Flashcards in Drains & Tubes Deck (53):
What is the purpose of drains?
1. Withdrawal of fluids
2. Apposition of tissues to remove a potential space by suction
What is a JP drain?
Closed drainage system attached to a suction bulb
What are the 3 "Ss" of JP drain removal?
1. Stitch removal
2. Suction discontinuation
3. Slow, steady pull
What is a Penrose drain?
Open drainage system composed of a thin rubber hose.
Associated with increased infection rate in clean wounds.
What is a G-tube?
Used for drainage or feeding
What is a J-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.
What is cholecystostomy tube?
Tube placed surgically or percutaneously with U/S guidance to drain the gallbladder
What is a T-tube?
Tube placed in the common bile duct with an ascending and descending limb that forms a "T".
Placed after common bile duct exploration.
What is a thoracostomy tube?
What is the purpose of a chest tube?
To appose the parietal and visceral pleura by draining blood, pus, fluid, chyle, or air
How is a chest tube inserted?
1. Administer local anesthetic
2. Incise skin in the 4th or 5th intercostal space between the 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
Is the chest tube placed under or over the rib?
Over to avoid the vessels and nerves
In most cases, where should the chest tube be positioned?
Posteriorly into the apex
How can you tell on CXR if the last hole on the chest tube is in the pleural cavity?
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
What are the cm measurements on a chest tube?
Centimeters from the last hole on the chest tube
What is the chest tube connected to?
Suction, water seal, collection system (three-chambered box, e.g. Pleuravac)
What are the 3 chambers of the Pleuravac?
1. Collection chamber
2. Water seal
3. Suction control
How does the collection chamber of a Pleuravac work?
Collects fluid, pus, blood, or chyle and measures the amount.
Connects to the water-seal chamber and to the chest tube.
How does the water-seal chamber of a Pleuravac work?
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 chamber and to the collection chamber.
How does the suction-control chamber of the Pleuravac work?
Controls the amount of suction by height of the water column.
Sucking in room air releases excessive suction.
Connects to wall suction and to the water-seal chamber.
What is a good example of a water seal?
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.
How is a chest tube placed on water seal?
By removing the suction.
A tension PTX cannot form because the one-way valve (water seal) allows release of air buildup.
Should a chest tube ever be clamped off?
No, except to "run the system" momentarily
What does it mean to "run the system" of a chest tube?
To see if the air leak is from a leak in the pleural cavity or from a leak in the tubing.
Momentarily occlude the chest tube and if the air leak is still present, it is from the tubing or tubing connections not from the chest.
How can you check for an air leak?
Look at the water-seal chamber on suction:
If bubbles pass through the water seal fluid, a large air leak (i.e. 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.
What is the usual course for removing a chest tube placed for a PTX?
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 hours of water seal
How fast is a small, stable PTX absorbed?
1% daily, therefore a 10% PTX by volume will absorb in 10 days
How should a chest tube be removed?
1. Cut the stitch
2. Ask the patient to exhale or inhale maximally
3. Rapidly remove the tube (split second) and at the same time, place petroleum jelly gauze covered by 4X4's and then tape
4. Obtain a CXR
What is a Heimlich valve?
One-way flutter valve for a chest tube
How should an NGT be placed?
1. Use lubrication and have suction up on the bed
2. Use anesthetic to numb nose
3. Place head in flexion
4. Ask patient to drink a small amount of water when the tube is in the back of the throat and to swallow the tube. If the patient can talk without difficulty and succus returns, the tube should be in the stomach
How should an NGT be removed?
Give patient a tissue, discontinue suction, untape nose, remove quickly, and tell patient to blow nose
What test should be performed before feeding via any tube?
High AXR to confirm placement into the GI tract and not the lung
How does an NGT work?
Sump pump, dual lumen.
The large clear tube is hooked to suction and the small blue tube allows for air sump (i.e. circuit sump pump with air in the blue tube and air and succus sucked out through the large clear lumen).
How can you check to see if the NGT is working?
Blue port will make a sucking noise.
Always keep the blue port opening above the stomach.
Should an NGT be placed on continuous or intermittent suction?
Continuous low suction.
Side holes disengage if they are against mucosa because of the sump mechanism and multiple holes.
What happens if the NGT is clogged?
Tube will not decompress the stomach and will keep the LES open (i.e. a setup for aspiration)
How should an NGT be unclogged?
Saline-flush the clear port, reconnect to suction, and flush air down the blue sump port
What is a common cause of excessive NGT drainage?
Tip of the NGT is inadvertently placed in the duodenum and drains the pancreatic fluid and bile.
An XR should be taken and the tube repositioned into the stomach.
What is the difference between a feeding tube (Dobbhoff tube) and an NGT?
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.
What is a Foley catheter?
Catheter into the bladder, allowing accurate urine output determination
What is a coude catheter?
Foley catheter with a small, curved tip to help maneuver around a large prostate
If a Foley catheter cannot be inserted, what are the next steps?
1. Anesthetize the urethra with a sterile local anesthetic (e.g. lidocaine jelly)
2. Try a larger Foley catheter
What if a patient has a urethral injury and a Foley cannot be placed?
A suprapubic catheter will need to be placed
What are central lines?
Catheters placed into the major veins (central veins) via subclavian, internal jugular, or femoral vein approaches
What major complications result from central line placement?
PTX (always obtain post-placement CXR), bleeding, malposition (e.g. into the neck from subclavian approach), dysrhythmias
In long-term central lines, what does the cuff do?
Allows ingrowth of fibrous tissue, which holds the line in place and forms a barrier to the advance of bacteria
What is a Hickman or Hickman-type catheter?
External central line tunneled under the skin with a cuff
What is a Port-A-Cath?
Central line that has a port buried under the skin that must be accessed through the skin (percutaneously)
What is a cordis?
Large central line catheter.
Used for massive fluid resuscitation or for placing a Swan-Ganz catheter.
If you try to place a subclavian central line unsuccessfully, what must you do before trying the other side?
Get a CXR (a bilateral PTX can be fatal)
How can diameter in mm be determined from a French measurement?
Divide the French size by pi
How can needle-gauge size be determined?
n-gauge needle is 1/n of an inch