction—side holes disengage if they are against mucosa because of the sump mechanism and
multiple holes
- What happens if the NGT is clogged?
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Tube will not decompress the stomach and will keep the low esophageal sphincter (LES) open (i.e., a setup for aspiration)
- How should an NGT be unclogged?
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Saline-flush the clear port, reconnect to suction, and flush air down the blue sump port
- What is a common cause of excessive NGT drainage?
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Tip of the NGT is inadvertently placed in the duodenum and drains the pancreatic fluid and bile; an x-ray should be
taken and the tube repositioned into the stomach
- What is the difference between a feeding tube
(Dobbhoff tube) and an NGT?
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A feeding tube is a thin tube weighted at the end that is not a sump pump but a simple catheter; usually placed past the
pylorus, which is facilitated by the weighted end and peristalsis
FOLEY CATHETER
1. What is a Foley catheter?
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Catheter into the bladder, allowing accurate urine output determination
- What is a coudé catheter?
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Foley catheter with a small, curved tip to help maneuver around a large prostate
- If a Foley catheter cannot be inserted, what are the next steps?
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- Anesthetize the urethra with a sterile local anesthetic (e.g., lidocaine jelly)
- Try a larger Foley catheter
- What if a patient has a urethral injury and a Foley
cannot be placed?
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A suprapubic catheter will need to be placed
CENTRAL LINES
1. What are they?
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Catheters placed into the major veins (central veins) via subclavian, internal jugular, or femoral vein approaches
- What major complications result from placement?
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PTX (always obtain postplacement CXR), bleeding, malposition (e.g., into the neck from subclavian approach), dysrhythmias
- In long-term central lines, what does the “cuff” do?
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Allows ingrowth of fibrous tissue, which:
- Holds the line in place
- Forms a barrier to the advance of bacteria
- What is a Hickman® or Hickman-type catheter?
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External central line tunneled under the skin with a “cuff
- What is a Port-A-Cath®?
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Central line that has a port buried under the skin that must be accessed through the skin (percutaneously)
- What is a “cordis”?
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Large central line catheter; used for massive fluid resuscitation or for placing a Swan-Ganz catheter
- If you try to place a subclavian central line unsuccessfully,
what must you do before trying the other side?
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Get a CXR—a bilateral pneumothorax can be fatal!
MISCELLANEOUS
1. How can diameter in mm be determined from a French
measurement?
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Divide the French size by ⫪ or 3.14
e.g., a 15 French tube has a diameter of 5 mm
- How can needle-gauge size be determined?
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14-gauge needle is 1/14 of an inch (Thus, a 14-gauge needle is larger than a 21-gauge needle)
- What is a Tenckhoff catheter?
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Catheter placed into the peritoneal cavity for peritoneal dialysis
