dead space management in maxillofacial surgery

1. MANAGEMENT OF DEAD SPACE AND
SUCTION DRAINS
PRESENTED BY-
DR. SUJAY S. PATIL
1 YR PG
DEPT. OF ORALAND MAXILLOFACIAL SURGERY

2. WHAT IS A DEAD SPACE?
 Dead space, by definition, is a space left in the
body as a result of a surgical procedure.
 The term is commonly used to describe spaces resulting from the
removal of a space-occupying mass or evacuation of fluid, tissue
dissection resulting in disruption of tissue or facial planes, and
tissue separation or disruption secondary to trauma (e.g., bite
wounds, vehicular trauma, high-velocity projectile wounds).

3.  Dead space creates a pocket or cavity in which tissue fluid or
blood can accumulate (e.g., seromas, hematomas); excessive fluid
accumulation separates tissue planes, and its persistence can delay
or prevent normal healing. Moreover, fluid accumulation may
contribute to infection, especially in the presence of
contaminants. As a result, appropriate dead space management is
important to both the and management of infection.

4.  There are several techniques used to manage dead space,
depending on the size, location, and cause of the tissue pocket.
These options include no treatment, external bandage
compression, suture closure, use of a drainage system, and
aspiration; each can be used alone or in combination to control
dead space.

5. CAUSES OF DEAD SPACE
 The volume of a pocket or defect created when a space-occupying
mass (e.g., tumor, granuloma, organized hematoma) is removed
often approximates that of the lesion.
 Wide surgical dissection results in disruption of normal tissue
planes, creating a potential space. Combined with surgical trauma
and regional movement, seromas formation may occur.
 Loose or elastic fascial planes are potential areas for fluid
accumulation, especially in the face of regional trauma.
 Vehicular trauma is the most common form of blunt trauma. Both
direct and indirect trauma can cause soft tissue to stretch, tear, or
avulse, thereby creating dead space.

6.  Orthopedic trauma and subsequent fracture repair can result in
variable degrees of soft-tissue disruption and dead space
formation.
 Bite wounds often result in the crushing, stretching, tearing, and
laceration of the skin and underlying tissue. Without appropriate
wound management, tissue trauma, circulatory compromise,
contamination, and formation of dead space predispose the
patient to infection.
 High-velocity projectile wounds can cause significant tissue
disruption and significant dead space formation as a result of
cavitation and tissue trauma secondary to fragmentation of bone;
frangible bullets also intensify local tissue trauma.

7. PHYSICAL EXAMINATION
Dead Space Secondary to Trauma
 Vital signs should be immediately assessed, including the basic
“ABCs” (airway, breathing, and circulation). Emergency
treatment should be instituted in critically injured patients.
 All trauma patients require a complete physical examination,
regardless of presentation.
 Patients should be assessed and treated for pain at the time of
presentation as well as pain anticipated for the surgical procedure
after assessment of the injuries.

8.  Disrupted tissue planes may include separation of the skin from the
underlying tissue attachments. When grasped, the skin readily lifts
away from the underlying musculofascial layer. If a skin defect is
present, lifting the skin creates a vacuum effect, which sucks air into
the subcutaneous space.
 Palpation over areas of intact skin may reveal irregularities of the
musculofascial tissue; suspected areas of tissue disruption can be
compared with the corresponding area on the opposite side of the
patient (provided the area is uninjured). Muscle tears and avulsion
wounds are noted as gaps or depressions with deep digital palpation.
Herniation of abdominal contents also may be noted.

9.  Depending on the age and condition of the wound, tissue fluid,
blood, or pus may collect in the traumatized area and gravitate in a
ventral or distal direction. Palpable fluctuance may be noted with
significant accumulation of blood, serum, or pus. This accumulation
can further expand the dead space by stretching or displacing
adjacent tissues.
 Tears in the pharynx and trachea may result in mild to massive
accumulation of air beneath the skin (subcutaneous emphysema).
Air distention displaces the skin, creating a dead space pocket of air.

10.  Open wounds are usually easier to examine preoperatively than
are wounds covered by an intact skin surface; dead space volume
is assessed by the visible tissue disruption.
 Tissue is initially assessed for degree of contamination and
potential viability. However, intraoperative assessment of the
wound is more important in determining the appropriate options
for managing dead space.

11. Dead Space Associated with Surgery
 Extensive debridement, dissection, excision, and undermining of
tissues may be necessary; this should be followed by assessment
to determine how to manage the dead space created.
 The amount of excess skin present after removal of a space-
occupying mass is assessed to determine if additional skin
resection may improve dead space control and the resultant
cosmetic outcome.

12. TREATMENT RECOMMENDATIONS
Initial Treatment Options
 The primary goal of controlling dead space is to prevent tissue fluid
and blood from accumulating in the disrupted tissue area. Their
accumulation separates the normal tissue planes, thereby delaying
the normal healing process. Moreover, the risk of infection is
increased, especially in the presence of contaminants. Connective
tissue restoration (fibroplasia, collagen deposition) can be
accomplished more effectively by controlling dead space. There are
several surgical and nonsurgical options that can be used alone or in
combination to control dead space in wounds. Drains are generally
used for the more substantial dead space regions but may be
combined with compressive wraps and basic suture apposition
techniques employed in wound closure.

13.  In some cases, the presence of a small, self-limiting seroma may
require little or no treatment; over time, the body reabsorbs serum.
Because excessive activity can impair dead space management,
exercise restriction and the appropriate use of bandages can reduce
regional motion at the surgical site.
 Closure of small skin defects involving the mid to lower
extremities normally demonstrates a variable degree of incisional
tension at closure. Slight tension helps prevent the development of
seromas. Minimizing surgical trauma reduces the likelihood of
postoperative inflammation that contributes to seroma formation in
the surgical dead space created. Postoperatively, small incisional
seromas normally resolve without treatment. Warm compresses
applied for 10 to 15 minutes two or three times daily over a 1-week
period may facilitate fluid resorption.

14. ADDITIONAL TREATMENT OPTIONS INCLUDE THE
FOLLOWING
Compressive Bandages
 Application of mildly compressive bandages can be used to
compress dead space areas, reduce regional motion, and protect the
wound while helping to limit postoperative swelling. Fibrin
deposition and subsequent collagen deposition will occur between
apposed tissue layers during the reparative phase of wound
healing.

15. WHAT IS A SURGICAL DRAIN?
 A surgical drain is a tube used to remove pus, blood or other fluids
from a wound.
 Drain inserted after surgery do not result in faster wound healing
or prevent infection but are sometimes necessary to drain body
fluid which may accumaulate and in itself become a focus of
infection

16. INDICATIONS
1. Help to eliminate dead space.
2. To evacuate existing accumulation of fluid or gas, to
remove pus, blood, serous exudates etc.
3. To prevent the potential accumulation of fluid or gas.
4. To from a controlled fistula .
5. Accurate recording of the volume of drainage as well as
the contents
Drains may be hooked to wall suction, a portable
suction device, or they may be left to drain naturally.

17. CLASSIFICATION
 Open Vs Closed systems
 Open
 Closed
 Active Vs Passive
 Active
 Passive

18. OPEN DRAINS
 Includes corrugated rubber or plastic sheets
 Drain fluid collects in gauze pad or stoma bag.
 They increase the risk of infection
CLOSED DRAINS
 Consist of tubes draining into a bag or bottle.
 They include chest and abdominal drains.
 The risk of infection is reduced.

19. ACTIVE DRAINS
 Active drains are maintained under suction
 They can be under low or high pressure.
PASSIVE DRAINS
 Passive drains have no suction
 Drain by means of pressure differentials, overflow, and
gravity between body cavities and the exterior.

20. JACKSON-PRATT DRAIN
 Jackson-pratt drain, jp drain, bulb drain, is a drainage device
used to pull excess fluid from the body by constant suction.
 The device consists of flexible plastic bulb– that connects to an
internal plastic drainage tube.
 The jp drain is used as negative pressure vacuum, which also
collects fluid. As low negative pressure suction system, it is
designed so that intra abdominal content such as the omentum or
intestines are not sucked into the tube, minimizing the risk of
bowel perforation or ischemia.

23. CORRUGATED RUBBER DRAIN ( OPEN DRAIN)
 Rubber causes a tissue reaction and the drain track caused by this
material persists longer than when inert material persists longer
than when inert materials arc used. The drain is fixed by a suture
at the end of the wound and a safety pin must be placed through
the end to prevent the drain slipping inwards. Corrugated rubber
drains can be used for wound or for deep drainage.

24. CORRUGATED RUBBER DRAIN

25. T-TUBE
 Kehr’s T tube : a tube consisting of a stem and a cross head ( thus
shaped like T ). The cross head is placed into common bile duct
while the stem is connected to a small pouch ( i.e. bile bag ). It is
used as a temporary post-operative drainage of common bile duct.
Sometimes its used in uretic problems too.

26. T-TUBE

27. CHEST TUBE ( CLOSED DRAIN )

28. RISKS OF CHEST TUBE INSERTION
 Although chest tube insertion is commonly used as a therapeutic
measure, there are several complications that can develop,
including:
 Bleeding from an injured intercostal artery( running from the
aorta).
 Accidental injury to the heart, arteries, or lung resulting from the
chest tube insertion
 A local or generalized infection from the procedure.
 Persistent or unexplained air leaks in the tube
 The tube can be dislodged or inserted incorrectly
 Insertion of chest tube can cause open or tension pneumothorax.

29. CLOSED VACUUM DRAINAGE SYSTEMS
 Closed vacuum drainage systems have gained increasing
popularity in surgical field to control moderate to large dead
space pockets. The continuous vacuum effectively draws tissue
planes together, creating a “shrink wrap” or “vacuum pack” effect
as residual air and fluid are removed from the dead space pocket.
Unlike Penrose drains, vacuum drains function without relying on
gravity to facilitate fluid removal; they can be placed in a variety
of areas, including deeper dead space areas (e.g., deep pockets,
orthopedic surgeries with extensive soft-tissue trauma).

30.  A vacuum reservoir (100- to 150-ml capacity) attached to a
fenestrated drain aspirates serum that normally
accumulates in the dead space postoperatively. The
nonfenestrated portion of the tube exits the skin through a
small stab incision; a purse-string suture secures the tube
to the skin. The external end of the drain is connected to
the fluid reservoir; in most models, a one-way valve
prevents reflux of the reservoir contents and accumulated
contaminants back into the wound. Most commercial
reservoirs either use an internal spring to create a vacuum
by forcing the chamber walls apart or rely on the inherent
“rebound” elastic properties of the chamber to create the
vacuum. All reservoirs have a spout to evacuate air and
accumulated fluid, with a milliliter scale to measure the fluid
accumulated. Drains are normally removed when fluid
volumes become minimal.

31. NEGATIVE PRESSURE WOUND THERAPY
 Negative pressure wound therapy involves the use of enclosed
foam and a suction device attached ; this is one of the newer types
of wound healing/drain device which promotes faster tissue
granulation, often used for large surgical/trauma/non-healing
wounds.

33. PIGTAIL DRAIN
 A pigtail drain tube is a type of catheter that has the sole purpose
of removing unwanted body fluids from an organ, duct, or
abscess. Pigtail drains are inserted under strict radiological
guidance to ensure correct positioning.
 A pigtail is a sterile, thin, long, universal catheter with a locking
tip that( once inserted and adjusted by the radiologist) forms a
pigtail, shape, hence its name. A guide wire is also part of the
sterile insertion kit.
The tip of the pigtail has several holes, which
facilate the drainage process. The open end of the
catheter has an outlet, which is compatible with an
intravenous (IV) luer lock

34.  Pigtails are inserted percutaneously (through the skin) by a
radiologist. It may be inserted to allow, for ex. Urine is to drain
directly from a kidney, if the ureter is diseased or blocked. This is
called a nepherostomy.
 Other conditions requiring the insertion of a pigtail drain include a
blocked bile duct that needs to be drained of bile or a pus filled
abscess. The type of fluid that drains depends upon the reason for
its insertion.

35. PIG TAIL DRAIN

36. DAVOL DRAIN
 This closed wound suction system features soft, inert silicone
drains with x-ray opaque stripe for easy placement identification.
 It is designed to minimize tissue trauma and discourage clogging.
 Drains have a triple lumen configuration to increase drain
versatility and effectiveness. Large center lumen for maximum
removal; filtered air vent helps reduce risk of infection. Third
lumen permits irrigation and instillation of medicine. 0.3 micron
antibacterial filter removes virtually all bacteria from incoming air.
Suture cuff helps fasten drain.

37. DAVOL DRAIN

38. REDVIC DRAIN
 This is a fine tube with many holes at the end, which is attached
to an evacuated glass bottle providing suction. It is used to drain
blood beneath the skin, e.g. after mastectomy or throiodectomy,
or from deep spaces, e.g around a vsacular anastomosis.

39. REDVIC CLOSED DRAIN

40. PENROSE DRAIN (OPEN DRAIN)
 A penrose drain is a surgical device placed in a wound to drain
fluid. It consists of a soft rubber tube placed in a wound area, to
prevent the build up of fluid/ Pus.
 Penrose drains have been used in the management of dead space
and dead space seroma formation for decades.

41.  They are most commonly used to control small to moderate-sized
areas of dead space. They function by directing fluid by capillary
action over their external surface; the drain exits in a dependent
position, allowing fluid to exit the body by gravity. Such drains
normally are used to manage dead space for 3 to 5 days, unless
significant drainage persists after this time. Anchor the dorsal or
proximal end of the drain with an external skin suture and a single
suture placed into the drain and exit incision. The drain can be
covered with a protective or compressive wrap, depending on the
body region affected

42.  Penrose drains are a potential source of wound contamination; they
also allow air to enter the subcutaneous area. When used in the
axillary or inguinal areas, a “sucking wound effect” is occasionally
noted, whereby air is “pumped” beneath the skin. The resultant
subcutaneous emphysema normally is minimal but could become
more substantial if the drain is retained over an extended period.
Under these circumstances, air is slowly reabsorbed once the drain
is removed.

43. PENROSE DRAIN

44. GENERAL TIPS ON USING DRAINS
 The exit site is placed distal or ventral to the surgical area, at or
below the dead space pocket.
 The exit site is created with a scalpel blade (“stab incision”); the
incision should be of sufficient size to easily accommodate the
exiting of the drain and fluid exiting along the external surface of
the drain by capillary action.
 The drain normally exits the skin by 3–4 cm and is typically
secured to the skin with a single suture.

45.  The proximal or dorsal end of the drain can be secured with a
single 2-0 suture loop passing through the skin and capturing the
drain. Some surgeons prefer to “tack” the buried end of the drain
with a fine (4-0) absorbable suture to an adjacent musculofascial
layer; the suture will break or pull out of the tissue when traction
is applied to the external end of the drain.
 It is preferable to insert any drain before wound closure to assure
proper positioning.
 When possible, a drain should not cross or lie beneath the
incision.
 Care must be taken to avoid accidental suture entrapment of the
Penrose drain during closure of the incision.
 Penrose drains are radiopaque; radiography can confirm the
position or presence of a drain or fragment.

46.  Most drains are removed within 5 days after insertion.
 Timing of drain removal is assessed by the volume of fluid
exiting the site.
 Drains may be covered with a sterile dressing, especially
when the drain is likely to come into direct contact with
contaminated surfaces. The relative discharge in the
bandage can be used to assess the volume of drainage.
 Exposed drains can be maintained by cleansing around the
exit incision with antiseptic solution, followed by application
of a thin layer of antimicrobial ointment.
 An Elizabethan collar should be considered to prevent the
patient from removing the drain. Fluid volume is assessed by
the amount of drainage noted on absorbent cage mats.

47. SUTURE CLOSURE OF DEAD SPACE
 Often, surgical and traumatic dead space can be closed by
reapposing facial planes and adjacent soft tissue
structures. Suture closure can avoid the postoperative care
and overall cost factors associated with the use of surgical
drains. Suture apposition is particularly useful for moderate-
sized dead space areas involving the trunk. However, not
all dead space regions can be effectively eliminated by
suturing, especially in those areas lacking fascia and soft-
tissue structures for suture apposition. Many of the
synthetic, monofilament absorbable or nonabsorbable
suture materials on the market may be used for tissue
apposition; preferences vary with individual surgeons.

48.  When possible, the adjunctive use of bandages may reduce motion
to facilitate healing. In the inguinal, flank, and axillary areas,
where elastic skin and underlining subcutaneous tissue
accommodate limb motion, aggressive attempts at suture closure
can impair this normal gliding function, and vacuum drains are
preferred in these areas. In the presence of contamination and
infection, excessive use of suture material also can promote
infection; in some cases, separate infected pockets may be created,
making simple wound drainage problematic. Suture apposition
should be used sparingly in contaminated wounds. Contamination
or potential
contamination is also a good argument for using a
monofilament absorbable suture (or nonabsorbable
monofilament nylon/Prolene) of the smallest practical
size. Open wound management alone or combined
with drains is best for infected wounds.

49.  Should the drain become obstructed with a blood clot,
sterile saline can be flushed through the drain with a sterile
syringe using strict aseptic technique. Surgical gloves are
advised to further reduce the risk of contamination. The
drain is then reconnected to the reservoir and reactivated.
“Y” adaptors allow for the simultaneous use of two drains
with a single reservoir. Because the risk of ascending
infection is minimal when drains are properly maintained,
vacuum drains may be used to prevent or control dead
space seroma formation for extended periods (2 to 3
weeks). Vacuum drains also minimize the nursing care
required. The reservoir vacuum can be inactivated by air
enter-ing the wound, often as a result of small incisional
gaps between sutures. Surgical glue or topical ointment
may be used to seal an incisional leak until fibrin deposition
and early connective tissue naturally plug these sites.

50. OPTIONAL TREATMENT
Aspiration of Dead Space Seromas
 Hypodermic needle aspiration may be used alone or in
combination with a compressive wrap in the management of
moderate-sized seromas, provided that an effective compression
bandage can be applied to the area. Aspiration requires standard
surgical preparation of the skin and sterile technique to reduce the
likelihood of infection. If a seroma rapidly (within 24 to 48 hours)
re-forms after aspiration, it is an indication that a surgical drain is
best employed to resolve the problem.
 In some cases, dead space seromas slowly re-form to a variable
degree within 5 to 7 days of the initial aspiration. Under these
circumstances, one or two additional outpatient aspirations usually
resolve seroma formation. The primary advantages of aspiration
are that it allows outpatient management and has a low cost.

51. Bandages
Some surgeons recommend that all Penrose drains be covered with
a bandage because of the risk that contamination could result in
ascending infection. Bandages with a thicker secondary layer may be
needed to retain large volumes of fluid exiting the drain sites, and
frequent bandage changes would be indicated. Penrose drain
placement in the flank, inguinal, and axillary areas normally precludes
simple bandage coverage. The risk of ascending infection is low
without the use of a bandage cover, especially when the drain can be
removed a few days after insertion. However, bandage coverage is
advisable for body regions in direct contact with soiled or
contaminated
surfaces (e.g., ventral thorax, abdomen, paws).

52. Management of Subcutaneous Emphysema
 Subcutaneous emphysema normally is self-limiting; the air
is typically absorbed once the source of the air entering the
wound is eliminated. In cases in which there is a tear in the
trachea, large volumes of air may enter the subcutaneous
tissue, with dramatic expansion of the elastic skin from the
underlying musculofascial layers. Tears of the pharynx,
rhinotomy, and cutaneous sucking wounds also cause
subcutaneous emphysema, but rarely on the order of
magnitude noted with open tracheal wounds. When
significant stretching of the skin is present, air can be
removed with a large-gauge hypodermic needle connected
to a vacuum pump; however, this maneuver is rarely
needed. Despite the dead space created, drains are not
needed; most air is absorbed within days of eliminating the
air leak.

53. Supportive Treatment
 Supportive care depends on the health status of the
individual patient.
 A sterile dressing and protective bandage can be applied
over exposed Penrose drains, as noted above. Depending
on the volume of discharge, bandages may require
changing one or more times daily.
 Exposed Penrose drain sites can be maintained with the
application of a broad-spectrum antimicrobial ointment. Any
debris or discharge can be swabbed with antiseptic
solutions before the ointment is applied. Care should be
taken not to occlude the drainage area with too much
antibiotic ointment.

54.  Vacuum drains are emptied on an “as needed”
basis. Large effusions may require emptying of the
reservoir several times daily, depending on its
capacity. More commonly, fluid reservoirs are
emptied two to four times per day. The quantity of
fluid accumulated should be recorded each time the
reservoir is emptied. Quantitating the volume helps
determine the optimal time to remove the drain
(provided the drain is not obstructed).
 Elizabethan collars are strongly recommended to
prevent patients from damaging or removing drains.

55. PATIENTS MONITORING
 Normal health parameters should be assessed daily; critical care
patients require intensive monitoring and supportive care.
 Compression bandages require periodic assessment to ensure
circulation is not impaired. For bandages on the extremities, the
central toes may be exposed to assess for swelling. Bandages that
may restrict nor-mal respiration must be closely examined.
Problematic bandages may need to be adjusted or removed.
 The quality and volume of accumulated fluid should be monitored
and recorded.
 The surgical site should be assessed for dehiscence, infection,
necrosis, and self-mutilation.
 The integrity of the drain should be assessed; closed suction
drainage systems should be checked for air leaks and obstructions
that can negate their function.

56.  Bandages applied to the extremities require close
assessment for irritation and edema; owners should be
instructed to examine the middle two toes for swelling, color,
and warmth. Bandages should be reassessed if the patient
is in pain or chews at the bandage.
 Exposed surgical areas should be examined daily for
swelling, discharge, inflammation, discoloration, necrosis,
and dehiscence
 Until healing is complete, the patient’s activity should be kept
to a minimum.
 Owners should be advised to keep the Elizabethan collar on
their pet to prevent chewing on or removal of exposed
drains.

57. MILESTONES/RECOVERY TIME FRAME
 Skin sutures are normally removed in 8 to 10 days.
 Drains can be removed when the volume of drainage
decreases to minimal amounts.
— Most Penrose drains can be removed within 3 to 5
days. If little or no drainage is noted after 48 hours, the drain
can be removed at that time.
— Intact closed suction drains normally can be removed in
less than a week after insertion. The volume of drainage
dictates the appropriate time for its removal.

58. TREATMENT CONTRAINDICATIONS
 Excessive use of appositional (“tacking”) sutures to control
dead space in the face of wound contamination or infection.
 In cases of infection, open wound management may
provide optimal drainage. Deeper or recessed abscess
pockets can be effectively managed with vacuum drains.
 Penrose and closed suction drainage systems can-not
provide optimal wound support in the presence of necrotic
tissue.
 Penrose drains require a lower, dependent exit site for
proper gravitational flow from the wound. If this can-not be
provided, closed vacuum drains are advisable.

59.  Penrose drains require a lower, dependent exit site for
proper gravitational flow from the wound. If this can-not be
provided, closed vacuum drains are advisable.
 Penrose drains allow air to enter the subcutaneous space
through the exit site. They should therefore be avoided in
thoracic wall and inlet areas if there is potential for air to
enter the thoracic cavity (e.g., through intercostal muscle
tears, incisions).
 Vacuum drain systems must be closely monitored when
used to control dead space associated with thoracic wounds.
Drain tube displacement from the reservoir and a patient’s
chewing the tube are potential ways for air to enter the
thoracic cavity. Vacuum drains are contraindicated in
wounds in which an airtight seal cannot be maintained.

60. PROGNOSIS
Favorable Criteria
 Progressive reduction in drainage; drain removal.
 Complete healing.
 Absence of infection.
 No seroma formation after drain removal.
Unfavorable Criteria
 Persistent, excessive fluid drainage.
 Development of infection.
 Tissue necrosis.
 Partial or complete dehiscence.
 Repeated vacuum drain obstruction.
 Seroma formation despite treatment to control dead space.

61. COMPLICATIONS AND FAILURE OF DRAINS
 Breakdown of anastomotic sites
 Erosion into hollow organs
 Premature removal

62. REMOVAL
 Generally, drains should be removed once the drainage is
stopped or becomes less than 25ml/day. Drains can be
‘shortened ‘ by withdrawing by approximately 2cm per day,
allowing the site to heal gradually. Drains that protect post-
operative sites from leakage from a tract and are usually
kept in place for one week.
 Inform the pt. that there may be some discomfort when the
drain is pulled out.

64. REFERENCES
 David J A (1987) Wound Management: A comprehensive
guide to dressing and healing London: Martin Dunitz
Limited.
 Doughty L & Lister S (2004) The Royal Marsden Hospital
Manual of Clinical Nursing Procedures 6thEdition Oxford:
Blackwell Science.
 Wards procedures- Mansuk Patel