2. 2
Tubes and drains
- A mechanical conduit to allow passage of substance be it gas, fluid and pus from the
body to the external environment
- Not always a tube (e.g. Corrugated drain)
Classification
Active Passive
Open According to Prof Simon
Ng, this type of drain does
not exist
Corrugated drain
Yeaste drain
Close Chest drain
Jackson Pratt drain
Robinson drain (tube
drain)
- Passive vs Active
o Passive: Drain by the use of natural difference e.g. gravity, capillary action
o Active (Suction): Drain by the use of suction force e.g. vaccum
Better tissue apposition
Effective evacuation
Less debris blockage
But may have higher chance of tissue erosion, not used in
abdominal cavity
- Close vs Open
o Open system: Connected into the environment e.g. Dressing
o Close system: Connected into a container/bag
Lower infection rate
Accurate measurement of output
Reduce contamination and promote infectious control
Purpose
- Therapeutic:
o Drainage of collections of fluid, pus, blood or air
o Apposition of tissue to remove a potential space by suction
- Precautionary/ Prophylactic/ Monitor: Prevent leakage, Monitor of output e.g.
Foley/Tubal drain
Size
- Diameter of tubes are often numbered as multiples of 2
- Unit: French (Fr/Ch) : 24 Fr = 24/pi = ~8 mm
Materials
- Common materials (Choice depends on purpose)
3. 3
Tubes and drains
o Red rubber e.g. Sengstaken tube, corrugated drain
o Latex rubber e.g. T-tube
Irritative, stimulate tissue fibrotic reaction
o Silicon rubber e.g. Long term Foley
Widely use in clinically setting, expensive but inert, harder, suitable
for long-term usage
o Plastic
How to identify a drain during examination?
- By clinical photo
o Specific features: ‘waveform’ of corrugated drain, ‘grenade’ of JP drain
o Specific colour: NBT – pink, pigtail – white, T-tube – yellow (foley-like)
- By bedside
o Site: nose, neck, chest, abdomen, main-wound
o Output: NBT & PTBD - bile (golden yellow or deep green), R/D – blood
stained fluid
o Marking on Bedside bag
Complications
- Mechanical
o Trauma at insertion and removal
o Erosion of adjacent tissue: fistula, hemorrhage, perforation
o Herniation through tract
o Anastomotic leak: Place too near the anastomoses
- Physiological
o Infection
o Loss of fluid and electrolytes (excessive or inadequate)
o Pain
o Restricted mobility
- Malfunctioning
o Migration and dislodgment
o Blockage (Externally by kinking, compression /Internally by tissue, clot
o Suction failure
Common general drains
1. Robinson Drain (Simple drain, tube drain)
4. 4
Tubes and drains
a. Features
i. Passive and closed
ii. Made of latex
iii. Not inert, induce inflammatory reaction and fibrous tract formation
iv. Ease for later identification of site of tract
v. Quality/Colour varies from brand to brand
vi. Side-hole, radio-opaque line along the transparent tube, free
drainage to BSB
vii. Frequent change is necessary (1 week max)
b. Indication
i. Anticipated fluid collection in a closed space after major abdominal
surgery, to prevent seroma formation e.g. Pelvic surgery laparotomy
for perforated viscus
2. Jackson-Pratt drain (Vaccum drain)
a. Features
i. Active and close
ii. One-way close system
iii. The bulb must be deflated to provide suction
iv. Flat tube with side holes
v. Similar drain (Minivac)
5. 5
Tubes and drains
b. Indications
i. Use as wound drain (Often post-op)
ii. For obliteration of a close space e.g. Parotid, MRM, thyroid surgery
3. Redivac® drain
a. Features
i. Active and close
ii. Ready-to-use vaccum drain
iii. Vacuum established in OT
iv. Conventional: The angle of the antenna indicates vacuum status
1. V shape: good vacuum > Increase angle as vacuum loses
v. New: The antenna indicating system is replaced by the green suction
indicator (~ Minivac)
vi. Same principle as JP drain, connected to glass bottles
b. Indication: Same as JP
i. Commonly seen in orthopedics
c. Placement and Removal
i. Remove if < 30 milliliters of fluid are draining from it in a day
ii. Removal (3S)
1. Stitch removal
2. Suction discontinuation
6. 6
Tubes and drains
3. Slow and steady pull
4. Pigtail catheter
a. Features
i. Pigtail curve with side holes to avoid tissue trauma and improve
draining surface area
ii. Can be locked after placement to prevent dislodgement
b. Indication
i. For deep seated collection
ii. For percutaneous nephrostomy, renal pelvis drainage
c. Placement and Removal
i. Placed under imaging guidance
Urinary Catheter
5. Urinary Foley catheter
a. Features:
i. Balloon
1. For injection of water (which have the same density of urine)
7. 7
Tubes and drains
2. Self-retaining (Keep the catheter inside the bladder) to
prevent self-off when the patient urinates
3. SALINE SHOULD NOT BE USED TO INFLATE THE
BALLOON AS IT MAY CRYSTALIZE AND BLOCK THE
TUBE (ASK FOR “WATER FOR INJECTION”!)
4. In case balloon fails to deflate, keep pumping in water to burst
it in side the bladder
ii. Valve
1. Made of self-sealing rubber to prevent leakage from puncture
hole, gateway for inflation of balloon (Dome valve)
b. Types
i. Latex Foley: Short term drainage, yellow
ii. Silicon-treated Foley: Minimize inflammatory reaction for long term
placement, transparent
iii. 3-way Foley: To be used in hematuria patient, water can be used to
flush when necessary
iv. Hematuric catheter: Metal core, harder than normal
c. Indications
i. Drainage of urine
ii. Foley catheter can be used to drain suprapubic bladder
iii. Chest drain in emergency
iv. Stop nose bleeding by inserting into nasopharynx
v. Stop anorectal bleeding
d. Contraindication
i. Urethral trauma
e. Complications
i. UTI
ii. Trauma to urethral tissue
f. Placement and Removal
i. Suprapubic
1. Open method: OT
2. Close method: US guided at bedside
8. 8
Tubes and drains
ii. Procedure of insertion of Foley
1. Patient identification, assess indication and contraindication
2. Consent
3. Position (Leg spread and feet together)
4. Aseptic procedure and universal precautions
5. Gather equipment (urinary catheterization set, CHECK
EXPIRY DATE)
6. Open urinary catheterization set under aseptic technique
7. Ask assistance to pour you antiseptics solution and draw a
syringe of water for injection
8. Soak cotton wool with antiseptics and prepare lubricant
9. Check balloon of the catheter and coat the catheter with
lubricant
10.Clean the perineum with antiseptic solution, clamp the
forceps on outer wrapping of the set
a. Cleanse anterior to posterior, inner to outer, one
swipe per swab, discard swab away from sterile
field
11.Drape the sites with sterile cloths
12.Prepare the catheter and the kidney bean dish for urine
collection later (put it on the draped area)
a. 16-20 (Adult)
b. 28 (Post-op prostate surgery e.g. TURP)
c. 8 (Children)
13.Put a soaked gauze on the shaft of penis and pick up the
penis and retract the prepuce with the non-dominant hand
(NOW CONTAMINATED) and cleanse the urethral meatus
with the previous clamp
a. Using dominant hand to handle forceps, cleanse
peri-urethral mucosa with antiseptic solution.
b. LA catheter gel for analgesia (Can test the balloon of
the catheter now if not done yet while waiting for LA
to work)
14. Pick up the catheter by a new forceps (with the dominant
hand) and hold the penis with the non-dominant hand
through a soaked gauze, insert beyond 1-2 inches where
urine is noted (collect the urine with the kidney bean
container)
a. Male: Make sure urine flow out before pumping
balloon (Prevent the risk of damaging the
membranous urethra)
15.Inflate the balloon and gently pull the catheter until it is snug
against the bladder neck
16.Connect to bedside bag
a. Make sure the bag is LOCKED
17.Reduce the prepuce and tape the foley correctly
9. 9
Tubes and drains
18.Documentation and proper disposal of waste
19.Check for output and inspect for traumatic hypospadia
everyday
6. Malecot catheter
a. Features
i. Self-retaining
ii. Rubbery and elastic
b. Indications
i. Chest drain
ii. Jejunostomy feeding (No balloon has to be inflated to keep it in-situ
thus no risk of luminal obstruction
Abscess drainage
7. Corrugated drain
a. Features
i. Passive and open
ii. A waveform strip of rubber and fit loosely and push into the depth of
wound
b. Indications
i. Commonly used in limb wounds to drain DEEP SEATED ABSCESS
ii. Skin recovery > Subcutaneous tissue recovery, so delaying wound
closure
8. Yeates tissue drain
10. 1
Tubes and drains
a) Corrugated; b) Penrose; c) Yeates
a. Features
i. Passive and open drain
ii. Row of straws’ - Increase surface area and lumen provides capillary
action drainage
iii. Suitable for large volume drain
b. Indications
i. Same use as corrugated drain
Nasogastric drainage
9. Ryle’s tube
a. Features
i. Commonly used nasogastric tube
b. Indications:
i. To drain gastric content to decompress stomach and prevent
aspiration e.g IO or intraop use
ii. Feeding (Not for long-term uses due to microaspiration pneumonia
and discomfort
c. Placement and Removal
i. Estimate length: Nose > around ear > 5cm below xiphoid
ii. Place NGT straight back (not up or down) through the nose
iii. Keep asking the patient to swallow and neck flexed
11. 1
Tubes and drains
iv. Confirm by 1: Auscultate for gurgling sound over stomach while
injecting air; 2: Aspirating gastric content and test with Litmus paper
pH <2 ; 3: Chest XR to confirm correct placement
10.Entriflex® tube
a. Features
i. Metalic weight at the end of tube (to ease placemet)
ii. Radio-opaque: (to ease positioning by X-ray)
iii. Central guidewire to facilitate insertion
b. Indications
i. Nasogastric tube for prolonged usage (thinner, siliconized to
minimize tissue reaction and discomfort)
ii. NOT for aspiration
c. Placement
i. Must pass the pylorus to facilitate absorption
11.Infant feeding tube (Fine bore feeding tube)
12. 1
Tubes and drains
a. Indications
i. Infant feeding
ii. Temporary splinting of fibrous tract in PTBD dislodgment
iii. Probing in exploration of fistula
iv. Central line/Hickmann’s catheter
v. Renal transplant patient
1. Inserted in ureteric orifice to prevent obstruction by fibrosis
12.Sump drain (Salem sump drain)
a. Features
i. Active and OPEN system
ii. (Prof Simon Ng: Active and Close)
iii. Double lumen (larger outflow lumen and smaller inflow lumen)
iv. (Sieve system) The dual lumen tube allows for safer continuous and
intermittent gastric suctioning.
1. The large lumen allows for easy suction of gastric contents,
decompression, irrigation and medication delivery.
2. The smaller vent lumen (blue tube) allows for atmospheric
air to be drawn into the tube and equalizes the vacuum
pressure in the stomach once the contents have been
emptied. This prevents the suction eyelets from adhering to
13. 1
Tubes and drains
and damaging the stomach lining.
b. Indications
i. Pancreatic surgery
ii. As a nasogastric tube
13.Sengstaken-Blakmore tube
a. Features
i. 3 channels (+ eso aspiration port = Minnesota tube)
1. Esophageal balloon
2. Cardiac aspiration (Monitor bleeding)
3. Cardiac (Gastric) balloon
4. Esophageal aspiration (for saliva and monitor leakage, absent
in SB tube)
ii. 2 balloons
1. Cardiac balloon
a. As a tamponade to stop bleeding
b. Inflated by 200-300 cc contrast + water to ease
assessment of tube position by X-ray
c. Water + methylene blue to visualize leakage if the
balloon burst
2. Esophageal balloon
a. Inflate with gas, 40 mmHg (>capillary perfusion
pressure)
b. Markers in cm for measurement
iii. Stored in fridge to harden the tube for easier insertion
b. Indications
i. Temporary hemostasis of variceal hemorrhage by direct
compression at bleeding site (<24hr)
14. 1
Tubes and drains
ii. Aim:
1. Prevent exanguination (Massive bleeding that prevents
immediate endoscopy and sclerotherapy
2. Stabilize patient before more definite treatment e.g.
endoscopic sclerotherapy and banding
c. Contraindication
i. Large hiatal hernia
ii. Known esophageal stricture
iii. Unconfirmed variceal bleeding
1. Not even in a patient with chronic liver disease if variceal
bleeding not confirmed, since it may convert a MW tear into
a complete tear and esophageal perforation
d. Drawbacks
i. Hazardous and uncomfortable: GA and tracheal intubation in
confused or agitated patients may be need
ii. Skillful surgeons needed
iii. Achieve temporary control, prolonged pressure will lead to necrosis
of tissue
14. Flatus tubes
15. 1
Tubes and drains
a. ~ NGT but shorter
i. cf rectal tube: similar but shorter: For fleet enema and rectal
clearance
b. Short term use only
c. Indications
i. Decompression of the LB in pseudo-obstruction
ii. Prevent immediate recurrence In derotation of sigmoid volvulus
iii. Drainage of liquid feces and flatus
Cardiopulmonary drainage
15.Nelaton catheter
a. Suction catheter (Sputum suction)
b. Indications
i. Commonly used in emergency trolley/anesthesia to keep the airway
patent.
1. Cholinergic drug will increase parasympathetic activity and
highly increase mucus secretion
ii. Rectal irrigation/washout (Thick and big catheter used)
16.Chest drain
16. 1
Tubes and drains
a. Features
i. One bottle
1. Under water seal chamber only
ii. Two bottles
1. Additional collection chamber
2. Apply suction, same mechanism as Sump drain, open,
release the pressure
17. 1
Tubes and drains
iii. Three bottles
1. Additional suction regulation system
a. Collection chamber: To collect pleural fluid
b. Underwater seal: One way valve to prevent air from
being sucked in by negative pleural pressure during
inspiration
i. Check swinging
ii. Check bubbling
c. Suction regulator: The amount of vacuum is directly
proportionate to depth of the tip of the central tube
under water surface (e.g. suction of -20cm H2O is
achieved by placing tip of tube 20 cm below surface)
i. It should always be bubbling if suction is
on
18. 1
Tubes and drains
ii. Amount of suction is regulated by the
amount of water filled in the integrated 3
bottle system
iii. Amount of suction can only be determined
by temporarily stopping the pump
Underwater seal chamber Interpretation
Swinging Bubbling
Yes Yes Indicates air leak from the lung or somewhere along the
circuit
The degree of air leak can be assessed in the “air leak
meter” in the under water seal chamber in the integrated 3
bottle system
The swinging reflects the negative pressure within the
pleural space.
Swinging is only seen if suction is not applied and decreases
as the lung re-expands.
No No Indicates resolution of air leak and lung re-expansion
Make sure the tube is not obstructed.
No Yes Indicates a possible connection or system air leak.
Can temporarily occlude the chest tube right at the skin exit
and if the bubbling continues then the leak is external to the
patient.
A hissing sound may point to the leak.
Tape all connections securely.
Yes No May be seen with partial or total pneumonectomy and in stiff
lungs
b. Indications
i. Pneumothorax (>20%)
ii. Trauma patient (hemothorax)
iii. Effusion, empyema
c. Placement and Replacement
i. Note
1. Position of drain
a. Apex of pleural cavity: Pneumothorax
b. Base of pleural cavity: Effusion/Emphysema
c. Confirmed by X-ray
2. Size of chest tube with trocar:
a. 24 Fr (for effusion and air)
b. 28 Fr (for blood and pus)
19. 1
Tubes and drains
3. Suction pressure: 15 mmHg (~ negative pleural pressure)
ii. Caution
1. NEVER clamp a drain except in changing bottle as it can
result in tension pneumothorax
2. NEVER push the chest drain back into the pleural space as it
is now contaminated, change a new drain
iii. Insertion
1. Patient identification, assess indication and contraindication
2. Aseptic procedure and universal precautions
3. Administer local anesthetics, infiltrate all layers until needle
can aspirate free gas or fluid (inside pleural cavity)
4. Incision on the 4th
ICS between anterior and mid-axillary line
a. Safety triangle that avoid the long thoracic nerve and
the pectoral major muscle
b. More comfortable to the patient and allow less
painful shoulder movement
5. Perform a blunt dissection OVER the rib into the pleural space
a. Trocar puncture may injure lung parenchyma easily
6. Finger exploration to confirm intrapleural placement
7. Direct drains basally for effusion and apically for
pneumothorax
8. Skin suture over the wound and make a knot, form a 2 cm
sling by tying another square knot 2cm from previous knot.
Tie the sling to the drain, make several knots to prevent
slipping
9. Confirm position with CXR
10.Beware of re-expansion pulmonary edema
11.Daily CXR until removal
iv. Complications
1. Trauma (Pneumothorax, hemothorax, hemoptysis, air emboli,
liver and spleen)
2. Re-expansion edema
3. Empyema
4. Vagal shock
20. 2
Tubes and drains
5. Seeding mesothelioma
6. Surgical emphysema (MB question 2010)
a. Check chest tube for proper functioning
b. Relieve obstruction
c. ± Apply suction, use large bore drain
d. Release of air through skin incisions
v. Things to comment in examination
1. Site of insertion
a. left or right chest, safety triangle
b. wound complications
2. Collection chamber
a. Drainage substance (air, blood, pus or fluid)
b. Amount drained (massive hemothorax?)
3. Underwater seal chamber
a. Adequacy of seal (water level in the UWS chamber
should be at level marked 0)
b. Presence of bubbling indicates air leak (ask patient to
cough if no bubbles)
c. The column 1-5 indicates the degree of air leak
d. The calibration column in the UWS chamber indicates
the degree of negative pressure in the pleural cavity
e. Presence of swinging with respiration movement
indicates intrapleural position of the chest tube and
the lung is still not yet full expanded
i. Ask patient to take deep breath if not present
4. Suction regulation chamber
a. Use of suction (bubbling in the SR chamber)
b. Ask to stop the suction to look for the amount of
suction applied in the suction regulation chamber
17.Tracheostomy tube
a. Features
i. Surgical procedure
ii. Definitive airway
iii. Type: Nonmetal/metal, cuffed/uncuffed, fenestrated/unfenestrated,
short/long term, single/double lumen
iv. Size: the largest and the most tolerable one ~3/4 diameter of trachea
v. Materials: Portex and Shiley
21. 2
Tubes and drains
1. Portex (left panel): No inner tube, thermoplastic, used as
initial airway postoperatively, less likely to traumatize
trachea and allow the tract to mature
2. Shiley (right panel): With inner tube, fenestrated,
allow patient to speak, and easier care (clean the
inner tube regularly)
22. 2
Tubes and drains
Tube Indication Recommendations
CuffedTube with Disposable Inner Cannula
Used to obtain a
closed circuit for
ventilation
Cuff should be inflated when using with
ventilators.
Cuff should be inflated just enough to
allow minimal airleak.
Cuff should be deflated if patient uses
a speaking valve.
Cuff pressure should be checked twice
a day.
Inner cannula is disposable.
Cuffed Tube with Reusable Inner Cannula
Used to obtain a
closed circuit for
ventilation
Inner cannula is not disposable. You
can reuse it after cleaning it thoroughly.
Cuffless Tube with Disposable Inner Cannula
Used for patients with
tracheal problems
Used for patients who
are ready for
decannulation
Save the decannulation plug if the
patient is close to getting
decannulated.
Patient may be able to eat and may be
able to talk without a speaking valve.
Inner cannula is disposable
Cuffless Tube with Reusable Inner Cannula
Used for patients with
tracheal problems
Used for patients who
are ready for
decannulation
Inner cannula is not disposable. You
can reuse it after cleaning it thoroughly.
Fenestrated Cuffed Tracheostomy Tube
23. 2
Tubes and drains
Used for patients who
are on the ventilator
but are not able to
tolerate a speaking
valve to speak
There is a high risk for granuloma
formation at the site of the fenestration
(hole).
There is a higher risk for aspirating
secretions.
It may be difficult to ventilate the
patient adequately.
Fenestrated Cuffless Tracheostomy Tube
Used for patients who
have difficulty using a
speaking valve
There is a high risk for granuloma
formation at the site of the fenestration
(hole).
Metal Tracheostomy Tube
Not used as frequently
anymore. Many of the
patients who received
a tracheostomy years
ago still choose to
continue using the
metal tracheostomy
tubes.
Patients cannot get a MRI.
One needs to notify the security
personnel at the airport prior to metal
detection screening.
b. Indications
i. Failed intubation
ii. Expected prolonged intubation (>1wk)
iii. Therapeutic
1. Chronic airway obstruction (OSA, H&N Ca obstructing AW)
2. Acute airway obstruction: “When you think of it” Mosem’s
dictim
3. Facilitate pulmonary toileting: In paralysed patients and
prolonged intubated patients, allow easier suction
iv. Prophylactic
1. H&N surgery postoperative swelling
c. Care
i. Suck and humidify
ii. Hygiene: clean the inner tube and chest physio
d. Complications
i. Immediate
1. Trauma to the airway and neighbouring anatomical structures
24. 2
Tubes and drains
a. Brachicephalic vein: particularly in children
b. Esophagus
c. RLN
d. Trachea
e. Pleura: pneumothorax
2. Delayed
a. Irritation and Infection
b. Malpositioning, displacement, erosion
c. Obstruction
i. Acute emergency, CALL FOR HELP
ii. Replace with non-fenestrated inner tube (if
present)
iii. Try ventilating through the replaced tube
iv. Try pass suction catheter to look for
obstruction
v. Deflate the cuff and bag-mask around the
tracheotomy space
vi. Remove the tracheostomy, cover with
dressing and ventilate through mouth
vii. Avoid re-inserting if recently created (tract
not mature, may insert into the
mediastinum
viii.Avoid removal of tube if recently created, try
to unblock it with suction catheter
d. Subcutaneous emphysema
e. Aspiration
f. Persistent fistula (skin-trachea/ trachea-esophagus)
g. Stenosis of AW
h. Tracheomalacia
i. Difficulty in weaning off
j. Scar (keloid)
k. Unable to speak
18.Laryngeal mask airway
25. 2
Tubes and drains
a. Features
i. NOT a protected airway, aspiration can still happen, so not for
emergency OT, cesarean section, abdominal surgery
1. Usually for O&T surgery
ii. Inflatable cuff to seal off the larynx
iii. Can be sterilized and reused
iv. Newly introduced in late 1980s
v. Can be inserted blindly without laryngoscope
27. 2
Tubes and drains
a. Features
i. ET-tube
ii. Plastic, disposable
iii. ET cuff
iv. Size marked on the tubes, length marking for insertion depth
1. The double black line marks the position level for vocal cord
2. 7 for female and 8 for male (usual)
v. Can be double lumen for selected one lung ventilation
1. One lumen open in the trachea, one in the main bronchus,
usually the right main bronchus (more vertical, easier
insertion)
b. Indication
i. Airway protection (massive hemoptysis, hematemesis, GCS <8)
ii. Ventilation (during resuscitation, operation)
c. Contraindication
i. Cervical spine injury: fiberoptic intubation
ii. Mass lesion obscuring the upper AW
d. Placement
i. Insertion: With help of laryngoscope, stylet or bougie to guide the
insertion
ii. Sedation: With rapid sequence induction to prevent gag reflex and
aspiration, or usual induction
iii. Ventilation: With SaO2 and bag mask for oxygenation, end-tidal CO2
and monitoring
iv. Prepare equipment (laryngoscope, ET tube, syringe for air
insufflation, lubricants, bourgie/stylet, stethoscope for auscultation,
bag and mask for preoxygenation and ventilation
v. Check equipment (laryngoscope, balloon of the ET tube: inflate with
10 ml and deflate)
28. 2
Tubes and drains
vi. Prepare the patient by pre-oxygenating the patients with 100% O2 for
5 mins
vii. Prepare the airway with head-tilt chin lift maneuver
viii.Rapid sequence induction: (Pressure, Sedate, Paralysis)
1. Apply cricoid pressure
2. Short acting sedatives (midazolam and propofol)
3. Rapid acting paralytic agents (suxamethonium, ~3 min with
visible muscle twitching)
a. Need to continue oxygenating the patient if RSI is not
used, such as in routine GA setting
ix. Insertion (should be <15 sec, otherwise re-oxygenate before retrial)
1. Largngoscope (hold with left hand and tilt the tongue to the
left, avoid hinging on teeth, blade to valleculae, push the
tongue down and pull the jaw to the ceiling)
2. Slide the ET tube down after visualization of the vocal cord
(usually to 22 cm mark)
3. Inflate the cuff (10ml and feel the pilot balloon)
x. Position confirmation
1. By bagging: smooth bagging
2. By P/E: symmetrical and adequate chest expansion and
good AE on auscultation (3 pt: L/R chest and epigastrium)
3. By Ix: Positive ETCO2 (gold standard), CXR confirmation: 2
cm above the carina
e. Complications
i. Damage to oropharyngeal airway: teeth, trauma, hoarseness
ii. Esophageal intubation (inflated stomach with unprotected airway >
aspiration)
iii. Ventilation associated infection in long term use
iv. Sedation complications (malignant hyperthermia in suxamethonium)
Hepatobiliary drainage
20.Nasobiliary tube
a. Features
i. Pink in colour with side holes
b. Indication
i. Temporary relief of biliary obstruction similar to internal stent
1. Efficacy similar to internal stent
2. Enable drainage monitoring in very ill patients
3. Enable repeated aspiration in hemobilia
c. Relative C/I
29. 2
Tubes and drains
i. Confused patient (They will pull off the drain)
d. Placement and Removal
i. Placed via ERCP up to right hepatic duct
ii. Removed within same admission
iii. AXR showed alpha sign confirms good position
21.Percutaneous transhepatic biliary drainage
a. Features
i. Invasive
ii. Inserting a catheter through a skin incision into the obstructed bile
duct > CBD > Ampulla of Vater > Duodenum
iii. Cholangiogram is performed to define the anatomy
iv. Subsequent internalization
1. Internal/external drainage
2. Internal drainage by stenting on another day, usually days
or weeks after the initial PTBD) of the PTBD facilitates
internal drainage of bile, which reduces the loss of fluid and
electrolytes
v. Side-holes along the drain extending back to about 15 cm from the
tip (instead of 5 cm with multi-purpose catheters).
vi. Extra proximal holes allow the catheter to serve as a stent.
1. Bile from the upper part of biliary tree will enter the proximal
side-holes and run within the biliary catheter before exiting
into the duodenum via the distal side-holes.
b. Indication
i. Biliary decompression and ERCP contraindicated
ii. Palliative biliary drainage in cholangioCA
c. Placement and Removal
i. Placed under image guidance with DILATED DUCTS by
interventional radiologists
ii. Patient needs to hold breath at inspiration.
d. Complications
i. Cholangitis and wound infection
ii. Catheter dislodgment
30. 3
Tubes and drains
1. Splint the tract temporarily by inserting infant feeding tube
iii. Hemobilia and sepsis
iv. Injury to other organs (Kidney, perforation of duodenal diverticulum,
pleura > Pneumothorax and bilothorax
v. Contrast related
22.Cholecystostomy tube
a. Features
i. To drain the gallbladder (Percutaneous cholecystostomy)
ii. Difficult to differentiate from PTBD in bedside due to similar content
and position
b. Indication
i. Mx of acute cholecystitis in surgically unfit patients
c. Placement and removal
i. Placed in OT surgically or percutaneously
23.T-tube
a. Features
i. Siliconized/ non-siliconized/ latex
31. 3
Tubes and drains
ii. Normally used size: 14,16,18
iii. T-tube is placed inside the common bile duct
iv. If the distal portion of the duct is blocked: bile will be drained out
v. Intraluminal block removed: bile will flow down CBD, as a lower
pressure track
b. Indication
i. Monitoring of biliary complication after exploration of CBD
1. Safety valve for bile drainage in case of temporary
obstruction
ii. Small drain (with the head of T-tube cut, Max 18 Fr)
c. Placement and Removal
i. Placed in the OT
ii. Upper limb should not be longer than the level of hila
iii. Lower limb should not touch the ampulla of Vater
1. ‘Cut-open‘: To prevent crystallization of bile and blocking the
tube
2. ‘Tilted’: To prevent obstruction (CBD is not straight)
iv. Removal
1. Day 10: Retrograde/T-tube cholangiogram to reveal CBD/
choledocoscope
2. Clamp the T-tube and observe for few days to rule out biliary
leak before removal
3. Day 14: T-tube withdrawal with a fibre-tract well formed.
Spontaneous closure of the hole will be achieved <1 hr after
removal
