Surg Med - Drains, Tubes, and Lines - Exam 2

Surgical Drain Function

Allows air to escape

Allows liquid accumulation to be evacuated

Prevents collections that would elevate a skin flap

Minimizes dead space

Decompresses the wound

Intra-abdominal drains are a window into the abdomen

Seroma

Serous fluid in dead space that prevents proper tissue adhesion and healing

Seroma RF

obesity

lymphatic disruption

any surgically created dead space

Seroma Presentation

painless, fluctuant swelling

fluid wave

clinical +/- US

what is the diagnosis for a seroma?

Seroma Dx

prevent with drains

compression

aspiration

Hematoma

post-op bleeding into tissue

promotes infection, delays wound healing, increases inflammation and pressure

Anticoags, poor hemostasis

what are risk factors for a hematoma?

Hematoma Presentation

tender, firm swelling with discoloration

clinical, imaging if deep

what is the dx for a hematoma?

Hematoma Tx

observation vs surgical evacuation

Active Drains (Jackson-Pratt, Blake, Hemovac)

Use suction (bulb or wall) to draw fluid

Reduces infection risk

Hemovac

Used in ortho, spine, abdominal surgeries

Bulky but larger reservoir (up to 400 mL)

Slightly stronger suction

Passive Drains (Penrose)

Rely on gravity/capillary action

Allow fluid to exit without suction

Remove before 5 days or granulation tissue forms

Drain Removal

Most drains can be removed if they are putting out less than 30cc/day

Always wear gloves

Apply pressure at insertion site

Sometimes significant force may be required to remove the drain

Suturing of the drain site on case-by-case basis

Gastrostomy Tube

Placed percutaneously directly into stomach or through open surgical incision in the abdomen

PEG (percutaneous endoscopic gastrostomy) vs "open" G-tube

Provides adequate nutrition and delivery of medications

G Tube Indications

Dysphagia

Difficulty chewing

Poor PO intake/malnutrition

Aspiration

Intractable emesis

Severe reflux

Duodenostomy Tube

A tube placed into the duodenum, most commonly used for: Decompression, Drainage, Protection of a duodenal repair

NOT typically routine long-term feeding

D Tube Indications

Duodenal trauma

Perforated ulcer repair

Complex upper GI surgery

Anastomotic protection

Jejunostomy Tube

Feeding tube surgically placed into the jejunum

J Tube Indications

Esophageal/stomach/duodenal pathologies

Esophageal cancer

Gastroparesis - poor gastric emptying

Duodenal injury

Do not bolus feed

Cholecystostomy Tube

Used when gallbladder is too inflamed for removal

May be useful when patient is too ill to tolerate surgery

May be done percutaneously by IR or during laparoscopic/open procedure

Access for cholangiography

Goal is to decompress biliary system

T-Tube (Biliary Drainage)

Placed into common bile duct to drain bile

Decompress the biliary tree after surgery

Prevents pressure buildup or leakage

Allow access for imaging (T-Tube cholangiogram)

T Tube Indications

Cholangitis

Biliary stricture

Bile duct surgery/repair

Chest Tube

Removes air in the pleural space - pneumothorax

Removes fluid in the pleural space - hemothorax, pleural effusion, chylothorax

Removes pus from pleural space - empyema

Thoracostomy Tube

Free end is attached to an underwater seal below the level of the chest

Allows air or fluid to be removed from the pleural space but prevents anything from returning to the chest

Local anesthetic used; small incision made

Patient instructed to do a deep inspiration to depress the diaphragm

Cecostomy Tube

Accesses the colon directly for removing gas, stool, or irrigating the colon

Flushes help push stool toward the rectum

Reverse enema port

C Tube Indicatons

Neurogenic Bowel/Chronic Constipation

Severe Fecal Impaction

Central Venous Access

Fast, reliable central access - often urgent/emergent placement

Often for patients in intensive care

Monitoring for central venous pressure (CVP)

CVA Common Sites

Internal jugular

Subclavian (lower infection risk)

Femoral (higher infection/thrombosis risk)

Terminates in the SVC just above the right atrium

CVA Indications

Drugs that can't be given peripherally - vesicants/irritants that can cause severe damage to tissue if extravasated

Frequent blood draws

Resuscitation

Long term abx

Long term TPN - high osmolality solution that can damage peripheral veins

CVA - Common Drugs

Calcium Chloride

Chemo

Hypertonic saline

Potassium chloride

Amiodarone, levophed, epi

CVA Comp

Always CXR after placement

Look for correct placement and possible comp → PTX/hemothorax

Other comp: Infxn, Hemorrhage, Hematoma, Arrhythmia, Air embolism

CVA Removal

Trendelenberg position if possible

Ask patient to hold breath or time the removal on the patient's expiration

Hold pressure on the removal site for 5 minutes and cover with occlusive dressing

Leave dressing in palace for 24 hours

Tunneled Central Venous Catheter (Hickman)

Visible, external tubing

Direct external access

Requires routine flushing + drainage

Higher infection risk

Ideal for daily access (TPN, frequent labs)

Implanted Venous Access Ports (Port-A-Cath)

Not visible (completely under skin)

Needle access through skin

Maintenance minimal when not accessed

Lower infxn risk

Ideal for intermittent chemo, outpatient use

Peripherally Inserted Central Catheters (PICC)

Inserted:

Basilic/brachial/cephalic vein

Tip ends centrally in the SVC, just above the right atrium

PICC Advantages

Bedside placement

Good for prolonged abx

PICC Disadvantages

DVT risk

Cannot always support high flow

Not ideal in CKD patients needing future fistulas

Midline Catheters

Midline tip does NOT reach central circulation

Use:

-Intermediate-duration therapy (<1 month)

-Difficult access

-IV abx not requiring central delivery

-Single lumen

Midline Catheters - Do NOT use

Vesicants

TPN

Many pressors

Peripheral IV Catheter Indications

Short-term

Non-vesicants

Routine fluids/meds

PIV Catheter Limitations

Short duration

Extravasation risk

Limited flow/longevity

Arterial lines

Purpose:

-Continuous BP monitoring

-Frequent ABGs

Most common site: radial artery

Art Line Comp

Thrombosis

Ischemia

infection

Temporary Dialysis Catheter

Large bore

Non-tunneled

IJ preferred

Use: emergent dialysis

Tunneled Dialysis Catheter

Longer-term dialysis access

Lower infection risk

Dialysis Catheters Major Comp

Infection

Central stenosis

Thrombosis

Pulmonary Artery Catheters (Swan-Ganz)

Measures:

-Pulmonary artery pressures

-Cardiac output

-Filling pressures

Pulmonary Art Catheter Uses

Cardiogenic shock

Advanced ICU management

Complex heart failure

Pulmonary Art Catheters Classic Comp

Arrhythmias during insertion

Pathway: RA → RV → PA