MANAGEMENT OF DEAD SPACE AND SUCTION DRAINS

PRESENTED BY- DR. SUJAY S. PATIL1 YR PGDEPT. OF ORAL AND MAXILLOFACIAL SURGERY

WHAT IS A DEAD SPACE?

Dead space, by definition, is a space left in the body as a result of a surgical procedure. The term is commonly used to describe spaces resulting from the

removal of a space-occupying mass or evacuation of fluid, tissue dissection resulting in disruption of tissue or facial planes, and tissue separation or disruption secondary to trauma (e.g., bite wounds, vehicular trauma, high-velocity projectile wounds).

Dead space creates a pocket or cavity in which tissue fluid or blood can accumulate (e.g., seromas, hematomas); excessive fluid accumulation separates tissue planes, and its persistence can delay or prevent normal healing. Moreover, fluid accumulation may contribute to infection, especially in the presence of contaminants. As a result, appropriate dead space management is important to both the and management of infection.

There are several techniques used to manage dead space, depending on the size, location, and cause of the tissue pocket. These options include no treatment, external bandage compression, suture closure, use of a drainage system, and aspiration; each can be used alone or in combination to control dead space.

CAUSES OF DEAD SPACE The volume of a pocket or defect created when a space-

occupying mass (e.g., tumor, granuloma, organized hematoma) is removed often approximates that of the lesion.

Wide surgical dissection results in disruption of normal tissue planes, creating a potential space. Combined with surgical trauma and regional movement, seromas formation may occur.

Loose or elastic fascial planes are potential areas for fluid accumulation, especially in the face of regional trauma.

Vehicular trauma is the most common form of blunt trauma. Both direct and indirect trauma can cause soft tissue to stretch, tear, or avulse, thereby creating dead space.

Orthopedic trauma and subsequent fracture repair can result in variable degrees of soft-tissue disruption and dead space formation.

Bite wounds often result in the crushing, stretching, tearing, and laceration of the skin and underlying tissue. Without appropriate wound management, tissue trauma, circulatory compromise, contamination, and formation of dead space predispose the patient to infection.

High-velocity projectile wounds can cause significant tissue disruption and significant dead space formation as a result of cavitation and tissue trauma secondary to fragmentation of bone; frangible bullets also intensify local tissue trauma.

PHYSICAL EXAMINATION

Dead Space Secondary to Trauma Vital signs should be immediately assessed, including the basic

“ABCs” (airway, breathing, and circulation). Emergency treatment should be instituted in critically injured patients.

All trauma patients require a complete physical examination, regardless of presentation.

Patients should be assessed and treated for pain at the time of presentation as well as pain anticipated for the surgical procedure after assessment of the injuries.

Disrupted tissue planes may include separation of the skin from the underlying tissue attachments. When grasped, the skin readily lifts away from the underlying musculofascial layer. If a skin defect is present, lifting the skin creates a vacuum effect, which sucks air into the subcutaneous space.

Palpation over areas of intact skin may reveal irregularities of the musculofascial tissue; suspected areas of tissue disruption can be compared with the corresponding area on the opposite side of the patient (provided the area is uninjured). Muscle tears and avulsion wounds are noted as gaps or depressions with deep digital palpation. Herniation of abdominal contents also may be noted.

Depending on the age and condition of the wound, tissue fluid, blood, or pus may collect in the traumatized area and gravitate in a ventral or distal direction. Palpable fluctuance may be noted with significant accumulation of blood, serum, or pus. This accumulation can further expand the dead space by stretching or displacing adjacent tissues.

Tears in the pharynx and trachea may result in mild to massive accumulation of air beneath the skin (subcutaneous emphysema). Air distention displaces the skin, creating a dead space pocket of air.

Open wounds are usually easier to examine preoperatively than are wounds covered by an intact skin surface; dead space volume is assessed by the visible tissue disruption.

Tissue is initially assessed for degree of contamination and potential viability. However, intraoperative assessment of the wound is more important in determining the appropriate options for managing dead space.

Dead Space Associated with Surgery Extensive debridement, dissection, excision, and undermining of

tissues may be necessary; this should be followed by assessment to determine how to manage the dead space created.

The amount of excess skin present after removal of a space-occupying mass is assessed to determine if additional skin resection may improve dead space control and the resultant cosmetic outcome.

TREATMENT RECOMMENDATIONS

Initial Treatment Options The primary goal of controlling dead space is to prevent tissue fluid

and blood from accumulating in the disrupted tissue area. Their accumulation separates the normal tissue planes, thereby delaying the normal healing process. Moreover, the risk of infection is increased, especially in the presence of contaminants. Connective tissue restoration (fibroplasia, collagen deposition) can be accomplished more effectively by controlling dead space. There are several surgical and nonsurgical options that can be used alone or in combination to control dead space in wounds. Drains are generally used for the more substantial dead space regions but may be combined with compressive wraps and basic suture apposition techniques employed in wound closure.

In some cases, the presence of a small, self-limiting seroma may require little or no treatment; over time, the body reabsorbs serum. Because excessive activity can impair dead space management, exercise restriction and the appropriate use of bandages can reduce regional motion at the surgical site.

Closure of small skin defects involving the mid to lower extremities normally demonstrates a variable degree of incisional tension at closure. Slight tension helps prevent the development of seromas. Minimizing surgical trauma reduces the likelihood of postoperative inflammation that contributes to seroma formation in the surgical dead space created. Postoperatively, small incisional seromas normally resolve without treatment. Warm compresses applied for 10 to 15 minutes two or three times daily over a 1-week period may facilitate fluid resorption.

ADDITIONAL TREATMENT OPTIONS INCLUDE THE FOLLOWING

Compressive Bandages Application of mildly compressive bandages can be used to

compress dead space areas, reduce regional motion, and protect the wound while helping to limit postoperative swelling. Fibrin deposition and subsequent collagen deposition will occur between apposed tissue layers during the reparative phase of wound healing.

WHAT IS A SURGICAL DRAIN?

A surgical drain is a tube used to remove pus, blood or other fluids from a wound.

Drain inserted after surgery do not result in faster wound healing or prevent infection but are sometimes necessary to drain body fluid which may accumaulate and in itself become a focus of infection

INDICATIONS

1. Help to eliminate dead space.2. To evacuate existing accumulation of fluid or gas, to

remove pus, blood, serous exudates etc.3. To prevent the potential accumulation of fluid or gas.4. To from a controlled fistula .5. Accurate recording of the volume of drainage as well

as the contents Drains may be hooked to wall suction, a portable suction device, or they may be left to drain naturally.

CLASSIFICATION

Open Vs Closed systems Open Closed Active Vs Passive Active Passive

OPEN DRAINS

Includes corrugated rubber or plastic sheets Drain fluid collects in gauze pad or stoma bag. They increase the risk of infection

CLOSED DRAINS

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

ACTIVE DRAINS

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

PASSIVE DRAINS

Passive drains have no suction Drain by means of pressure differentials, overflow, and gravity between body cavities and the exterior.

JACKSON-PRATT DRAIN

Jackson-pratt drain, jp drain, bulb drain, is a drainage device used to pull excess fluid from the body by constant suction.

The device consists of flexible plastic bulb– that connects to an internal plastic drainage tube.

The jp drain is used as negative pressure vacuum, which also collects fluid. As low negative pressure suction system, it is designed so that intra abdominal content such as the omentum or intestines are not sucked into the tube, minimizing the risk of bowel perforation or ischemia.

CORRUGATED RUBBER DRAIN ( OPEN DRAIN)

Rubber causes a tissue reaction and the drain track caused by this material persists longer than when inert material persists longer than when inert materials arc used. The drain is fixed by a suture at the end of the wound and a safety pin must be placed through the end to prevent the drain slipping inwards. Corrugated rubber drains can be used for wound or for deep drainage.

CORRUGATED RUBBER DRAIN

T-TUBE

Kehr’s T tube : a tube consisting of a stem and a cross head ( thus shaped like T ). The cross head is placed into common bile duct while the stem is connected to a small pouch ( i.e. bile bag ). It is used as a temporary post-operative drainage of common bile duct. Sometimes its used in uretic problems too.

T-TUBE

CHEST TUBE ( CLOSED DRAIN )

RISKS OF CHEST TUBE INSERTION Although chest tube insertion is commonly used as a therapeutic

measure, there are several complications that can develop, including:

Bleeding from an injured intercostal artery( running from the aorta).

Accidental injury to the heart, arteries, or lung resulting from the chest tube insertion

A local or generalized infection from the procedure. Persistent or unexplained air leaks in the tube The tube can be dislodged or inserted incorrectly Insertion of chest tube can cause open or tension pneumothorax.

CLOSED VACUUM DRAINAGE SYSTEMS

Closed vacuum drainage systems have gained increasing popularity in surgical field to control moderate to large dead space pockets. The continuous vacuum effectively draws tissue planes together, creating a “shrink wrap” or “vacuum pack” effect as residual air and fluid are removed from the dead space pocket. Unlike Penrose drains, vacuum drains function without relying on gravity to facilitate fluid removal; they can be placed in a variety of areas, including deeper dead space areas (e.g., deep pockets, orthopedic surgeries with extensive soft-tissue trauma).

A vacuum reservoir (100- to 150-ml capacity) attached to a fenestrated drain aspirates serum that normally accumulates in the dead space postoperatively. The nonfenestrated portion of the tube exits the skin through a small stab incision; a purse-string suture secures the tube to the skin. The external end of the drain is connected to the fluid reservoir; in most models, a one-way valve prevents reflux of the reservoir contents and accumulated contaminants back into the wound. Most commercial reservoirs either use an internal spring to create a vacuum by forcing the chamber walls apart or rely on the inherent “rebound” elastic properties of the chamber to create the vacuum. All reservoirs have a spout to evacuate air and accumulated fluid, with a milliliter scale to measure the fluid accumulated. Drains are normally removed when fluid volumes become minimal.

NEGATIVE PRESSURE WOUND THERAPY

Negative pressure wound therapy involves the use of enclosed foam and a suction device attached ; this is one of the newer types of wound healing/drain device which promotes faster tissue granulation, often used for large surgical/trauma/non-healing wounds.

PIGTAIL DRAIN

A pigtail drain tube is a type of catheter that has the sole purpose of removing unwanted body fluids from an organ, duct, or abscess. Pigtail drains are inserted under strict radiological guidance to ensure correct positioning.

A pigtail is a sterile, thin, long, universal catheter with a locking tip that( once inserted and adjusted by the radiologist) forms a pigtail, shape, hence its name. A guide wire is also part of the sterile insertion kit.

The tip of the pigtail has several holes, which facilate the drainage process. The open end of the catheter has an outlet, which is compatible with an intravenous (IV) luer lock

Pigtails are inserted percutaneously (through the skin) by a radiologist. It may be inserted to allow, for ex. Urine is to drain directly from a kidney, if the ureter is diseased or blocked. This is called a nepherostomy.

Other conditions requiring the insertion of a pigtail drain include a blocked bile duct that needs to be drained of bile or a pus filled abscess. The type of fluid that drains depends upon the reason for its insertion.

PIG TAIL DRAIN

DAVOL DRAIN

This closed wound suction system features soft, inert silicone drains with x-ray opaque stripe for easy placement identification. 

It is designed to minimize tissue trauma and discourage clogging. Drains have a triple lumen configuration to increase drain

versatility and effectiveness. Large center lumen for maximum removal; filtered air vent helps reduce risk of infection. Third lumen permits irrigation and instillation of medicine. 0.3 micron antibacterial filter removes virtually all bacteria from incoming air. Suture cuff helps fasten drain.

DAVOL DRAIN

REDVIC DRAIN

This is a fine tube with many holes at the end, which is attached to an evacuated glass bottle providing suction. It is used to drain blood beneath the skin, e.g. after mastectomy or throiodectomy, or from deep spaces, e.g around a vsacular anastomosis.

REDVIC CLOSED DRAIN

PENROSE DRAIN (OPEN DRAIN)

A penrose drain is a surgical device placed in a wound to drain fluid. It consists of a soft rubber tube placed in a wound area, to prevent the build up of fluid/ Pus.

Penrose drains have been used in the management of dead space and dead space seroma formation for decades.

They are most commonly used to control small to moderate-sized areas of dead space. They function by directing fluid by capillary action over their external surface; the drain exits in a dependent position, allowing fluid to exit the body by gravity. Such drains normally are used to manage dead space for 3 to 5 days, unless significant drainage persists after this time. Anchor the dorsal or proximal end of the drain with an external skin suture and a single suture placed into the drain and exit incision. The drain can be covered with a protective or compressive wrap, depending on the body region affected

Penrose drains are a potential source of wound contamination; they also allow air to enter the subcutaneous area. When used in the axillary or inguinal areas, a “sucking wound effect” is occasionally noted, whereby air is “pumped” beneath the skin. The resultant subcutaneous emphysema normally is minimal but could become more substantial if the drain is retained over an extended period. Under these circumstances, air is slowly reabsorbed once the drain is removed.

PENROSE DRAIN

GENERAL TIPS ON USING DRAINS

The exit site is placed distal or ventral to the surgical area, at or below the dead space pocket.

The exit site is created with a scalpel blade (“stab incision”); the incision should be of sufficient size to easily accommodate the exiting of the drain and fluid exiting along the external surface of the drain by capillary action.

The drain normally exits the skin by 3–4 cm and is typically secured to the skin with a single suture.

The proximal or dorsal end of the drain can be secured with a single 2-0 suture loop passing through the skin and capturing the drain. Some surgeons prefer to “tack” the buried end of the drain with a fine (4-0) absorbable suture to an adjacent musculofascial layer; the suture will break or pull out of the tissue when traction is applied to the external end of the drain.

It is preferable to insert any drain before wound closure to assure proper positioning.

When possible, a drain should not cross or lie beneath the incision.

Care must be taken to avoid accidental suture entrapment of the Penrose drain during closure of the incision.

Penrose drains are radiopaque; radiography can confirm the position or presence of a drain or fragment.

Most drains are removed within 5 days after insertion. Timing of drain removal is assessed by the volume of

fluid exiting the site. Drains may be covered with a sterile dressing,

especially when the drain is likely to come into direct contact with contaminated surfaces. The relative discharge in the bandage can be used to assess the volume of drainage.

Exposed drains can be maintained by cleansing around the exit incision with antiseptic solution, followed by application of a thin layer of antimicrobial ointment.

An Elizabethan collar should be considered to prevent the patient from removing the drain. Fluid volume is assessed by the amount of drainage noted on absorbent cage mats.

SUTURE CLOSURE OF DEAD SPACE

Often, surgical and traumatic dead space can be closed by reapposing facial planes and adjacent soft tissue structures. Suture closure can avoid the postoperative care and overall cost factors associated with the use of surgical drains. Suture apposition is particularly useful for moderate-sized dead space areas involving the trunk. However, not all dead space regions can be effectively eliminated by suturing, especially in those areas lacking fascia and soft-tissue structures for suture apposition. Many of the synthetic, monofilament absorbable or nonabsorbable suture materials on the market may be used for tissue apposition; preferences vary with individual surgeons.

When possible, the adjunctive use of bandages may reduce motion to facilitate healing. In the inguinal, flank, and axillary areas, where elastic skin and underlining subcutaneous tissue accommodate limb motion, aggressive attempts at suture closure can impair this normal gliding function, and vacuum drains are preferred in these areas. In the presence of contamination and infection, excessive use of suture material also can promote infection; in some cases, separate infected pockets may be created, making simple wound drainage problematic. Suture apposition should be used sparingly in contaminated wounds. Contamination or potential

contamination is also a good argument for using a monofilament absorbable suture (or nonabsorbable monofilament nylon/Prolene) of the smallest practical size. Open wound management alone or combined with drains is best for infected wounds.

Should the drain become obstructed with a blood clot, sterile saline can be flushed through the drain with a sterile syringe using strict aseptic technique. Surgical gloves are advised to further reduce the risk of contamination. The drain is then reconnected to the reservoir and reactivated. “Y” adaptors allow for the simultaneous use of two drains with a single reservoir. Because the risk of ascending infection is minimal when drains are properly maintained, vacuum drains may be used to prevent or control dead space seroma formation for extended periods (2 to 3 weeks). Vacuum drains also minimize the nursing care required. The reservoir vacuum can be inactivated by air enter-ing the wound, often as a result of small incisional gaps between sutures. Surgical glue or topical ointment may be used to seal an incisional leak until fibrin deposition and early connective tissue naturally plug these sites.

OPTIONAL TREATMENT Aspiration of Dead Space Seromas

Hypodermic needle aspiration may be used alone or in combination with a compressive wrap in the management of moderate-sized seromas, provided that an effective compression bandage can be applied to the area. Aspiration requires standard surgical preparation of the skin and sterile technique to reduce the likelihood of infection. If a seroma rapidly (within 24 to 48 hours) re-forms after aspiration, it is an indication that a surgical drain is best employed to resolve the problem.

In some cases, dead space seromas slowly re-form to a variable degree within 5 to 7 days of the initial aspiration. Under these circumstances, one or two additional outpatient aspirations usually resolve seroma formation. The primary advantages of aspiration are that it allows outpatient management and has a low cost.

Bandages

Some surgeons recommend that all Penrose drains be covered with a bandage because of the risk that contamination could result in ascending infection. Bandages with a thicker secondary layer may be needed to retain large volumes of fluid exiting the drain sites, and frequent bandage changes would be indicated. Penrose drain placement in the flank, inguinal, and axillary areas normally precludes simple bandage coverage. The risk of ascending infection is low without the use of a bandage cover, especially when the drain can be removed a few days after insertion. However, bandage coverage is advisable for body regions in direct contact with soiled or contaminatedsurfaces (e.g., ventral thorax, abdomen, paws).

Management of Subcutaneous Emphysema Subcutaneous emphysema normally is self-limiting;

the air is typically absorbed once the source of the air entering the wound is eliminated. In cases in which there is a tear in the trachea, large volumes of air may enter the subcutaneous tissue, with dramatic expansion of the elastic skin from the underlying musculofascial layers. Tears of the pharynx, rhinotomy, and cutaneous sucking wounds also cause subcutaneous emphysema, but rarely on the order of magnitude noted with open tracheal wounds. When significant stretching of the skin is present, air can be removed with a large-gauge hypodermic needle connected to a vacuum pump; however, this maneuver is rarely needed. Despite the dead space created, drains are not needed; most air is absorbed within days of eliminating the air leak.

Supportive Treatment

Supportive care depends on the health status of the individual patient.

A sterile dressing and protective bandage can be applied over exposed Penrose drains, as noted above. Depending on the volume of discharge, bandages may require changing one or more times daily.

Exposed Penrose drain sites can be maintained with the application of a broad-spectrum antimicrobial ointment. Any debris or discharge can be swabbed with antiseptic solutions before the ointment is applied. Care should be taken not to occlude the drainage area with too much antibiotic ointment.

Vacuum drains are emptied on an “as needed” basis. Large effusions may require emptying of the reservoir several times daily, depending on its capacity. More commonly, fluid reservoirs are emptied two to four times per day. The quantity of fluid accumulated should be recorded each time the reservoir is emptied. Quantitating the volume helps determine the optimal time to remove the drain (provided the drain is not obstructed).

Elizabethan collars are strongly recommended to prevent patients from damaging or removing drains.

PATIENTS MONITORING

Normal health parameters should be assessed daily; critical care patients require intensive monitoring and supportive care.

Compression bandages require periodic assessment to ensure circulation is not impaired. For bandages on the extremities, the central toes may be exposed to assess for swelling. Bandages that may restrict nor-mal respiration must be closely examined. Problematic bandages may need to be adjusted or removed.

The quality and volume of accumulated fluid should be monitored and recorded.

The surgical site should be assessed for dehiscence, infection, necrosis, and self-mutilation.

The integrity of the drain should be assessed; closed suction drainage systems should be checked for air leaks and obstructions that can negate their function.

Bandages applied to the extremities require close assessment for irritation and edema; owners should be instructed to examine the middle two toes for swelling, color, and warmth. Bandages should be reassessed if the patient is in pain or chews at the bandage.

Exposed surgical areas should be examined daily for swelling, discharge, inflammation, discoloration, necrosis, and dehiscence

Until healing is complete, the patient’s activity should be kept to a minimum.

Owners should be advised to keep the Elizabethan collar on their pet to prevent chewing on or removal of exposed drains.

MILESTONES/RECOVERY TIME FRAME

Skin sutures are normally removed in 8 to 10 days. Drains can be removed when the volume of

drainage decreases to minimal amounts. — Most Penrose drains can be removed within 3 to 5 days. If little or no drainage is noted after 48 hours, the drain can be removed at that time. — Intact closed suction drains normally can be removed in less than a week after insertion. The volume of drainage dictates the appropriate time for its removal.

TREATMENT CONTRAINDICATIONS

Excessive use of appositional (“tacking”) sutures to control dead space in the face of wound contamination or infection.

In cases of infection, open wound management may provide optimal drainage. Deeper or recessed abscess pockets can be effectively managed with vacuum drains.

Penrose and closed suction drainage systems can-not provide optimal wound support in the presence of necrotic tissue.

Penrose drains require a lower, dependent exit site for proper gravitational flow from the wound. If this can-not be provided, closed vacuum drains are advisable.

Penrose drains require a lower, dependent exit site for proper gravitational flow from the wound. If this can-not be provided, closed vacuum drains are advisable.

Penrose drains allow air to enter the subcutaneous space through the exit site. They should therefore be avoided in thoracic wall and inlet areas if there is potential for air to enter the thoracic cavity (e.g., through intercostal muscle tears, incisions).

Vacuum drain systems must be closely monitored when used to control dead space associated with thoracic wounds. Drain tube displacement from the reservoir and a patient’s chewing the tube are potential ways for air to enter the thoracic cavity. Vacuum drains are contraindicated in wounds in which an airtight seal cannot be maintained.

PROGNOSISFavorable Criteria Progressive reduction in drainage; drain removal. Complete healing. Absence of infection. No seroma formation after drain removal.Unfavorable Criteria Persistent, excessive fluid drainage. Development of infection. Tissue necrosis. Partial or complete dehiscence. Repeated vacuum drain obstruction. Seroma formation despite treatment to control

dead space.

COMPLICATIONS AND FAILURE OF DRAINS

Breakdown of anastomotic sites Erosion into hollow organs Premature removal

REMOVAL

Generally, drains should be removed once the drainage is stopped or becomes less than 25ml/day. Drains can be ‘shortened ‘ by withdrawing by approximately 2cm per day, allowing the site to heal gradually. Drains that protect post-operative sites from leakage from a tract and are usually kept in place for one week.

Inform the pt. that there may be some discomfort when the drain is pulled out.

Be sure to wash your hands

carefully with soap before

and after each dressing change.

REFERENCES David J A (1987) Wound Management: A

comprehensive guide to dressing and healing London: Martin Dunitz Limited.

Doughty L & Lister S (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6thEdition Oxford: Blackwell Science.

Wards procedures- Mansuk Patel