Surgical Recall: 16 - Drains And Tubes

Front 1

What is the purpose of drains?

Back 1

1. Withdrawal of fluids

2. Apposition of tissues to remove a potential space by suction

Front 2

What is a Jackson Pratt (JP) drain?

Back 2

Closed drainage system attached to a suction bulb ("grenade")

Front 3

What are the "three S's" of Jackson Pratt (JP) drain removal?

Back 3

1. Stitch removal

2. Suction discontinuation

3. Slow, steady pull

Front 4

What is a Penrose drain?

Back 4

Open drainage system composed of a thin rubber hose; associated with increased infection rate in clean wounds

Front 5

Define the following: G-tube

Back 5

Gastrostomy Tube

- Used for drainage or feeding

Front 6

Define the following: J-tube

Back 6

Jejunostomy Tube

- Used for feeding

- May be a small-needle catheter (remember to flush after use or it will clog) or a large, red rubber catheter

Front 7

Define the following: Cholecystostomy Tube

Back 7

Tube placed surgically or percutaneously with ultrasound guidance to drain gallbladder

Front 8

Define the following: T-tube

Back 8

- Tube placed in the common bile duct with an ascending and descending limb that forms a "T"

- Drains percutaneously; placed after common bile duct exploration

Front 9

What is a thoracostomy tube?

Back 9

Chest tube

Front 10

What is the purpose of a thoracostomy / chest tube?

Back 10

To appose the parietal and visceral pleura by draining blood, pus, fluid, chyle, or air

Front 11

How is a chest tube inserted?

Back 11

1. Administer local anesthetic

2. Incise skin in 4th or 5th intercostal space between mid and anterior axillary lines

3. Perform blunt Kelly-clamp dissection over the rib into the pleural space

4. Perform finger exploration to confirm intrapleural placement

5. Place tube posteriorly and superiorly

Front 12

Is the chest tube placed under or over the ribs?

Back 12

Over to avoid the vessels and nerves

Front 13

What are the goals of chest tube insertion?

Back 13

- Drain the pleural cavity

- Appose parietal and visceral pleura to seal any visceral pleural holes

Front 14

In most cases, where should the chest tube be positioned?

Back 14

Posteriorly into the apex

Front 15

How can you tell on CXR if the last hole on the chest tube is in the pleural cavity?

Back 15

Last hole is cut through the radiopaque line in the chest tube and is seen on CXR as a break in the line, which should be within the pleural cavity

Front 16

What are the cm measurements on a chest tube?

Back 16

Cm from the last hole on the chest tube

Front 17

What is the chest tube connected to?

Back 17

Suction, waterseal, collection system (three-chambered box, eg, Pleuravac)

Front 18

What are the three chambers of the Pleuravac?

Back 18

1. Collection chamber

2. Water seal

3. Suction control

Front 19

Describe how the Collection Chamber of the Pleuravac box works as part of the old three-bottle system?

Back 19

Collects fluid, pus, blood, or chyle and measures the amount; connects to the water seal bottle and to the chest tube

Front 20

Describe how the Water-Seal Chamber of the Pleuravac box works as part of the old three-bottle system?

Back 20

One way valve

- Allows air to be removed from the pleural space

- Does not allow air to enter pleural cavity

- Connects to the suction control bottle and to the collection chamber

Front 21

Describe how the Suction-Control Chamber of the Pleuravac box works as part of the old three-bottle system?

Back 21

- Controls the amount of suction by the height of the water column

- Sucking in room air releases excessive suction

- Connects to wall suction and to the water seal bottle

Front 22

Give a good example of a water seal?

Back 22

Place a straw in a cup of water - you can blow air out but if you suck in, the straw fills with water and thus forms a one-way valve for air just like the chest tube water seal

Front 23

How is a chest tube placed on water seal?

Back 23

By removing the suction; a tension pneumothorax (PTX) cannot form because the one-way valve (water seal) allows release of air build-up

Front 24

Should a chest tube ever be clamped off?

Back 24

No, except to "run the system" momentarily

Front 25

What does it mean to "run the system" of a chest tube?

Back 25

To see if the air leak is from a leak in the pleural cavity (eg, hole in lung) or from a leak in the tubing

Front 26

How can you tell if the chest tube is "tidling"?

Back 26

Take the Pleuravac off of suction and look at the water seal chamber: fluid should move with respiration / ventilation (called "tidling"): this decreases and ceases if the pleura seals off the chest tube

Front 27

How can you check for an air leak in a chest tube?

Back 27

Look at the water seal chamber on suction:

- If bubbles pass through the water seal fluid, a large air leak (ie, air leaking into chest tube) is present; if no air leak is evident on suction, remove suction and ask the patient to cough

- If air bubbles through the water seal, a small air leak is present

Front 28

What is the usual course for removing a chest tube placed for a PTX?

Back 28

1. Suction until the PTX resolves and the air leak is gone

2. Water seal for 24 hours

3. Remove the chest tube if no PTX or air leak is present after 24 hrs of water seal

Front 29

How fast is a small, stable PTX absorbed?

Back 29

About 1% daily

Therefore a 10% PTX by volume will absorb in about 10 days

Front 30

How should a chest tube be removed?

Back 30

1. Cut the stitch

2. Ask the patient to exhale or inhale maximally

3. Rapidly remove the tube (split second) and at same time, place petroleum jelly gauze covered by 4x4's and then tape

4. Obtain CXR

Front 31

What is a Heimlich valve?

Back 31

One-way flutter valve for a chest tube

Front 32

How should an NGT be placed?

Back 32

1. Use lubrication and have suction up on the bed

2. Use anesthetic to numb nose

3. Place head in flexion

4. Ask pt to drink a small amount of water when tube is in back of throat and to swallow the tube; if pt can talk without difficulty and succus returns, tube should be in stomach (get an x-ray if any question of position)

Front 33

How should an NGT be removed?

Back 33

Give pt a tissue, discontinue suction, untape nose, remove quickly, and tell pt to blow nose

Front 34

What test should be performed before feeding via any tube?

Back 34

High abdominal x-ray to confirm placement into GI tract and not lung

Front 35

How does NGT work?

Back 35

Sump pump, dual lumen tube - the large clear tube is hooked to suction and small blue tube allows for air sump (ie, circuit sump pump with air in the blue tube and air and succus sucked out through large clear lumen)

Front 36

How can you check to see if NGT is working?

Back 36

Blue port will make a sucking noise; always keep blue port opening above stomach

Front 37

Should an NGT be placed on continuous or intermittent suction?

Back 37

Continuous low suction - side holes disengage if they are against mucosa because of the sump mechanism and multiple holes

Front 38

What happens if the NGT is clogged?

Back 38

Tube will not decompress stomach and will keep the low esophageal sphincter (LES) open (ie, a setup for aspiration)

Front 39

How should an NGT be unclogged?

Back 39

Saline-flush the clear port, reconnect to suction, and flush air down blue sump port

Front 40

What is a common cause of excessive NGT drainage?

Back 40

Tip of NGT is inadvertently placed in duodenum and drains pancreatic fluid and bile; x-ray should be taken and tube repositioned in stomach

Front 41

What is the difference between a feeding tube (Dobbhoff tube) and an NGT?

Back 41

A feeding tube is a thin tube weighted at the end that is not a sump pump but a simple catheter; usually placed past the pylorus, which is facilitated by the weighted end and peristalsis

Front 42

What is a Foley catheter?

Back 42

Catheter into bladder, allowing accurate urine output determination

Front 43

What is a coudé catheter?

Back 43

Foley catheter with a small curved tip to help maneuver around a large prostate

Front 44

If a Foley catheter cannot be inserted, what are the next steps?

Back 44

1. Anesthetize urethra with a sterile local anesthetic (eg, lidocaine jelly)

2. Try a larger Foley catheter

Front 45

What if a patient has a urethral injury and a Foley cannot be placed?

Back 45

A suprapubic catheter will need to be placed

Front 46

What are central lines?

Back 46

Catheters placed into the major veins (central veins) via subclavian, internal jugular, or femoral vein approaches

Front 47

What major complications result from central line placement?

Back 47

- PTX (always obtain a post-placement CXR)

- Bleeding

- Malposition (eg, into neck from subclavian approach)

- Dysrhythmia

Front 48

In long-term central lines, what does the "cuff" do?

Back 48

Allows ingrowth of fibrous tissue, which:

- Holds the line in place

- Forms a barrier to the advance of bacteria

Front 49

What is a Hickman or Hickman-type catheter?

Back 49

External central line tunneled under the skin with a "cuff"

Front 50

What is a Port-A-Cath?

Back 50

Central line that has a port buried under the skin that must be accessed through the skin (percutaneously)

Front 51

What is a "cordis"?

Back 51

Large central line catheter; used for massive fluid resuscitation or for placing a Swan-Ganz catheter

Front 52

If you try to place a subclavian central line unsuccessfully, what must you do before trying the other side?

Back 52

Get a CXR - a b/l PTX can be fatal!

Front 53

How can diameter in mm be determined from a French measurement?

Back 53

Divide the French size by pi or 3.14 (eg a 15 French tube has a diameter of 5 mm)

Front 54

How can needle-gauge size be determined?

Back 54

14-gauge needle is 1/14 of an inch (thus, a 14-gauge needle is larger than a 21-gauge needle)

Front 55

What is a Tenckhoff catheter?

Back 55

Catheter placed into the peritoneal cavity for peritoneal dialysis