Fluid Management
Indications
Refractory ascites or pleural effusion. Generally placed for palliative relief in the end stage of a terminal illness such as metastatic cancer or decompensated cirrhosis with poor prognosis.
Contraindications
Unsafe window for percutaneous access.
Some require thoracenetses and paracenteses first to ensure the drain will provide palliation.
Uncorrected coagulopathy
Pre-procedure Care
Review imaging to ensure a safe window for access.
Goals of care discussion with risks and benefits of repeat paracenteses/thoracenteses (more procedures and appointments, less infection risk) vs tunneled drain (more infection risk, less procedures and appointments).
Ensure sufficient social support to manage the tunneled drain.
Ask patient about preferences for where they would prefer the catheter to exit the skin, e.g., to avoid where they wear their pants.
Procedure
Pre-scan with ultrasound and mark spot with access.
Anesthetize the skin, subcutaneous tissues, and peritoneum/pleura.
Advance needle into the pleural or peritoneal space under ultrasound guidance.
Advance working wire (e.g. Amplatz) across targeting contralateral lower quadrant/pelvis of peritoneal cavity or posteromedial pleural space.
Anesthetize subcutaneous track and exit site.
Make a small incision and tunneled catheter to access site.
Advance peel-away sheath into the peritoneal cavity or pleural space.
Remove wire and advance tunneled catheter through the peel-away.
Remove the peel-away sheath.
Attached catheter to suction to confirm adequate functioning.
Close access site skin with absorbable suture and secure catheter at exit site with non-absorbable suture.
Apply dressing.
Complications
Rarely - bleeding, infection, catheter malpositioning/dysfunction
If persistent leakage around the catheter, check radiograph or drain study to ensure a side hole is not within the subcutaneous tissues. Gelfoam inject around the track can be helpful if no clear problem.
If poor drainage, check location and for loculated or viscous fluid which will not drain well
Post-procedure care
Coordinate drain teaching with patient and/or caretaker.
Drain kits often come with paperwork for ordering supplies at given intervals for the patient/caregivers.
If infection develops, can sometimes treat through it. Otherwise, the drain can be removed and replaced later much like a tunneled dialysis catheter.