Editing Drains


== '''Classification''' ==

* '''Therapeutic'''
** Provide egress for established intra-abdominal infection/contamination
** Control a source of infection that cannot be controlled by more definitive means
* '''Prophylactic'''
** Prevent recurrent infection (prevent reaccumulation)
** Control prospective or expected leakage from a suture line
** Warn about complications (bleeding/leak)
* Active - connected to a source of suction - tend to block up quickly as fibrin/tissue is drawn into tube
* Passive - 'open system' - stays open longer, but allows contamination from skin

== Common indications ==

* Good indications:
** High probability of leakage of bile or pancreatic juice
** Established pus-containing abscess (non-collapsible)
** Not satisfied with source control
** Urine leak is expected
** High-risk UGI anatomosis
** Expected bleeding - but be very selective
* Specifically:
** Draining an anastomosis: J-P drain 
** Lap chole: Leave a drain only if worried about unsolved or potential bile leak. 14-16Fr Blakes likely connected to Bellovac.
** Appendix - almost never indicated, given source control has been achieved and peritoneal toilet has been performed
** Perf DU - not unless you are worried about the quality of repair
** Emergency left colon resection - unnecessary
** Generalised peritonitis - do not drain unless there is a defined rigid cavity, or a controlled fistula is required

== Suturing in place ==

* I think the Roman sandal method is most secure
* Security can be increased by plastic ties or steristrips around the Roman sandal

== Draining an intra-abdominal abscess ==

* If there's an established abscess with rigid walls, need to leave a long-term drain (2-5 weeks)
* Can do a tubogram prior to removal - once the cavity is no longer significantly larger in diameter than the drainage tract, it can be removed



== Closed suction: ==
Bellovac: closed, active drain system. Negative pressure about 90mmHg and a reservoir of 220mL.

Exudrain: closed, active drain system. Negative pressure about 75mmHg and a reservoir of 100mL.

Redivac/Surimex Fixvac: closed, active drain system. Negative pressure about 338mmHg. Reservoir of 600mL, but note the bottle will only half fill, and will need to be emptied regularly.



Jackson-Pratt: typically connects to this, which is a closed, active drain system with variable negative pressure a reservoir of 100mL. Inverse relationship between reservoir contents and level of suction - suction pressure decreases as the bottle fills.

* To empty: kink tube proximal to bottle; release plug on bulb; squeeze out contents; ensure bulb remains compressed and replace plug.
* Don't leave fenestrated closed suction drains in the abdomen for longer than 10 days - can get tissue ingrowth

== Free drainage: closed, passive drainage system, with no negative pressure. ==
Penrose: open, passive drain with collapsible walls. Will form a well-established tract in 8-10 days if left alone. Ensure to bring it out in a straight line - if there are wrinkles, stagnant pools of fluid will accumulate around the wrinkles. Ideally, place it so that gravity can assist drainage.

Pigtail: closed, passive drain.

Silastic

* Non-reactive - so won't form a tract to outside
* Therefore not useful for draining bile


== Problems: ==

* Lost suction
** Check for leaks
* Exudate on op-site at skin
** If needing to change more than twice in 24 hours, change to a polyurethane foam dressing (Biotain) at skin
** Consider change to coloplast bag
* Shortening drain
** Cut drain tube about 10cm clear of skin
** Remove suture and pull out about 2cm
** Insert a safety pin through drain
** Place drain in coloplast bag
* Cut and bag drain
** Difference between cut and bagging and shortening is that the sutures are left in situ and the drain is not withdrawn
* Blocked drain
** Strip
** Can flush with sterile technique and a small amount of saline if needed, especially to keep small-calibre tubes open

[[Category:Operating theatre]]