Surgical drains & its recent advancements
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- 2. Surgical Drains & its Recent Advancements By Dr. Hakeemullah khan (TMO SDW LRH) 2
- 3. Contents Introduction Why to Drain ? Classification Advantages/Disadvantages Ideal Drain General Guidance Removal Evidence and Controversy Mechanical Problems of Drains Recent Advancements Conclusion 3
- 4. Introduction A drain is a tube to allow fluid or air that might collect at an operation site or in a wound to drain freely to the surface. The fluid to be drained may include – Blood, serum, pus, urine, faeces, bile or lymph. It can be used for longer or short periods. 4
- 5. Why to Drain ? To allow wound irrigation in certain specific circumstances. ( reduce - haematoma formation ) To prevent an excessive amount of blood and fluid that collects in the cavities of the body, and around organs that may delay wound healing. 5
- 6. Classification of Drains Surgical Drains can be classified as: Open and Closed Active and Passive 6
- 7. Classification (Continued) Open Drains Include corrugated rubber or plastic sheets. Drain fluid collects in gauze pad or stoma bag. They increase the risk of infection. 7
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- 9. Classification (Continued) Closed Drains Consist of tubes draining into a bag or bottle. They include chest and abdominal drains. The risk of infection is reduced. 9
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- 12. Classification (Continued) Active Drains Active drains are maintained under suction They can be under low or high pressure 12
- 13. Classification (Continued) Passive Drains Passive drains have no suction Function by the differential pressure between body cavities and the exterior 13
- 14. Comparison of Active & Passive Drains Active Drain Passive Drain Function Works by negative pressure created by compressible drums or mechanical evacuation system Depends upon pressure differentials & gravity Pressure Gradient Negative Pressure Normal Drain Exit Site Dependent Position is not necessary Dependent position for best function Retrograde Infection Lower incidence Higher incidence Fluid Collection Decreased incidence because negative pressure improves tissue apposition & obliterates dead space Increased incidence because of limited effect on dead space Obstruction of Drain More common Less common Pressure necrosis Greater incidence Less common 14
- 15. Advantages of Drain Removal of any intraperitoneal or wound collection of ascites, serum, bile, chyle, pancreatic or intestinal secretions. Act as a signal for any post-op. hge or anastomotic leakage. Provides a track for later drainage. 15
- 16. Disadvantages of Drain Presence of a drain increases the risk of infection. ( intra-abdominal & wound ) Drains may induce an anastomotic leak. Increase abdominal pain. Increase hospital stay. Decrease pulmonary function. 16
- 17. Ideal Drain An ideal drain should be…. Drain should be firm, not too rigid. It should not be too soft as it may twist or kink or become blocked. It should be smooth. It should be resistant to decomposition or disintegration. Wide and patent enough to prevent easy blockage. It should be non electrolyte non carcinogenic and thrombogenic when used in vascular surgery. 17
- 18. General Guidance If active, the drain can be attached to a suction source (and set at a prescribed pressure). Ensure the drain is secured (dislodgement is likely to occur when transferring patients after anaesthesia). Dislodgement can increase the risk of infection and irritation to the surrounding skin. Accurately measure and record drainage output. Monitor changes in character or volume of fluid. Identify any complications resulting in leaking fluid (particularly, for example, bile or pancreatic secretions) or blood. Use measurements of fluid loss to assist intravenous replacement of fluids. 18
- 19. Removal Generally, drains should be removed once the drainage has stopped or becomes less than about 25 ml/day. Drains can be 'shortened' by withdrawing them gradually (typically by 2 cm per day) and so, in theory, allowing the site to heal gradually. Usually drains that protect postoperative sites from leakage form a tract and are kept in place longer (usually for about a week). Warn the patient that there may be some discomfort when the drain is pulled out. Consider the need for pain relief prior to removal. 19
- 20. Removal (Continued) Place a dry dressing over the site where the drain was removed. Some drainage from the site commonly occurs until the wound heals. When to remove: Drains left in place for prolonged periods may be difficult to remove. Early removal may decrease the risk of some complications, especially infection. 20
- 21. Evidence & Controversy There is insufficient evidence from randomised controlled trials (RCTs) to support the routine use of closed suction drainage in orthopaedic surgery. Further RCTs with larger patient numbers are required for different operations before definite conclusions can be made for all types of orthopaedic operations. Despite the paucity of clinical evidence demonstrating any benefit supporting their use, drains continue to be placed after elective orthopaedic procedures. The routine use of drains may be abandoned in uncomplicated thyroid surgery. 21
- 22. Evidence & Controversy (Continued) The routine use of a suction drain is unnecessary after an uncomplicated total joint arthroplasty. There are insufficient studies which compare differing methods of chest drain clearance to support or refute the relative efficacy of the various techniques in preventing cardiac tamponade. The need to manipulate chest drains can neither be supported nor refuted by results from RCTs. The optimal time to remove drains after total joint arthroplasty is 24 hours. 22
- 23. Evidence & Controversy (Continued) Pelvic drainage may act as an early detector of anastomotic leaks and reduce the need for re-operation in selected patients undergoing rectal cancer surgery. However, others consider that leaks usually occur after drains have been removed and that they are not useful in this way. Drain use after elective laparoscopic cholecystectomy increases wound infection rates and delays hospital discharge. Evidence to support the use of drain after the following procedures could not be found: Laparoscopic cholecystectomy. Open cholecystectomy. 23
- 24. Evidence & Controversy (Continued) Evidence for drains reducing infection and haematoma formation after breast surgery is inconsistent. There is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications. Damage may be caused by mechanical pressure or suction and drains may even induce an anastomotic leak. Drains are not a substitute for good surgical technique. 24
- 25. Mechanical Problems of Drains Trauma to tissues. Erosion of adjacent tissues, may lead to perforation or fistula formation, haemorrhage. Herniation of viscera through the drain tract. Anastomotic leak- drains are sometimes placed near anastomoses. 25
- 26. Recent Advancements Several attempts have been made to improve the functionality and reduce significantly, complications associated with the use of drains in surgery. Thus, over the few years, major advances in surgical drains have been recorded in the following areas. 1. Drains with one way entry valves to secure against reflux of contaminated fluid from reservoir have now been developed. 2. Bottom drainage ports placed at the opposite end of the reservoir from entrance port, to prevent contamination, and ease the emptying process. 26
- 27. Recent Advancements (Continued) 3. Soft, supple and low profile drains to enhance easy positioning and conformation to anatomical curvatures. 4. Multiple sump lumens to create high internal flow rates that accelerate fluid removal without applying excessive or traumatic suction to delicate tissues. 5. Dual lumen to allow introduction of saline, anesthetic or use as a sump. 27
- 28. Recent Advancements (Continued) 6. Rotating garment clips to bring about convenience to care giver and increase mobility to the patient have been developed. 7. The use of variable sizes of drains with special specifications to meet specialist demands is expanding rapidly . 8. Non-clogging silicone formulation has solved the problem of clot build-up. The high flow through accelerates fluid movement without excessive suction. 28
- 29. Recent Advancements (Continued) 9. Anti-thrombogenic coating of drains (both internally and externally) provides surfaces with lowest coefficient of friction. It makes insertion and removal easier and reduces the problem of adjacent tissue trauma or erosion. 10. Further efforts are in place to provide surgeons the needed specificity, functionality and greater flexibility in their selection of drain systems. The drainage need of all surgical specialties is intended to be met by offering the widest range of sizes, options and specialty specific features. 29
- 30. Conclusion There are a variety of factors which are very important for the use of surgical drains but surgeons should understand the benefits and application of drains and the tissue responses to the constituent material so as to prevent some of the commonly seen complications. Three questions are essential and serve as a basic frame work which must be considered when deciding on the value of surgical drains. 1. What purpose would a drain serve if placed? 2. What type of drains should be used? 3. 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 advantages can be maximized with minimal problems. 30
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