Management of drains

.

classification

drain

Open(penrose drain)

Closed(Jackson-pratt drain)

drain

Active(suction) Passive(gravity,over flow)

Types of drain1.Jackson-pratt drain2.Hemovac drain3.Pigtail drain4.Penrose drain5.t-tube6.Chest tube7.Negative pressure wound therapy8.RT/NJ/FJ9.Urinary catheter

. DRAIN assessment

Volume content

Post operative care DEPENDS ON THE TYPE,PURPOSE AND LOCATION OF THE DRAIN.• SKIN AROUND THE WOUND MUST BE KEPT CLEAN,AND DRY TO PREVENT

INFECTION AND SKIN IRRITATION.• METICULOUS SKIN CARE AND ASEPTIC TECHNIQUES MUST BE OBSERED DURING

APPLICATION AND CHANGE OF DRESSING OVER DRAIN.• GAUZE DRESSING ARE USED AROUND AND OVER DRAINAGE TUBES.

• TO PROTECT THE TUBE• ABSORB SOME AMOUNT OF DRAINAGE.• ASSIST WITH THE STABILIZATION OF THE TUBES.• PROTECT FROM EXTERNAL CONTAMINATION.

• AN ACCURATE MEASUREMENT AND RECORD KEEPING OF DRAINAGE OUTPUT.• DRAIN CONTAINER SHOULD BE EMPTIED AT LEAST ONCE A DAY.

When to remove…?• ONCE THE DRAINAGE HAS STOPED.• ITS OUT PUT HAS BECOME <20 ML/DAY.• THE DRAIN HAS STOPPED SERVING THE DESIRED FUNCTION.

Inadvertent removal/drain dislodgement1.if the drain suspected to have been moved,it should be secured and inform the treating team

2.in the event a drain has been dislodged , sterile dressing/insert smaller drain after informing the treating team

3.if drain suspected to have receded into the patient , imaging & the treating team should be notified

Educate the patient• Daily charting (if discharging with drain)• Regarding content of drain(pus/blood/bile/PF)• Take care when moving

Removal of drain in pancreatic surgery

• What is the drain fluid amylase(POD1,3,5,7,9..?.......low/high

• How much daily drain out put?

• What is the content?...PF/chylous/bile/haemorrhagic/purulent/ascites• If PF grade >A,do not remove drain,can be discharged with drain, later on

down sizing drain and removal in follow up visits• If content is haemorrhagic in drain (minimal or large volume),immediately

inform treating teammay require CT/angio/exploration

Removal of drain in total gastrectomy• What was the oral dye study(POD 5th)….?• How much daily drain out put….?• What is the

content….?purulent/ascites/chylous/haemorrhagic/PF/bile• Oral diet started or not….?

Drain removal in LAR/ULAR• Oral diet started or not…?• What is the content..? …serous/ascetic/purulent/faecal/haemorrhagic• How much volume..?

Drain removal in post cholecystectomy/HJ/hepatectomy• What is the content…?bile/serous/haemorrhagic

• How much daily volume…?• In post hepatectomy,if its high volume ascetic and c/s no

growthremove and stich drain site

Drain removal after esophagectomy• Neck corrugated draindaily dressings,remove if dry on POD2/3• Abdominal drain-look for volume/content—remove after oral diet

starting• Chest drain—look for volume/content, do fluid triglyceride to r/ o chylothorax if high volume• If TG value >110,start MCT oil based feed• During removal of ICD, take help of fellow colleague as purse string

suture require at the time of ICD removal.do check x ray also after removal

Drain(romovac) removal in post incisional hernioplasty • How much Daily Drain out put in both suction bag…..?(if two seprately

placed)• If mesh is there and still not able to temove drain due to

volumesend fluid for c/s to r/o infection • Remove drain if <20cc/day on day 2/3/4

For ascitic high drain output• Start Diuretics low dose and increase dose if require

• If low s.albumin causing high ascitic drain out put,then iv h.albumin /oral high protein supplement

• Do drain fluid c/s to r/o infectionremove drain if no growth

Post removal• Monitor the site (for bleeding/discharge)• Put stoma bag if more soakage • If its ascetic fluid and send for c/s close the drain site if no growth.

For urinary catheter removal• In LAR/ULAR may require for 6/7 days , see the operative notes for

any bladder repair before removing.do not clamp it if any bladder suture have taken during surgery• In AR/hemicolectomy early removal if possible , no need to even

clamp it.• If delayed removal better to clamp and remove it on sensation

For rectal catheter removal

• When placed for LAR/ULAR4/5th day ,if stool + ,inform operating team

For Ryle’s tube removal • In total or extended gastrectomy,do not remove till oral dye

study(pod5th)• In post Whipple’ssee volume,usually 4th /5th day removal• If Ryle’s accidently dislodged early ,DO NOT put it back in case of

esophagectomy /gastrectomy patient• If colostomy closure/left hemicolectomyremove 1st POD after

informing operating team

conclusionsTHE ESSENTIAL QUESTIONS A SURGEON NEEDS TO ANSWER WHEN DECIDING ON THE VALUE OF SURGICAL DRAINS ARE..

• WHAT PURPOSE WOULD A DRAIN SERVE IF PLACED?• WHAT TYPE OF DRAIN SHOULD BE USED?• HOW LONG SHOULD THE DRAIN BE LEFT IN PLACE?

ONCE THESE QUESTIONS ARE CAREFULLY AND ADEQUATELY ANSWERED EACH TIME A DRAIN IS USED, THE EFFECTIVENESS AND ADVANTAGE CAN BE MAXIMIZED WITH MINIMAL PROBLEMS.