SR 16 - Drains and Tubes Flashcards
What is the purpose of drains?
WIthdrawal of fluids
Apposition of tissues to remove a potential space by suction
What is a JP drain?
Jackson Pratt
Closed drainage system attached to a suction bulb
What are the steps of JP drain removal?
Three Ss
Stitch removal
Suction discontinuation
Slow, steady pull
What is a Penrose drain?
Open drainage system compsed of a thin rubber hose
Associated with increased infection rate in clean wounds
Define G-tube
Gastrostomy tube
Used for drainage or feeding
Define J-tube
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
Define Cholecystostomy tube
Tube placed surgically (or percutaneously with US guidance) to drain the gallbladder
Define T-Tube
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
What is a thoracostomy tube?
Chest tube
What is the purpose of a chest tube?
To appose the parietal and visceral pleura by draining blood/pus/fluid/chyle/air
How is a chest tube inserted?
Local anesthetic
Incise skin (4-5th ICS) between 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 place over or under the rib?
OVER to avoid vessels and nerves
What are the goals of chest tube insertion?
Drain the pleural cavity
Appose parietal and visceral pleura to seal any visceral pleural holes
How can you tell on CXR if the last hole on the chest tube is in the pleural cavity?
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?
Centimeters from the last hole on the chest tube
What is the chest tube connected to?
Suction, waterseal, collection system (three-chambered box)
What are the three chambers of the Pleuravac?
Collection chamber
Water seal
Suction
Should a chest tube ever be clamped off?
No, except to ‘run the system’ momentarily
What does it mean to ‘run the system’ of a chest tube?
To see if the air leak is form a leak in the pleural cavity 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 the chest
How can you tell if the chest tube is ‘tidling’?
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?
Look at the water seal chamber on suction
If bubbles pass through the water seal fluid, a large leak is present; if no 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?
Suction until the PTX resolves and the air leak is gone
Water seal for 24 hours
Remove the chest tube is not PTX or air leak is present after 24 hours of water seal
How fast is a small, stable PTX absorbed?
~1% lung area/daily
Therefore, as 10% PTX will absorb in 10 days
How should a chest tube be removed?
Cut the stitch
Ask patient to exhale or inhale maximally
Rapidly remove the tube and, at the same time, place petroleum jelly gauze covered by 4x4 and then tape
Obtain CXR
What is a Heimlich valve?
One-way flutter valve for a chest tube
How should a NGT be placed?
Use lbrication and have suction up on 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
How should a NGT be removed?
Give the patient a tissue, discontinue suction, untape nose, remove quickly and have patient blow nose
What test should be performed before feeding by any tube?
High abdominal XR to confirm the placement into the GIT and not the lungs
How does an NGT work?
Sump pump - dual lumen tube
The large clear tube is hooked to suction and the small blue tube allows for air sump (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?
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?
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?
Tube will not decompress the stomach and will keep the LES open (risk for aspiration)
How should an NGT be unclogged?
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?
Tip of the NGT is inadvertently placed in the duodenum and drains the pancreatic fluid and bile
XR taken and reposition the tube into the stomach
What is the difference between a feeding tube (Dobbhoff tube) and an NGT)?
A feeding tube is a thin tube weighted at the end that is not a sump pump, but a simple catheter
Usually placed paced the pylorus, which is facilitated by the weighted end and peristalsis
What is a Foley catheter?
Catheter into the bladder
Allows accurate urine output monitoring
What is a coude catheter?
Foley with a small, curved tip to help maneuver around a large prostate
If a foley cannot be inserted, what are the next steps?
Anesthetize the urethra with a sterile local anesthetic (i.e. lidocaine jelly)
Try a larger foley catheter
What if the patient has a urethral injury and a foley cannot be placed?
A suprapubic catheter will need to be placed
What are central lines?
Catheters placed into the major veins via subclavian, internal jugular or femoral vein approaches
What major complication results from central line placement?
PTX - always get a post placement CXR
Bleeding
Malposition (i.e. into the neck)
Dysrhythmias
In long-term central lines, what does the ‘cuff’ do?
Allows ingrowth of fibrous tissue
- Holds the line in place
- Forms a barrier to the advance of bacteria
What is a HIckman catheter?
External central line tunneled under the skin with a cuff
What is a Port-A-Cath?
Central line that has a port buried under the skin that must be accessed through the skin (percutaneously)
What is a ‘cordis’?
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?
CXR - bilateral PTX can be fatal
How can diameter in mm be determine from a french measurement?
Divide the french size by Pi
How can needle-gauge size be dtermined?
14-gauge needle is 1/14 of an inch
What is a Tenckhoff catheter?
Catheter placed into the peritoneal cavity for peritoneal dialysis
