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Tubes and Drains

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Tubes and Drains

  1. 1. 1 Tubes and drains Tube and Drains Definition
  2. 2. 2 Tubes and drains - A mechanical conduit to allow passage of substance be it gas, fluid and pus from the body to the external environment - Not always a tube (e.g. Corrugated drain) Classification Active Passive Open According to Prof Simon Ng, this type of drain does not exist Corrugated drain Yeaste drain Close Chest drain Jackson Pratt drain Robinson drain (tube drain) - Passive vs Active o Passive: Drain by the use of natural difference e.g. gravity, capillary action o Active (Suction): Drain by the use of suction force e.g. vaccum  Better tissue apposition  Effective evacuation  Less debris blockage  But may have higher chance of tissue erosion, not used in abdominal cavity - Close vs Open o Open system: Connected into the environment e.g. Dressing o Close system: Connected into a container/bag  Lower infection rate  Accurate measurement of output  Reduce contamination and promote infectious control Purpose - Therapeutic: o Drainage of collections of fluid, pus, blood or air o Apposition of tissue to remove a potential space by suction - Precautionary/ Prophylactic/ Monitor: Prevent leakage, Monitor of output e.g. Foley/Tubal drain Size - Diameter of tubes are often numbered as multiples of 2 - Unit: French (Fr/Ch) : 24 Fr = 24/pi = ~8 mm Materials - Common materials (Choice depends on purpose)
  3. 3. 3 Tubes and drains o Red rubber e.g. Sengstaken tube, corrugated drain o Latex rubber e.g. T-tube  Irritative, stimulate tissue fibrotic reaction o Silicon rubber e.g. Long term Foley  Widely use in clinically setting, expensive but inert, harder, suitable for long-term usage o Plastic How to identify a drain during examination? - By clinical photo o Specific features: ‘waveform’ of corrugated drain, ‘grenade’ of JP drain o Specific colour: NBT – pink, pigtail – white, T-tube – yellow (foley-like) - By bedside o Site: nose, neck, chest, abdomen, main-wound o Output: NBT & PTBD - bile (golden yellow or deep green), R/D – blood stained fluid o Marking on Bedside bag Complications - Mechanical o Trauma at insertion and removal o Erosion of adjacent tissue: fistula, hemorrhage, perforation o Herniation through tract o Anastomotic leak: Place too near the anastomoses - Physiological o Infection o Loss of fluid and electrolytes (excessive or inadequate) o Pain o Restricted mobility - Malfunctioning o Migration and dislodgment o Blockage (Externally by kinking, compression /Internally by tissue, clot o Suction failure Common general drains 1. Robinson Drain (Simple drain, tube drain)
  4. 4. 4 Tubes and drains a. Features i. Passive and closed ii. Made of latex iii. Not inert, induce inflammatory reaction and fibrous tract formation iv. Ease for later identification of site of tract v. Quality/Colour varies from brand to brand vi. Side-hole, radio-opaque line along the transparent tube, free drainage to BSB vii. Frequent change is necessary (1 week max) b. Indication i. Anticipated fluid collection in a closed space after major abdominal surgery, to prevent seroma formation e.g. Pelvic surgery laparotomy for perforated viscus 2. Jackson-Pratt drain (Vaccum drain) a. Features i. Active and close ii. One-way close system iii. The bulb must be deflated to provide suction iv. Flat tube with side holes v. Similar drain (Minivac)
  5. 5. 5 Tubes and drains b. Indications i. Use as wound drain (Often post-op) ii. For obliteration of a close space e.g. Parotid, MRM, thyroid surgery 3. Redivac® drain a. Features i. Active and close ii. Ready-to-use vaccum drain iii. Vacuum established in OT iv. Conventional: The angle of the antenna indicates vacuum status 1. V shape: good vacuum > Increase angle as vacuum loses v. New: The antenna indicating system is replaced by the green suction indicator (~ Minivac) vi. Same principle as JP drain, connected to glass bottles b. Indication: Same as JP i. Commonly seen in orthopedics c. Placement and Removal i. Remove if < 30 milliliters of fluid are draining from it in a day ii. Removal (3S) 1. Stitch removal 2. Suction discontinuation
  6. 6. 6 Tubes and drains 3. Slow and steady pull 4. Pigtail catheter a. Features i. Pigtail curve with side holes to avoid tissue trauma and improve draining surface area ii. Can be locked after placement to prevent dislodgement b. Indication i. For deep seated collection ii. For percutaneous nephrostomy, renal pelvis drainage c. Placement and Removal i. Placed under imaging guidance Urinary Catheter 5. Urinary Foley catheter a. Features: i. Balloon 1. For injection of water (which have the same density of urine)
  7. 7. 7 Tubes and drains 2. Self-retaining (Keep the catheter inside the bladder) to prevent self-off when the patient urinates 3. SALINE SHOULD NOT BE USED TO INFLATE THE BALLOON AS IT MAY CRYSTALIZE AND BLOCK THE TUBE (ASK FOR “WATER FOR INJECTION”!) 4. In case balloon fails to deflate, keep pumping in water to burst it in side the bladder ii. Valve 1. Made of self-sealing rubber to prevent leakage from puncture hole, gateway for inflation of balloon (Dome valve) b. Types i. Latex Foley: Short term drainage, yellow ii. Silicon-treated Foley: Minimize inflammatory reaction for long term placement, transparent iii. 3-way Foley: To be used in hematuria patient, water can be used to flush when necessary iv. Hematuric catheter: Metal core, harder than normal c. Indications i. Drainage of urine ii. Foley catheter can be used to drain suprapubic bladder iii. Chest drain in emergency iv. Stop nose bleeding by inserting into nasopharynx v. Stop anorectal bleeding d. Contraindication i. Urethral trauma e. Complications i. UTI ii. Trauma to urethral tissue f. Placement and Removal i. Suprapubic 1. Open method: OT 2. Close method: US guided at bedside
  8. 8. 8 Tubes and drains ii. Procedure of insertion of Foley 1. Patient identification, assess indication and contraindication 2. Consent 3. Position (Leg spread and feet together) 4. Aseptic procedure and universal precautions 5. Gather equipment (urinary catheterization set, CHECK EXPIRY DATE) 6. Open urinary catheterization set under aseptic technique 7. Ask assistance to pour you antiseptics solution and draw a syringe of water for injection 8. Soak cotton wool with antiseptics and prepare lubricant 9. Check balloon of the catheter and coat the catheter with lubricant 10.Clean the perineum with antiseptic solution, clamp the forceps on outer wrapping of the set a. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile field 11.Drape the sites with sterile cloths 12.Prepare the catheter and the kidney bean dish for urine collection later (put it on the draped area) a. 16-20 (Adult) b. 28 (Post-op prostate surgery e.g. TURP) c. 8 (Children) 13.Put a soaked gauze on the shaft of penis and pick up the penis and retract the prepuce with the non-dominant hand (NOW CONTAMINATED) and cleanse the urethral meatus with the previous clamp a. Using dominant hand to handle forceps, cleanse peri-urethral mucosa with antiseptic solution. b. LA catheter gel for analgesia (Can test the balloon of the catheter now if not done yet while waiting for LA to work) 14. Pick up the catheter by a new forceps (with the dominant hand) and hold the penis with the non-dominant hand through a soaked gauze, insert beyond 1-2 inches where urine is noted (collect the urine with the kidney bean container) a. Male: Make sure urine flow out before pumping balloon (Prevent the risk of damaging the membranous urethra) 15.Inflate the balloon and gently pull the catheter until it is snug against the bladder neck 16.Connect to bedside bag a. Make sure the bag is LOCKED 17.Reduce the prepuce and tape the foley correctly
  9. 9. 9 Tubes and drains 18.Documentation and proper disposal of waste 19.Check for output and inspect for traumatic hypospadia everyday 6. Malecot catheter a. Features i. Self-retaining ii. Rubbery and elastic b. Indications i. Chest drain ii. Jejunostomy feeding (No balloon has to be inflated to keep it in-situ thus no risk of luminal obstruction Abscess drainage 7. Corrugated drain a. Features i. Passive and open ii. A waveform strip of rubber and fit loosely and push into the depth of wound b. Indications i. Commonly used in limb wounds to drain DEEP SEATED ABSCESS ii. Skin recovery > Subcutaneous tissue recovery, so delaying wound closure 8. Yeates tissue drain
  10. 10. 1 Tubes and drains a) Corrugated; b) Penrose; c) Yeates a. Features i. Passive and open drain ii. Row of straws’ - Increase surface area and lumen provides capillary action drainage iii. Suitable for large volume drain b. Indications i. Same use as corrugated drain Nasogastric drainage 9. Ryle’s tube a. Features i. Commonly used nasogastric tube b. Indications: i. To drain gastric content to decompress stomach and prevent aspiration e.g IO or intraop use ii. Feeding (Not for long-term uses due to microaspiration pneumonia and discomfort c. Placement and Removal i. Estimate length: Nose > around ear > 5cm below xiphoid ii. Place NGT straight back (not up or down) through the nose iii. Keep asking the patient to swallow and neck flexed
  11. 11. 1 Tubes and drains iv. Confirm by 1: Auscultate for gurgling sound over stomach while injecting air; 2: Aspirating gastric content and test with Litmus paper pH <2 ; 3: Chest XR to confirm correct placement 10.Entriflex® tube a. Features i. Metalic weight at the end of tube (to ease placemet) ii. Radio-opaque: (to ease positioning by X-ray) iii. Central guidewire to facilitate insertion b. Indications i. Nasogastric tube for prolonged usage (thinner, siliconized to minimize tissue reaction and discomfort) ii. NOT for aspiration c. Placement i. Must pass the pylorus to facilitate absorption 11.Infant feeding tube (Fine bore feeding tube)
  12. 12. 1 Tubes and drains a. Indications i. Infant feeding ii. Temporary splinting of fibrous tract in PTBD dislodgment iii. Probing in exploration of fistula iv. Central line/Hickmann’s catheter v. Renal transplant patient 1. Inserted in ureteric orifice to prevent obstruction by fibrosis 12.Sump drain (Salem sump drain) a. Features i. Active and OPEN system ii. (Prof Simon Ng: Active and Close) iii. Double lumen (larger outflow lumen and smaller inflow lumen) iv. (Sieve system) The dual lumen tube allows for safer continuous and intermittent gastric suctioning. 1. The large lumen allows for easy suction of gastric contents, decompression, irrigation and medication delivery. 2. The smaller vent lumen (blue tube) allows for atmospheric air to be drawn into the tube and equalizes the vacuum pressure in the stomach once the contents have been emptied. This prevents the suction eyelets from adhering to
  13. 13. 1 Tubes and drains and damaging the stomach lining. b. Indications i. Pancreatic surgery ii. As a nasogastric tube 13.Sengstaken-Blakmore tube a. Features i. 3 channels (+ eso aspiration port = Minnesota tube) 1. Esophageal balloon 2. Cardiac aspiration (Monitor bleeding) 3. Cardiac (Gastric) balloon 4. Esophageal aspiration (for saliva and monitor leakage, absent in SB tube) ii. 2 balloons 1. Cardiac balloon a. As a tamponade to stop bleeding b. Inflated by 200-300 cc contrast + water to ease assessment of tube position by X-ray c. Water + methylene blue to visualize leakage if the balloon burst 2. Esophageal balloon a. Inflate with gas, 40 mmHg (>capillary perfusion pressure) b. Markers in cm for measurement iii. Stored in fridge to harden the tube for easier insertion b. Indications i. Temporary hemostasis of variceal hemorrhage by direct compression at bleeding site (<24hr)
  14. 14. 1 Tubes and drains ii. Aim: 1. Prevent exanguination (Massive bleeding that prevents immediate endoscopy and sclerotherapy 2. Stabilize patient before more definite treatment e.g. endoscopic sclerotherapy and banding c. Contraindication i. Large hiatal hernia ii. Known esophageal stricture iii. Unconfirmed variceal bleeding 1. Not even in a patient with chronic liver disease if variceal bleeding not confirmed, since it may convert a MW tear into a complete tear and esophageal perforation d. Drawbacks i. Hazardous and uncomfortable: GA and tracheal intubation in confused or agitated patients may be need ii. Skillful surgeons needed iii. Achieve temporary control, prolonged pressure will lead to necrosis of tissue 14. Flatus tubes
  15. 15. 1 Tubes and drains a. ~ NGT but shorter i. cf rectal tube: similar but shorter: For fleet enema and rectal clearance b. Short term use only c. Indications i. Decompression of the LB in pseudo-obstruction ii. Prevent immediate recurrence In derotation of sigmoid volvulus iii. Drainage of liquid feces and flatus Cardiopulmonary drainage 15.Nelaton catheter a. Suction catheter (Sputum suction) b. Indications i. Commonly used in emergency trolley/anesthesia to keep the airway patent. 1. Cholinergic drug will increase parasympathetic activity and highly increase mucus secretion ii. Rectal irrigation/washout (Thick and big catheter used) 16.Chest drain
  16. 16. 1 Tubes and drains a. Features i. One bottle 1. Under water seal chamber only ii. Two bottles 1. Additional collection chamber 2. Apply suction, same mechanism as Sump drain, open, release the pressure
  17. 17. 1 Tubes and drains iii. Three bottles 1. Additional suction regulation system a. Collection chamber: To collect pleural fluid b. Underwater seal: One way valve to prevent air from being sucked in by negative pleural pressure during inspiration i. Check swinging ii. Check bubbling c. Suction regulator: The amount of vacuum is directly proportionate to depth of the tip of the central tube under water surface (e.g. suction of -20cm H2O is achieved by placing tip of tube 20 cm below surface) i. It should always be bubbling if suction is on
  18. 18. 1 Tubes and drains ii. Amount of suction is regulated by the amount of water filled in the integrated 3 bottle system iii. Amount of suction can only be determined by temporarily stopping the pump Underwater seal chamber Interpretation Swinging Bubbling Yes Yes Indicates air leak from the lung or somewhere along the circuit The degree of air leak can be assessed in the “air leak meter” in the under water seal chamber in the integrated 3 bottle system The swinging reflects the negative pressure within the pleural space. Swinging is only seen if suction is not applied and decreases as the lung re-expands. No No Indicates resolution of air leak and lung re-expansion Make sure the tube is not obstructed. No Yes Indicates a possible connection or system air leak. Can temporarily occlude the chest tube right at the skin exit and if the bubbling continues then the leak is external to the patient. A hissing sound may point to the leak. Tape all connections securely. Yes No May be seen with partial or total pneumonectomy and in stiff lungs b. Indications i. Pneumothorax (>20%) ii. Trauma patient (hemothorax) iii. Effusion, empyema c. Placement and Replacement i. Note 1. Position of drain a. Apex of pleural cavity: Pneumothorax b. Base of pleural cavity: Effusion/Emphysema c. Confirmed by X-ray 2. Size of chest tube with trocar: a. 24 Fr (for effusion and air) b. 28 Fr (for blood and pus)
  19. 19. 1 Tubes and drains 3. Suction pressure: 15 mmHg (~ negative pleural pressure) ii. Caution 1. NEVER clamp a drain except in changing bottle as it can result in tension pneumothorax 2. NEVER push the chest drain back into the pleural space as it is now contaminated, change a new drain iii. Insertion 1. Patient identification, assess indication and contraindication 2. Aseptic procedure and universal precautions 3. Administer local anesthetics, infiltrate all layers until needle can aspirate free gas or fluid (inside pleural cavity) 4. Incision on the 4th ICS between anterior and mid-axillary line a. Safety triangle that avoid the long thoracic nerve and the pectoral major muscle b. More comfortable to the patient and allow less painful shoulder movement 5. Perform a blunt dissection OVER the rib into the pleural space a. Trocar puncture may injure lung parenchyma easily 6. Finger exploration to confirm intrapleural placement 7. Direct drains basally for effusion and apically for pneumothorax 8. Skin suture over the wound and make a knot, form a 2 cm sling by tying another square knot 2cm from previous knot. Tie the sling to the drain, make several knots to prevent slipping 9. Confirm position with CXR 10.Beware of re-expansion pulmonary edema 11.Daily CXR until removal iv. Complications 1. Trauma (Pneumothorax, hemothorax, hemoptysis, air emboli, liver and spleen) 2. Re-expansion edema 3. Empyema 4. Vagal shock
  20. 20. 2 Tubes and drains 5. Seeding mesothelioma 6. Surgical emphysema (MB question 2010) a. Check chest tube for proper functioning b. Relieve obstruction c. ± Apply suction, use large bore drain d. Release of air through skin incisions v. Things to comment in examination 1. Site of insertion a. left or right chest, safety triangle b. wound complications 2. Collection chamber a. Drainage substance (air, blood, pus or fluid) b. Amount drained (massive hemothorax?) 3. Underwater seal chamber a. Adequacy of seal (water level in the UWS chamber should be at level marked 0) b. Presence of bubbling indicates air leak (ask patient to cough if no bubbles) c. The column 1-5 indicates the degree of air leak d. The calibration column in the UWS chamber indicates the degree of negative pressure in the pleural cavity e. Presence of swinging with respiration movement indicates intrapleural position of the chest tube and the lung is still not yet full expanded i. Ask patient to take deep breath if not present 4. Suction regulation chamber a. Use of suction (bubbling in the SR chamber) b. Ask to stop the suction to look for the amount of suction applied in the suction regulation chamber 17.Tracheostomy tube a. Features i. Surgical procedure ii. Definitive airway iii. Type: Nonmetal/metal, cuffed/uncuffed, fenestrated/unfenestrated, short/long term, single/double lumen iv. Size: the largest and the most tolerable one ~3/4 diameter of trachea v. Materials: Portex and Shiley
  21. 21. 2 Tubes and drains 1. Portex (left panel): No inner tube, thermoplastic, used as initial airway postoperatively, less likely to traumatize trachea and allow the tract to mature 2. Shiley (right panel): With inner tube, fenestrated, allow patient to speak, and easier care (clean the inner tube regularly)
  22. 22. 2 Tubes and drains Tube Indication Recommendations CuffedTube with Disposable Inner Cannula Used to obtain a closed circuit for ventilation Cuff should be inflated when using with ventilators. Cuff should be inflated just enough to allow minimal airleak. Cuff should be deflated if patient uses a speaking valve. Cuff pressure should be checked twice a day. Inner cannula is disposable. Cuffed Tube with Reusable Inner Cannula Used to obtain a closed circuit for ventilation Inner cannula is not disposable. You can reuse it after cleaning it thoroughly. Cuffless Tube with Disposable Inner Cannula Used for patients with tracheal problems Used for patients who are ready for decannulation Save the decannulation plug if the patient is close to getting decannulated. Patient may be able to eat and may be able to talk without a speaking valve. Inner cannula is disposable Cuffless Tube with Reusable Inner Cannula Used for patients with tracheal problems Used for patients who are ready for decannulation Inner cannula is not disposable. You can reuse it after cleaning it thoroughly. Fenestrated Cuffed Tracheostomy Tube
  23. 23. 2 Tubes and drains Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak There is a high risk for granuloma formation at the site of the fenestration (hole). There is a higher risk for aspirating secretions. It may be difficult to ventilate the patient adequately. Fenestrated Cuffless Tracheostomy Tube Used for patients who have difficulty using a speaking valve There is a high risk for granuloma formation at the site of the fenestration (hole). Metal Tracheostomy Tube Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes. Patients cannot get a MRI. One needs to notify the security personnel at the airport prior to metal detection screening. b. Indications i. Failed intubation ii. Expected prolonged intubation (>1wk) iii. Therapeutic 1. Chronic airway obstruction (OSA, H&N Ca obstructing AW) 2. Acute airway obstruction: “When you think of it” Mosem’s dictim 3. Facilitate pulmonary toileting: In paralysed patients and prolonged intubated patients, allow easier suction iv. Prophylactic 1. H&N surgery postoperative swelling c. Care i. Suck and humidify ii. Hygiene: clean the inner tube and chest physio d. Complications i. Immediate 1. Trauma to the airway and neighbouring anatomical structures
  24. 24. 2 Tubes and drains a. Brachicephalic vein: particularly in children b. Esophagus c. RLN d. Trachea e. Pleura: pneumothorax 2. Delayed a. Irritation and Infection b. Malpositioning, displacement, erosion c. Obstruction i. Acute emergency, CALL FOR HELP ii. Replace with non-fenestrated inner tube (if present) iii. Try ventilating through the replaced tube iv. Try pass suction catheter to look for obstruction v. Deflate the cuff and bag-mask around the tracheotomy space vi. Remove the tracheostomy, cover with dressing and ventilate through mouth vii. Avoid re-inserting if recently created (tract not mature, may insert into the mediastinum viii.Avoid removal of tube if recently created, try to unblock it with suction catheter d. Subcutaneous emphysema e. Aspiration f. Persistent fistula (skin-trachea/ trachea-esophagus) g. Stenosis of AW h. Tracheomalacia i. Difficulty in weaning off j. Scar (keloid) k. Unable to speak 18.Laryngeal mask airway
  25. 25. 2 Tubes and drains a. Features i. NOT a protected airway, aspiration can still happen, so not for emergency OT, cesarean section, abdominal surgery 1. Usually for O&T surgery ii. Inflatable cuff to seal off the larynx iii. Can be sterilized and reused iv. Newly introduced in late 1980s v. Can be inserted blindly without laryngoscope
  26. 26. 2 Tubes and drains 19.Endotracheal tube
  27. 27. 2 Tubes and drains a. Features i. ET-tube ii. Plastic, disposable iii. ET cuff iv. Size marked on the tubes, length marking for insertion depth 1. The double black line marks the position level for vocal cord 2. 7 for female and 8 for male (usual) v. Can be double lumen for selected one lung ventilation 1. One lumen open in the trachea, one in the main bronchus, usually the right main bronchus (more vertical, easier insertion) b. Indication i. Airway protection (massive hemoptysis, hematemesis, GCS <8) ii. Ventilation (during resuscitation, operation) c. Contraindication i. Cervical spine injury: fiberoptic intubation ii. Mass lesion obscuring the upper AW d. Placement i. Insertion: With help of laryngoscope, stylet or bougie to guide the insertion ii. Sedation: With rapid sequence induction to prevent gag reflex and aspiration, or usual induction iii. Ventilation: With SaO2 and bag mask for oxygenation, end-tidal CO2 and monitoring iv. Prepare equipment (laryngoscope, ET tube, syringe for air insufflation, lubricants, bourgie/stylet, stethoscope for auscultation, bag and mask for preoxygenation and ventilation v. Check equipment (laryngoscope, balloon of the ET tube: inflate with 10 ml and deflate)
  28. 28. 2 Tubes and drains vi. Prepare the patient by pre-oxygenating the patients with 100% O2 for 5 mins vii. Prepare the airway with head-tilt chin lift maneuver viii.Rapid sequence induction: (Pressure, Sedate, Paralysis) 1. Apply cricoid pressure 2. Short acting sedatives (midazolam and propofol) 3. Rapid acting paralytic agents (suxamethonium, ~3 min with visible muscle twitching) a. Need to continue oxygenating the patient if RSI is not used, such as in routine GA setting ix. Insertion (should be <15 sec, otherwise re-oxygenate before retrial) 1. Largngoscope (hold with left hand and tilt the tongue to the left, avoid hinging on teeth, blade to valleculae, push the tongue down and pull the jaw to the ceiling) 2. Slide the ET tube down after visualization of the vocal cord (usually to 22 cm mark) 3. Inflate the cuff (10ml and feel the pilot balloon) x. Position confirmation 1. By bagging: smooth bagging 2. By P/E: symmetrical and adequate chest expansion and good AE on auscultation (3 pt: L/R chest and epigastrium) 3. By Ix: Positive ETCO2 (gold standard), CXR confirmation: 2 cm above the carina e. Complications i. Damage to oropharyngeal airway: teeth, trauma, hoarseness ii. Esophageal intubation (inflated stomach with unprotected airway > aspiration) iii. Ventilation associated infection in long term use iv. Sedation complications (malignant hyperthermia in suxamethonium) Hepatobiliary drainage 20.Nasobiliary tube a. Features i. Pink in colour with side holes b. Indication i. Temporary relief of biliary obstruction similar to internal stent 1. Efficacy similar to internal stent 2. Enable drainage monitoring in very ill patients 3. Enable repeated aspiration in hemobilia c. Relative C/I
  29. 29. 2 Tubes and drains i. Confused patient (They will pull off the drain) d. Placement and Removal i. Placed via ERCP up to right hepatic duct ii. Removed within same admission iii. AXR showed alpha sign confirms good position 21.Percutaneous transhepatic biliary drainage a. Features i. Invasive ii. Inserting a catheter through a skin incision into the obstructed bile duct > CBD > Ampulla of Vater > Duodenum iii. Cholangiogram is performed to define the anatomy iv. Subsequent internalization 1. Internal/external drainage 2. Internal drainage by stenting on another day, usually days or weeks after the initial PTBD) of the PTBD facilitates internal drainage of bile, which reduces the loss of fluid and electrolytes v. Side-holes along the drain extending back to about 15 cm from the tip (instead of 5 cm with multi-purpose catheters). vi. Extra proximal holes allow the catheter to serve as a stent. 1. Bile from the upper part of biliary tree will enter the proximal side-holes and run within the biliary catheter before exiting into the duodenum via the distal side-holes. b. Indication i. Biliary decompression and ERCP contraindicated ii. Palliative biliary drainage in cholangioCA c. Placement and Removal i. Placed under image guidance with DILATED DUCTS by interventional radiologists ii. Patient needs to hold breath at inspiration. d. Complications i. Cholangitis and wound infection ii. Catheter dislodgment
  30. 30. 3 Tubes and drains 1. Splint the tract temporarily by inserting infant feeding tube iii. Hemobilia and sepsis iv. Injury to other organs (Kidney, perforation of duodenal diverticulum, pleura > Pneumothorax and bilothorax v. Contrast related 22.Cholecystostomy tube a. Features i. To drain the gallbladder (Percutaneous cholecystostomy) ii. Difficult to differentiate from PTBD in bedside due to similar content and position b. Indication i. Mx of acute cholecystitis in surgically unfit patients c. Placement and removal i. Placed in OT surgically or percutaneously 23.T-tube a. Features i. Siliconized/ non-siliconized/ latex
  31. 31. 3 Tubes and drains ii. Normally used size: 14,16,18 iii. T-tube is placed inside the common bile duct iv. If the distal portion of the duct is blocked: bile will be drained out v. Intraluminal block removed: bile will flow down CBD, as a lower pressure track b. Indication i. Monitoring of biliary complication after exploration of CBD 1. Safety valve for bile drainage in case of temporary obstruction ii. Small drain (with the head of T-tube cut, Max 18 Fr) c. Placement and Removal i. Placed in the OT ii. Upper limb should not be longer than the level of hila iii. Lower limb should not touch the ampulla of Vater 1. ‘Cut-open‘: To prevent crystallization of bile and blocking the tube 2. ‘Tilted’: To prevent obstruction (CBD is not straight) iv. Removal 1. Day 10: Retrograde/T-tube cholangiogram to reveal CBD/ choledocoscope 2. Clamp the T-tube and observe for few days to rule out biliary leak before removal 3. Day 14: T-tube withdrawal with a fibre-tract well formed. Spontaneous closure of the hole will be achieved <1 hr after removal

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