Indications:
Management of bowel obstruction
Symptom relief in patients with nausea and/or emesis (e.g., acute pancreatitis).
Types of tubes:
Salem sump – standard double-lumen gastric tube. The larger lumen allows for evacuation of air and fluid. The smaller-vent lumen allows for air to be drawn into the stomach to equalize pressures. Available in multiple sizes from 6 to 18 Fr.
Andersen – very soft, comfortable double-lumen tube made from vinyl.
Replogle – used most commonly for evacuating proximal esophageal pouch in unrepaired esophageal atresia.
Management: Can be placed to gravity drainage or to low intermittent wall suction. Suction provides better decompression but risks gastric irritation. Ventilation port must remain unoccluded for proper function. If occluded, the drainage port should be flushed with water and the ventilation port with air.
Removal: Generally removed when gastric output is nonbilious and output volume is decreased. Some surgeons opt to continue nasogastric/orogastric (NG/OG) decompression until return of bowel function.
EBM Pearl: Routine nasogastric drainage after abdominal surgery is not indicated. A Cochrane review demonstrated that NG tubes are associated with delayed return of bowel function, with no difference in anastomotic leak, wound infection, or other complications.1
Indications:
Prevention of seroma or hematoma under flaps
Monitoring and control of biliary or pancreatic leak following biliary or pancreatic anastomosis, liver resection, or pancreatic resection
Monitoring and control of chyle leak following extensive retroperitoneal dissection
Monitoring and control of urine leak following partial nephrectomy, bladder augmentation, and other urologic procedures
Drainage of abscess cavity
Monitoring and drainage following esophageal or duodenal perforation +/− repair
Drainage of neonatal perforation in extremely low-birth-weight (ELBW) infants (<1 kg) with Penrose drain
Types of drains:
Jackson-Pratt – closed suction drain with suction provided by compressed bulb. Often used intra-abdominally or under skin flaps.
Hemovac – closed suction drain with suction provided by spring-loaded accordion-type container.
TLS – small-caliber closed suction drain with suction provided by Vacutainer. Often used in head and neck surgery or other times when output is expected to be low.
Penrose – open drain. Tube provides passive route of egress for fluid and air.
Management:
Stripping and flushing – closed suction drains may require stripping and/or flushing to maintain patency, especially when drainage is thicker (blood or abscess). Flushing must be performed using sterile technique. Drains are flushed with saline to maintain patency. Tissue plasminogen activator (tPA) can also be used if the drain is clotted or if trying to break up loculations in an abscess cavity.
Drains should be emptied and output volume recorded at least every shift and more frequently if needed.
Removal:
Timing – dependent on indication. Drains placed to monitor for bile, pancreatic, or chyle leak should remain until patient is on a general diet. If monitoring for a leak following a biliary, pancreatic, or urologic procedure, it is sometimes helpful to check a drain bilirubin, amylase, or creatinine, respectively, prior to removal. Abdominal drains are removed, even with moderately high volume of output, if character is serosanguinous. Drains in subcutaneous flaps require lower volume (approximately 10–20 mL/day) for removal.
Technique – drains should be taken off suction for removal. Drains can be removed outright or slowly backed out in cases where the clinician is trying to establish a fistula tract (e.g., bile leak).
EBM Pearl: Routine abdominal drainage is not indicated for preventing postoperative abscess, nor should they be used routinely around surgical anastomoses. A Cochrane review found that routine drain placement following complicated appendectomy increased length of stay without reducing the risk of intraperitoneal abscess or wound infection.2
Indications: The Centers for Disease Control and Prevention (CDC) provides guidelines for the prevention of catheter-associated urinary tract infections, which include guidelines for appropriate indications for urethral catheterization.3
Urinary retention
Need for accurate urine output measurement in critically ill patients
Selected perioperative indications
Urologic surgery or other surgery on genitourinary (GU) structures
Prolonged duration of surgery (remove ASAP postoperatively)
Patients receiving large fluid volume or diuretics in surgery
Need for intraoperative monitoring of urine output
To assist healing of perineal or sacral wounds in incontinent patients
Patient requiring prolonged immobilization
To improve comfort in end-of-life care
Types of catheters:
Foley urethral catheter – standard urethral catheter comes in a variety of sizes
Coude – curved tip useful when placement is difficult, especially in males with enlarged prostrate
Management: maintain a closed drainage system. Keep the drainage tubing unkinked and the urine collection bag below the level of the bladder.
Bladder irrigation: irrigation only indicated when obstruction is anticipated, such as with bleeding or mucus production after bladder surgery. In general, urethral catheters should be maintained as a closed drainage system. However, after urologic surgery, irrigation (manual or continuous) is often also necessary to remove clots or mucus within the bladder.
Removal: remove as soon as possible when the previous indications no longer apply.
Other urologic tubes:
Suprapubic tubes – placed percutaneously or during open bladder surgery. Catheter goes directly into the bladder in patients for whom urethral catheterization is contraindicated or not possible, or as an extra drainage tube after major urologic reconstruction. Maintenance similar to uretheral tubes. Cannot be exchanged for several weeks until a tract has formed.
Percutaneous nephrostomy tubes – tube placed through renal parenchyma and into the collecting system to treat hydronephrosis when transurethral drainage is contraindicated or not possible. Also occasionally placed during a definitive urologic procedure as a postoperative drainage modality. Can be flushed with sterile saline to maintain patency.
Vaginostomy tubes – tube placed percutaneously into the vagina, most commonly in girls with a cloaca in whom urine refluxes back into the vagina, creating a massive hydrocolpos, which compresses the bladder and urethra. Maintenance similar to suprapubic tube.
EBM Pearl: Although data is still limited, there is mounting evidence that urethral catheters can be removed in patients with thoracic epidurals with a low incidence of urinary retention.4
Indications: central venous catheters are often placed at the time of surgery. These lines serve three main purposes in the perioperative patient:
Access for medication and volume infusion
Repeated blood draws
Monitoring of central venous pressure
Types of catheters:
Nontunneled central lines – nontunneled lines (e.g., Cook or Arrow) can be placed in the internal jugular, subclavian, or femoral veins at the time of surgery. They are indicated for short-term access.
PICC – peripherally inserted central venous catheters work well for infusion and aspiration, but are less reliable for central venous pressure measurement.
Tunneled central lines – tunneled lines (e.g., Broviac, Hickman, etc.) are typically placed in neonates or in children with malignancy or short gut syndrome who require frequent (often daily) access.
Implantable venous port – placed in children who require ongoing, but intermittent, access. Can be utilized in the perioperative period.
Management:
A sterile dressing should be maintained. Sterile dressing changes are performed according to each hospital’s policy.
Central venous pressure (CVP) is measured at the level of the heart with the patient lying flat. CVP is utilized to guide fluid resuscitation and/or diuresis, as well as to monitor for acute perioperative complications such as acute pulmonary hypertensive crisis. Fluid resuscitation beyond a CVP of around 15 mm Hg is unlikely to be beneficial.
Removal: temporary lines placed for perioperative use can be removed when no longer needed for volume or medication infusion (including total parenteral nutrition [TPN]), repeated blood draws, or CVP monitoring. Lines should be removed as soon as peripheral access will suffice to reduce the risk of central line–associated bloodstream infection (CLABSI). To reduce the risk of air embolus, lines are removed with the patient lying flat and creating positive intrathoracic pressure (e.g., by humming). Pressure is held over the venipuncture site and a sterile dressing is applied.
EBM Pearl: The implementation of central line insertion and maintenance bundles has been shown to reduce the risk of CLABSI, from 6.4 per 1,000 catheter days to 2.5 per 1,000 catheter days in one meta-analysis of adult, pediatric, and neonatal patients.5
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