Surgical drains

y y

Drains are inserted to: o Evacuate establish collections of pus, blood or other fluids (e.g. lymph) o Drain potential collections Their use is contentious Arguments for their use include: o Drainage of fluid removes potential sources of infection o Drains guard against further fluid collections o May allow the early detection of anastomotic leaks or haemorrhage o Leave a tract for potential collections to drain following removal Arguments against their use include: o Presence of a drain increases the risk of infection o Damage may be caused by mechanical pressure or suction o Drains may induce an anastomotic leak o Most drains abdominal drains infective within 24 hours

Passive drains

y Passive drains have no suction y Function by the differential pressure between body
cavities and the exterior Nasogastric tubes

y Following abdominal surgery gastointestinal

motility is reduced for a variable period of time

y Gastrointestinal secretions accumulate in stoma y

and proximal small bowel May result in: o Postoperative distension and vomiting o Aspiration pneumonia Little clinical evidence is available to support the routine use of nasogastric tubes May increase the risk of pulmonary complications Of proven value for gastrointestinal decompression in intestinal obstruction Tubes are usually left on free drainage Can be also aspirated maybe every 4 hours Can be removed when volume of nasogastric aspirate is reduced

y y y y y y

Types of drains

y Drains can be: o Open or closed o Active or passive y Drains are often made from inert silastic material y They induce minimal tissue reaction y Red rubber drains induce an intense tissue reaction
allowing a tract to form

Urinary catheters

y In some situations this may be useful (e.g. biliary ttube) Open drains

y A urinary catheter is a form of drain y Commonly used to: o Alleviate or prevent urinary retention o Monitor urine output y Can be inserted transurethrally or suprapubically y Catheters vary by: o The material from which they are
made (latex, plastic, silastic, tefloncoated) o The length of the catheter (38 cm 'male' or '22 cm 'female') o The diameter of the catheter (10 Fr to 24 Fr) o The number of channels (two or three) o The size of the balloon ( 5ml to 30 ml) o The shape of the tip y Special catheters exist such as: o Gibbon catheters o Nelaton catheters o Tiemann catheters o Malecot catheters

y Include corrugated rubber or plastic sheets y Drain fluid collects in gauze pad or stoma bag y They increase the risk of infection
Closed drains

y Consist of tubes draining into a bag or bottle y They include chest and abdominal drains y The risk of infection is reduced
Active drains

y Active drains are maintained under suction y They can be under low or high pressure

Complications

y y y y y y

Paraphimosis Blockage By-passing Infection Failure of balloon to deflate Urethral strictures

Do's and don'ts of urinary catheters

y y y y y y y y

Choose an appropriate sized catheter Insert using an aseptic technique Never insert using force Do not inflate the balloon until urine has been seen coming from the catheter Record the residual volume Do not use a catheter introducer unless you have been trained in its use If difficulty is encountered inserting a urinary catheter consider a suprapubic Remove at the earliest possibility

Introduction The ability to insert a urinary catheter is an essential skill in medicine. Catheters are sized in units called French, where one French equals 1/3 of 1 mm. Catheters vary from 12 (small) FR to 48 (large) FR (3-16mm) in size.

They also come in different varieties including ones without a bladder balloon, and ones with different sized balloons - you should check how much the balloon is made to hold when inflating the balloon with water!

Universal precautions The potential for contact with a patient's blood/body fluids while starting a catheter is present and increases with the inexperience of the operator. Gloves must be worn while starting the Foley, not only to protect the user, but also to prevent infection in the patient. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns.

Indications By inserting a Foley catheter, you are gaining access to the bladder and its contents. Thus enabling you to drain bladder contents, decompress the bladder, obtain a specimen, and introduce a passage into the GU tract. This will allow you to treat urinary retention, and bladder outlet obstruction. Urinary output is also a sensitive indicator of volume status and renal perfusion (and thus tissue perfusion also). In the emergency department, catheters can be used to aid in the diagnosis of GU bleeding. In some cases, as in urethral stricture or prostatic hypertrophy, insertion will be difficult and early consultation with urology is essential.

Contraindications Foley catheters are contraindicated in the presence of urethral trauma. Urethral injuries may occur in patients with multisystem injuries and pelvic factures, as well as straddle impacts. If this is suspected, one must perform a genital and rectal exam first. If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicion of urethral tear is present. One must then perform retrograde urethrography (injecting 20 cc of contrast into the urethra).

Equipment Sterile gloves - consider Universal Precautions Sterile drapes Cleansing solution e.g. Savlon Cotton swabs Forceps Sterile water (usually 10 cc) Foley catheter (usually 16-18 French) Syringe (usually 10 cc) Lubricant (water based jelly or xylocaine jelly) Collection bag and tubing

Procedure 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Gather equipment. Explain procedure to the patient Assist patient into supine position with legs spread and feet together Open catheterization kit and catheter Prepare sterile field, apply sterile gloves Check balloon for patency. Generously coat the distal portion (2-5 cm) of the catheter with lubricant. Apply sterile drape If female, separate labia using non-dominant hand. If male, hold the penis with the non-dominant hand. Maintain hand position until preparing to inflate balloon. Using dominant hand to handle forceps, cleanse peri-urethral mucosa with cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile field. Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled in palm of dominant hand. In the male, lift the penis to a position perpendicular to patient's body and apply light upward traction (with non-dominant hand) Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size) Gently pull catheter until inflation balloon is snug against bladder neck Connect catheter to drainage system Secure catheter to abdomen or thigh, without tension on tubing Place drainage bag below level of bladder Evaluate catheter function and amount, color, odor, and quality of urine Remove gloves, dispose of equipment appropriately, wash hands Document size of catheter inserted, amount of water in balloon, patient's response to procedure, and assessment of urine

Complications The main complications are tissue trauma and infection. After 48 hours of catheterization, most catheters are colonized with bacteria, thus leading to possible bacteruria and its complications. Catheters can also cause renal inflammation, nephro-cysto-lithiasis, and pyelonephritis if left in for prolonged periods. The most common short term complications are inability to insert catheter, and causation of tissue trauma during the insertion. The alternatives to urethral catheterization include suprapubic catheterization and external condom catheters for longer durations.