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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.

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

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2. When should a drain be removed?

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Drains

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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.

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Answers
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  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 ...

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