Resident Readiness General Surgery 1st Ed.

A 78-year-old Woman and a 62-year-old Man With Drains

Michael F. McGee, MD and Brian C. George, MD

Mrs. Blackwell is 78-year-old woman who underwent a pancreaticoduodenectomy (Whipple procedure) 3 days ago. After the team sees the patient during morning rounds, your senior resident instructs you to remove the left-sided Jackson-Pratt (JP) drain. You confirm that the left-sided drain output has fallen to 10 cm3/day, and the drain amylase levels are normal. Later, as you are collecting the necessary supplies, you are paged by the nurse of Mr. Whitepoor, a 62-year-old man who underwent percutaneous image-guided drainage catheter placement by interventional radiology (IR) yesterday. The nurses report he is leaking large amounts of brown fluid from around his drain. You decide to first investigate Mr. Whitepoor’s drain issue.

1. What are the principles of drain management and how do you manage a leaking drain?

2. When should a drain be removed?

3. What bedside supplies are necessary to remove a drain?

4. What are the steps to remove a Penrose drain?

5. What are the steps to remove a closed-suction drain (eg, a JP drain attached to a suction bulb)?

6. How should an image-guided percutaneous drainage catheter be removed?

DRAINS

In the broadest sense, drains can be classified as active or passive. JP, Hemovac, and Blake drains are each attached to a suction apparatus and use active suction. When attached to a bulb, these drains form a closed system that applies negative pressure to the drain allowing suction-assisted evacuation of the target fluid. Some drains contain additional channels that allow sumping (ie, atmospheric venting) or combined irrigation–suction capabilities. In contrast, Penrose, Malecot, and Pezzer drains are passive drains reliant on gravity drainage, intra-abdominal pressure gradients, or capillary phenomena to drain fluid collections. Image-guided percutaneous drainage catheters can be either active or passive gravity drains depending on the collection apparatus used.

Answers

1. Drains require maintenance; therefore, knowledge of drain principles is essential for the surgical house officer. Narrow-bore closed drainage systems are prone to clogging from fibrinous exudates and clots and may become ineffective in the postoperative period. Drainage from around the drain site usually indicates a clogged drain rather than too large a skin aperture and should be treated with drain patency maneuvers rather than skin sutures or dressing reinforcement. Drain systems with elastic tubing can be “stripped” by carefully milking drain debris into the suction bulb thereby assuring continued drain patency. It should be noted that drain stripping is not a universally accepted practice as some surgeons fear high suction pressures can be harmful to the structures adjacent to the drain. Some drains, including sumping multichannel systems, allow for continuous or intermittent bolus irrigation (ie, flushing) of sterile saline to ensure drain patency. For example, scheduled, routine flushing is often performed for drains placed by IR.

2. The decision to remove a drain is irreversible; therefore, you must be sure of your actions. If uncertain about drain removal, confer with your senior resident or attending. Removing the wrong drain can put the patient at risk of needing a procedure to replace it.

There are some general guidelines regarding the timing of drain removal. Routinely placed intra-abdominal drains (like pelvic drains during routine pelvic dissection or perianastomotic JP during pancreaticoduodenectomy) are generally removed in the early postoperative period provided drainage is minimal and there is no evidence of leak or abscess. For intra-abdominal abscesses, the decision to remove a drain rests largely on the etiology of the abscess and the surgeon’s preference. Drains placed to control a septic source are managed on a more individualized basis. Evidence of succus, bile, or amylase-rich fluid in a drain is worrisome for leak and typically precludes early removal of the drain.

3. Regardless of the gravity of the procedure, surgeons must first ensure the correct supplies and instruments are gathered prior to commencing. Typically, a pair of suture removal scissors (generally part of a suture removal “kit”), dry sterile gauze, and tape are needed to remove most drain types at the bedside. A disposable impermeable sheet (eg, “Chux”) can also be helpful by limiting linen soilage and improving your standing with nursing.

After collecting the supplies, ensure that the patient is lying down and that the bed is raised to an appropriate height. The patient should be positioned so the drain site is easily accessed. The physician should be positioned on the side of the patient that provides the best access to the drain. A garbage can, if not already close at hand, should be positioned nearby.

4. Simple passive abdominal drains (eg, Malecot and Penrose drains) can simply be removed by cutting the securing suture (if used) and gently applying constant pressure until the drain slides out. Resistance may indicate an occult securing suture and merits investigation. The wound can be covered with dry gauze and typically is allowed to heal secondarily. Persistent leakage from the drain tract is expected until the wound epithelializes.

5. Closed-suction systems should be opened to the atmosphere prior to removal. Opening the drainage system eliminates suction and is thought to minimize the likelihood of intra-abdominal tissue injury when the drain is removed.

6. Image-guided percutaneous drains are typically referred to as “pigtail” catheters due to the coiled configuration of the catheter tip and require special consideration during removal. Some brands of pigtail catheters are “nonlocking” and will uncoil automatically when pulled. Other types of “locking” catheters contain an embedded wire or suture within the catheter that is drawn and secured to lock the catheter into a rigid coiled configuration. Removal of locking pigtail drains requires the deployment suture to be found and released prior to removal. Releasing the embedded suture in a locking catheter allows the drain to uncoil into a straight configuration for atraumatic removal. To avoid premature removal and confusion between locking and unlocking drain systems (and out of courtesy), any image-guided drain removal must first be discussed with the interventional radiologist.

TIPS TO REMEMBER

Image Drain removal is irreversible. Be doubly certain the correct drain is being removed at the appropriate time.

Image Just because a drainage tube is in place does not guarantee it is working. Follow drain outputs and check for patency each day.

Image Any image-guided percutaneous drain should be managed in consultation with the IR team.

COMPREHENSION QUESTIONS

1. Three days following an uneventful pancreaticoduodenectomy, you evaluate a patient for persistent drainage around a JP site. The patient’s gown is soaked in serous fluid and 8 large gauze pads overlying the drain are saturated. This should best be handled by which of the following?

A. Tightening the skin aperture around the drain site with an encircling skin stitch

B. Carefully stripping the drain tube to remove clot and fibrin

C. Applying additional pressure dressings to the drain site

D. Beginning diuresis to manage ascites leak

2. You are asked to remove a pigtail catheter placed by IR 6 days ago. While pulling the drain, you encounter resistance and patient discomfort. This should be handled by which of the following?

A. Opening the gravity collection bag to atmospheric pressure

B. Obtaining a sinogram through the tube

C. Carefully applying more tension when removing

D. Checking the catheter for a locking suture

Answers

1. B. Fluid follows the path of least resistance. Carefully stripping the drain (or flushing, if possible) will ensure a low-resistance path through the system and should fix this problem. Generally, extra skin sutures will not fix the leakage and will be painful for the patient. Note that while the patient may have ascites, ascites is not the problem—collecting it is.

2. D. Many pigtail catheters are locked into a coiled position and require release of the locking suture prior to removal. While venting a drain during removal is generally a good principle, resistance encountered during drain removal is an ominous sign and merits a call for help. A sinogram will not be helpful in diagnosing this problem.