Practical use of tubes and drains (Proceedings)


Practical use of tubes and drains (Proceedings)

Nov 01, 2010

I. Thoracostomy Tubes
Tube drainage of the thorax is indicated to drain free air or fluid in the pleural space. This is not an absolute indication as small amounts of air within the thorax do not require a thoracostomy tube. Similarly, the presence of blood within the p leural space is not usually an indication for thoracic drainage.

A. Closed Thoracic Drain Placement
Two most common indications would be for animals with pneumothorax that is causing dyspnea and is usually caused by trauma or spontaneous pneumothorax (rupture of a pulmonary bleb or bulla). A second indication would be free pleural fluid; i.e.-Pyothorax Drainage of free pleural fluid such as chyle may be performed short term only; long term drainage of chylous effusion will lead to hypoalbuminemia.
      1. The animal is usually anesthetized. If the animal is dyspneic, needle thoracentesis initially followed by stabilization for short time may make the animal a better anesthesia candidate. If absolutely necessary, a tube can be put in with heavy narcotic sedation and local blocks.
      2. Place the animal in lateral recumbency and prep the hemithorax for aseptic placement of the tube.
      3. Make a small skin incision at the mid to upper 1/3rd of the thorax; a subcutaneous tunnel is created over 2-3 intercostal spaces rostrally in a cranioventral direction. This tunnel may be made with a Kelly hemostat or with the trocar/stylet that comes on many commercial thoracic tubes.
      4. The hemostat or stylet is used to penetrate the 7th or 8th IC space and is briskly thrust through the IC muscle. If a hemostat is being used and the patient is a larger dog using a scalpel to penetrate the IC muscle will make the job much easier. In smaller patients a forceful thrust is necessary to enter the pleural space.
      5. Obvious caution is used when a stylet is used; the non-dominant hand is used as a safety "stop"to protect against penetrating lung or heart.
      6. The size of the tube should be that of the main stem bronchus, in cats that usually means a tube 12-16 french in dogs it may be 18-24 french.
      7. The tube is fed into the cranial ventral thorax and then secured to the skin with a "Chinese finger cuff" suture. Antibiotic ointment is placed around the skin entrance and a bandage applied to protect the tube.
      8. Either intermittent or continuous suction drainage is used to drian air or fluid.
      9. An adaptor and 3-way valve are attached to the tube and secured with wire or glue. BE CERTAIN that personnel know how to operate the 3-way valve.
      10. Drains may remain in hours to days depending on their use and how much drainage is being obtained.

B. Open Drain Placement Post-Thoracotomy
      1. Similar to what is described above but easier since you can visualize the tube in the thorax. The tube should enter the thorax outside the primary intercostals incision.
      2. Secure as above. Often pulled early in the postop course.

II. Cystostomy tubes/catheters
A. Cystostomy catheters can be used to divert urine from the urinary bladder on either a temporary or permananent basis. Indications include injury to the lower urinary tract such as torn or ruptured urethra, neurologic bladder, or obstructive disease caused by cancer such as transitional cell carcinoma of the bladder or proximal urethra.
      1. General anesthesia required. Abdomen is prepped for aseptic surgery.
      2. A limited approach is made to the caudal abdomen and the bladder located and a stay suture placed to manipulate the bladder.
      3. A purse-string suture is placed in the bladder using 2/0 or 3/0 PDS.
      4. A small incision is made lateral to the abdominal incision and a Foley cather or Pezzar feeding tube brought through the small incision and then placed through a stab incision that is made in the middle of the purse-string suture.
      5. Tie the purse-string suture snugly.
      6. Place 2-3 supporting sutures between the bladder wall and the abdominal wall.
      7. Close the abdomen routinely.
      8. Connect the catheter to a closed urinary system or alternatively the bladder can be drained intermittently by hospital personnel or the owner at home.
      9. If the need for the catheter improves then the catheter can be removed and the stoma heal by second intention.