Drains (nontunneled)

Unsafe anatomy, e.g., completely surrounded by vessels and bowel
Uncorrected coagulopathy (Plt <50K, INR >1.7)
Necrotic tissue that would require surgical debridement
Abscess <3 cm, sterile hematoma (some will offer later for palliation of pain with chronic hematoma), phlegmon, tumor (unlikely to achieve source control), adjacent/involving a surgical implant (will seed it)
Lung abscess - classic teaching is abx alone due to risk of bronchopleural fistula. Can consider drainage if >6 cm, immunocompromised, unstable, or not resolving after 2-3 wks of abx

Generally >90% clinically successful if uncomplicated.

Recurrence in 8-20%.

Main alternative is surgical debridement and/or washout or conservative management with antibiotics alone

Plan approach with cross-sectional imaging. Should have sufficient tissue to stabilize needle while avoiding vessels, bowel, gallbladder, or crossing pleura (if possible).
Hold coumadin and ASA/Plavix 5d prior if possible.
Should get an antibiotic 1 hr prior to access if not already being treated.

Drain Placement

Pre-scan and mark planned skin entry site. Can use radio-opaque grid or hemostats if using CT.
Access the collection under imaging guidance (US, CT, or fluoro)

Common access needles include 5F Yueh, 19G coaxial, and micropuncture set
Should have sufficient tissue to stabilize needle while avoiding vessels, bowel, gallbladder, or crossing pleura (if possible, unless placing a chest tube).
Chest tubes for effusions: classic teaching is 6-7th intercostal space, midaxillary line
Chest tubes for PTX: can have the head at 30* to accumulate air anteriorly and apically. Goal to get the pigtail to form at the apex.

Optional gentle contrast injection to confirm access if using fluoro. Avoid over-pressurizing if concern for infection as this can cause bacteremia and worsening infection.
Obtain sample for culture either via access needle or drain at the end.
Advance 0.035” wire, e.g., Amplatz. Would need to use transitional dilator to upsize to 0.035” system if access with micropuncture set.
Dilate percutaneous tract as needed pending drain size.
Advance and form drain.
- Size depends of the viscosity of what is being drained. For example, 8-10 Fr for simple fluid or seromas vs 12+ Fr for thicker purulent output.
- Uresil drains are one of the only non-luer systems. Most drains are luer systems that decrease the effective size to 10-12 Fr regardless of drain size.
- For smaller collections, Dawson-Mueller catheters have a smaller pigtail at the end.
Optional gentle contrast injection to confirm placement if using fluoro.
Optional gentle aspiration of collection.
- Avoid being too aggressive as this can also worsen the infection.
- For pleural effusions, avoid removal of >1200 mL or once patient starts coughing to avoid reexpansion pulmonary edema.
- For ascites, albumin should be administered if >5L removed. See paracentesis guide.
Secure in place and attach to drainage bag

Some will instill 2 mg t-PA with 1-2 hr dwell if thick to help facilitate drainage. This is actually more common in pediatrics.

Example peds daily drain protocol: (<10 kg) 4 mg t-PA in 10 mL, Dornase 5 mg in 10 mL; (>10 kg) 4 mg t-PA in 20 mL, Dornase 5 mg in 20 mL

Abscessogram / Sinogram

Anesthetize around existing drain is planning manipulation beyond simple removal.
Gentle contrast injection via existing drain. If high concern for fistula, it can be helpful to do the initial injection as a DSA.
Assess the residual collection and/or fistula if present in multiple projections.
If removing, aspirate back any injected contrast to collapse any residual cavity. Some will also irrigate the cavity prior to removal.
If loculations, can twist a locked pigtail drainage catheter with a metal stiffener to break them up while irrigating and aspirating.
If persistent collection, exchange for a new drain positioned within the dominant residual collection.
If fistula, people vary dramatically in management. Some will exchange for a few months to give it time to heal on its own and stop flushing the drain. Others will more quickly trial injecting substances to embolization the tract (e.g. Tisseel or glue)

Wide range of reported clinical success with conservative management with serially downsizing the drain (~57-100% in small studies). Some will place a drain in the collection/cavity as well as a second drain through the fistula if high output (~200 mL/d).
Some evidence that the mature lining of the tract should be disrupted/debrided prior to embolization to stimulate healing, e.g., one can use the brush that comes with Cook’s fistula plugs. After debridement, they sanitize the tract by irrigating it with hydrogen peroxide.
Fibrin glue (e.g. Tisseel) - mix of fibrin/fibrinogen and thrombin that form clot laced back from the bowel wall
Autologous platelet-rich fibrin glue (PRFG) or histocryl with lipiodol - good for long-tract, low-output
SurgiSIS (Cook), BioDesign (Cook, shown to outperform glue)

Complications occur in <15%; however, 30-day mortality 1-6% for abscess drain placements.

Complications include hemorrhage, septic shock, enteric fistula, hemopneumothorax, bowel puncture and peritonitis

Flush volume and frequency based cavity size and complexity of fluid being drained.
Evaluate if output <20 mL for >2 days with resolution of infectious signs/symptoms OR if persistent high volume output for multiple weeks (concerning for fistula).

If decreased output and superficial or imaging evidence of resolution without concern for fistula, can removed bedside or in clinic. Some suggest using a wire if the drain is in a solid organ.
If persistent collection with decreased output, can first try 2 mg t-PA with 1-2 hour dwell and aggressive flushing to open up a clogged drain. Otherwise, it needs evaluation and exchange.

If fistula forms, options include prolonged drainage with bowel rest if enteric fistula, surgery, or using Tisseel or Glue to attempt to occlude the fistula. Octreotide can also help for pancreatic duct involvement.
Chest tubes

Can hook up to pleur evac or heimlich valve if discharging with tube for motility
Removal: classic teaching is to check for air leak -> clamp for 4hrs -> check CXR prior to pulling and after