1. A General Introduction of Drainage System Mediliance Ltd Oliver Hsu

2. Definition A drain is a tube used to remove gas, pus, blood or other fluids from a wound,abscess or an area.

3. Objectives Indication/Goal for Drainage Why use a drain Types What are the major type of drains and how do they work Principle of use Which drain to use What are the complication

4. Types What are the major type of drains and how do they work PassiveActiveSumpPDC Open Close Suction Strength

5. Types Concept of Open / Close Open system- Drain fluid collects in gauze pad or stoma bag, they increase the risk of infection Open system with filters Close System- Drain into a bottle or bag Gas Closed system Fluid Closed system Infection Closed system

6. Types Suction Strength

7. Tubing 4mm(~12 FR) Drain 7.5mm

8. Types Suction Strength Drains may be connected wall suction,a portable suction device, or they may be left to drain naturally 100 ml Reservoir: 0~90 mm/Hg Power suction : 0~ expected Chest tube drainage: -20 cm/H20 -20 * 0.7 = -14 mm/Hg (continuous)

9. Types Collection Device Bulb Bag Vac Bottle Pleur-evac type Vacuum tube Others

10. Type coating vs. un-coating

11. The Benefit of Coating- Clot Stop Clot Stop –A safe Antithrombogenic coating FDA approved lubricating properties- reacting povidone with Isocyanates prepolymer The lowest affinity for platelets Provide surface with lowest coefficient of friction available, can make insertion and removal easier and trauma free, prevent clogging Long standing (Indwelling drain, above 10 days) Reduce the workload of stripping & milking

12. A minimalist Approach to the care of Indwelling Closed Suction Drain Clot Stop CWV Drain- a total 73 patients 192 drains left Abdomen 41, Chest/Breast 44, Back 10, other 4 Drain left in place on average over 10 days 3.6 days in inpatient, 7.0 days in outpatients averagely 5 major complications, 5 minor complications, 2 “unrelated to drain” wound complication A safe and efficacy simple approach to the management of closed suction drains - call the office when the drain output is less than 30 ml/day - encourage to shower - pat the drain exit site dry Annals of Plastic Surgery V51, N6, Dec 2003, Plastic Surgery, Northwestern University

13. Chest Tube (1) There are usually 2 types of tubes used : PLEURAL AND MEDIASTINAL CHEST TUBES

14. Chest Tube (2) Pleural fluid gravitates to the most dependent point, so the tube is placed at the 4th to 5th intercostal space along the mid-axillary line (figure 1). Mediastinal tubes placed to drain the pericardial space are used to drain post- operative bleeding and pericardial effusion that usually occurs after heart surgery (figure 2).

15. CHEST DRAINAGE AS A THERAPEUTIC INTERVENTION The purpose of a chest drainage unit is to evacuate the air and/or fluid from the chest cavity to help re-establish normal intrathoracic pressure. This facilitates the re-expansion of the lung to restore normal breathing dynamics The need also arises following heart surgery to prevent the accumulation of fluid around the heart.

16. Pleural Chest Tube Drainage Chest Tube Chest tube size: 8F ~40F Coating Vs. Uncoating (anti thrombogenic coating vs. heparin coating) Newborn ~Pediatric: 8F~16F Small bore Vs. Large bore (Pigtail vs. CT) Pleural effusion or Pneumothorax are being treated with small bore rather than large bore

17. Incidence of deep and superficial sternal infection after open heart surgery – A ten years restrospective study from 1981 to 1991 4137 adult patients The overall infection rate was 1.33%, including superficial wound infection (SWI) (1.18%), and deep sternal infection (DSI) (0.145%) Suction drain with a vent allow a better drainage Department of Cardiovascular Surgery, CHUV, CH-1011 Lausanne, Switzerland Eur J Cardio-thorac Surg, 1995, 9: 153~157

18. A comparison between small bore and large bore Small boreLarge bore Incidence of injury 0.2%1.4% Malposition0.6%6.5% empyema0.2%1.4% drainage blockage 8.1%5.2% 2003~2008, 17 facilities UK

19. The Fanning equation V= π^2 x r ^5 x P / f l V= flow velocity r= radius l= length p= pressure f = friction factor

20. Some examples of an ideal size for drainage Primary Spontaneous Pnenmothorax(PSS) : small bore (<= 14F) or 16~ 22 Fr. Stable Secondary Spontaneous Pnenmothorax (SSP): 16~ 22 Fr. Unstable SSP and SSP on mechanical ventilation : 22~24 Fr. Fluid within the pleural space especially if the fluid is particularly viscous: >= 28 Fr. Pleural air and free flowing fluid will generally drain from the chest without need of suction

21. Mediastinal Chest Tube Drainage New designed flat tube with 4 eye patterns to be placed for pericardial space drainage or mediastinal surgery drain Large inner diameter provide maximum drainage w/o or with Clot Stop 5mm, 7mm, 9mm, 11mm- 4 sizes, including pediatric size Easy to place, remains as positions

22. Postoperative mediastinitis after cardiac surgery Prior to the development of modern cardiovascular surgery, most cases of mediastinitis arose from either esophageal perforation or from contiguous spread of odontogenic or retropharyngeal infections. Rarely, primary infections of the mediastinum developed as a result of penetrating trauma or hematogenous spread of infection. However, in modern practice, most cases of mediastinitis are a postoperative complication of cardiovascular or other thoracic surgical procedures (0.5~5%) Postoperative mediastinitis after cardiac surgery Author Daniel J Sexton, MD Professor of Medicine Duke University Medical Center

23. Mediastinal Sump Drainage Sump lumens create high flow rate to accelerate fluid removal Does not permit pressure build up in the mediastinum (Filtered Sump) Medication port with capped filter (Mills sump, round configuration) Air Open system for Mediastinal Drainage

24. Drainage bag- Chest Drainage(1) The use of integral Heimlich flutter valve has been advocated in patients with pneumothoraces, especially as they permit ambulatory or even outpatient management. The use of a drainage bag with an incorporated flutter valve and vented outlet has been successfully used postoperatively. BTS guidelines for the insertion of a chest drain, Thorax 2003

25. Drainage bag- Chest Drainage(2) Drainage System A chest drain should be connected to a drainage system that contains a valve mechanism to prevent fluid or air entering the pleural cavity. This may be an underwater seal, flutter valve or other recognized mechanism. BTS Pleural Disease Guideline 2010, BTS

26. Uresil Tru-Close Drainage bag Tru-Close Gravity drainage bag Pleural Effusion, Malignant Pleural Effusion, Drainage for Pleurodesis etc. Tru-Close Suction drainage bag Pneumothoraces, Pleural Effusion, Malignant Pleural Effusion, Pleurodesis, Postoperatively drainage, Abcess drainage etc. It is appropriate for a patient who need a chest tube for drain but doesn’t need suction to re- expanded his lung Home care consideration

27. Uresil Tru-Close Drainage bag

28. Malignant Pleural Effusion: Recent Advance and Ambulatory Sclerotherapy (Chest 1998; 113; 74S-77S) Pleurodesis using small-bore catheters permits less expensive outpatient ambulatory therapy, which is expected to further reduce patient discomfort and costly hospitalization.

29. Management of Malignant Pleural Effusion and Pneumothorax (Radiologic Clinics of North America, Volume 38, Issue 2, March 2000) Ambulatory Sclerotherapy: The catheter is then connected to a Tru-Close 600ml bag for gravity drainage. This bag is designed to be emptied by the patient without danger of backflow of air into the pleural space.

30. Minidrainage in pneumothorax is expensive, but still beneficial. Considerate for the patient, reducing the number of hospitalization days Lakartidningen, 2000 Aug 30; 97 (35): 3726-8 (article in Swedish) Tru-close, for the evacuation of pneumothorax, it consists of small-bore plastic catheter combined with a small box containing a flutter-valve. Ease of insertion, safe function, stable fixation and painless removal were feature found. The unit is expensive, but in case of simple pneumothorax without fluid it would seem possible to manage on an out-patient basis, thus saving several days’ worth of hospitalization costs

31. Exposure risk related to the management of three wound drainage systems (Am J Infect Control 1996; 24: 346-352) There are no contaminations with the Tru- Close system Analysis of satisfaction questionnaires for the Tru-Close drainage system indicated that nurses tended to be most satisfied with the Tru-Close system’s protection from exposure

32. Patient Experience of a Nurse Led Therapeutic Pleural Aspiration Service (Thorax 2010 65: A173) Salford Royal NHS Foundation Trust, Salford, UK Fluid was removed using the TRU-CLOSE suction drainage system. Overall the service was rated as excellent by 100% of patients.

33. 健保給付 update