Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Principles of Tube NAJEEB AFTAB Thoracostomy  Indications for chest tube placement. Objectives  Anatomy and Physiology review  Chest tube parts and equipment  Proper techniques  Troubleshoot common chest tube problems  Tips and tricks  Questions  The need for EMERGENT thoracotomy is a Contraindications contraindication for TUBE thoracostomy.  RELATIVE contraindications are: 1. Coagulopathy 2. Pulmonary bullae. 3. Multiple pleural adhesions. 4. Multi Loculated pleural effusion/Empyema thoracis. 5. Skin infection over insertion site. 6. Distorted anatomy of the thorax/ congenital malformations. 7. Mass in the chest.Anatomy review  Idealistic picture.  Varies from patient to patient.  These landmarks can help in very obese patients as well.Pleural Physiology FLIUID OR AIR RAISES FLUID WILL COME OUT INTO INTRAPLEURAL PRESSURE. THE CHEST DRAIN ONCE ITS PRESSURE REACHES ABOVE -4 MMHG.Chest drainage cathetersBe preparedBasic pathways  Simplified diagrams.  Allow air and fluid to drain from patient into collection chambers.  Water seals do not allow air or fluid to return to patient.  Understanding this is critical to safe chest drain management.The triple chamberInsertion Technique  Multiple ways to confirm chest tube insertion Confirmation site 1. Fogging of chest drain. 2. Swinging of coloumn. 3. Drainage of air/fluid. 4. Chest X-ray 5. Ct scan of Chest.Securing a Chest TubeSeldinger TechniqueSeldinger Technique  Incision  Needle  Guidewire  Dilator  Tube insertion  Wire out.  Secure.Breathing mechanics When to remove? Most chest tubes can be removed when: • NO air leakage • Drain output is less than 50mm/day • Clear Serous/Serosanginous fluid. • Full Expansion on CXR.Removing Chest tubeTroubleshooting  Column not moving: Usually due to blockage of tube by blood clots or exudates. Another reason can be kinking/misplacement. Easily remedied by reviewing CXR and washing of chest tube.  Column moving too much >5cm: is common in pneumothorax ,if tube end is placed in the apex or if lung is significantly deflated.  Leakage from drain site: common after pleural effusion drainage, usually due to fluid leaking from pleura into wound. Remedy by tightly securing chest drain and proper dressings frequently.Troubleshooting  Pain during procedure: Patient needs adequate counselling beforehand, usually due to pain from the stretch/injury of parietal pleura. Remedy by using proper technique QUICKLY and using local anesthetic again.  Chest drain malpostioned on CXR: the tube maybe kinked, too far in or outside the chest. Remedy by adjusting the chest tube accordingly.  Air leak from wound: usually when we do not use OPSITE as air seal on the wound. Remedy by ensuring proper wound closure and using OPSITE.Troubleshooting  Air bubbles continuously on suction application: Usually due to air leak in the chest drainage system. Clamp the chest tube while suction is applied, if bubbles persist then it’s a leak in the system and if bubbles disappear then its likely persistent air leak inside the pleura (broncho pleural fistula, ruptured bullae, air leak from parenchymal injury). Tips and Tricks  Talking to the patient and proper counselling is at times the best painkiller.  Consent is NECESSARY.  Review the relevant radiology thoroughly before proceeding.  Orient your landmarks according to patient anatomy and size.  Locating chest drain insertion site becomes easier when you perform needle thoracentesis first.  Be quick but be accurate.  Observe first, learn from others experience and mistakes.Questions?D RAINS,WOUNDS ,STOMAS AND PRACTICAL TIPS Najeeb Aftab General Surgical SpRDRAINS When are they used? What is the purpose? What types are there? Open Vs Closed Active Vs PassiveCORRUGATEDwDRAINelinedelhi.com/pcat-gifs/products-large1/corrugated-drain-sheet.jpg http://haqs.com/fundamentals/drains/pencor.jpg ROBINSON D RAIN http://www.redax.it/webdisk/articles/img-art-67-View.jpg http://img27.fansshare.com/pic37/w/drain--surgery-/369/814_surgical_drain_tubes_tummy_tuck.jpgREDIVAC D RAIN http://upload.wikimedia.org/wikipedia/commons/5/57/Drainage.JPGP IGTAIL DRAIN http://www.mrmjournal.com/content/figures/2049-6958-8-18-5-l.jpg http://posterng.netkey.at/esr/viewing/index.php?module=viewimagetask=maxheight=300maxwidth=300mediafile_id=390891201201232047.gif http://www.allwinmedical.com/ProductImage/326.jpgOPEN VS CLOSESYSTEMPOSSIBLE DRAIN CONTENT Read the operation note for clues Expected Vs Unexpected drain content EXPECTED Washout fluid http://journals.lww.com/em-news/PublishingImages/Procedural%20Pause/May%202014/Photo%207.jpg Serous Haemoserous http://www.drbrennerarticles.com/wp-content/uploads/2010/08/DSC_02681.jpgU NEXPECTED  Blood (look for clots, unstable patient) Pus Faeces Bile Chylehttp://i.imgur.com/2EO470l.jpg http://i.ytimg.com/vi/LhuuaMhpdss/maxresdefault.jpgW HEN TO PULL A DRAIN (Never?) When drainage is <50ml Beware accurate documentationWOUNDS http://www.sciencephoto.com/image/253472/large/M1310500-Infected_post-operative_wound-SPL.jpgW OUNDS ABCDE Septic screen Mark area? Remove clips? Red flags TVN VACW OUND DEHISCIENCE  7-14 days post op  Heralded by salmon pink discharge  Warning signs Patient factors Operative factors Post operative factorsB URST ABDOMEN -MANAGEMENT DONT PANIC! ABCDE Warm saline http://image.slidesharecdn.com/managementoftheburstabdomen-140626144849-phpapp02/95/management-of-the-burst-abdomenppt-6-638.jpg?cb=1403794203 Large packs Analgaesia Call seniorhttp://www.eakin.eu/DatabaseImages/cas_7672846__img3553-web.jpghttps://s-media-cache-ak0.pinimg.com/736x/d0/ca/e3/d0cae332c393bb8a6827f8d38bad3477.jpg S TOMAS http://www.coloplast.co.uk/Global/2_Stoma/HCP/Oedema.jpg http://www.convatec.com/media/4457068/flushstoma_m.jpghttp://www.ainscorp.com.au/assets/upload/images/prolapse.JPG http://dansac.com/files/miscellaneous/ostomy_glossary/hernia.jpgQUESTIONS ?