Cardiovasc Intervent Radiol (19911) 13: 119-121
CardioVascular andInterventional (c') Springer-Verlag New York Inc. 1990
A Closed Irrigation and Drainage System for Use with Percutaneous Abscess Drainage: Technical Note A u b r e y M. P a l e s t r a n t , Cordell A. E s p l i n , and G a r y T. Shaw Department of Radiology. Good Samaritan Medical Center. Phoenix, Arizona, USA
Abstract. A closed irrigation a n d d r a i n a g e s y s t e m has b e e n used in 50 c o n s e c u t i v e p a t i e n t s to assess its effectiveness in m a i n t a i n i n g c a t h e t e r p a l e n c y and draining fluid collections. It c o n s i s t s of an irrigation fluid s o u r c e , flushing syringe, d r a i n a g e bag, a n d tubing to c o n n e c t the c o m p o n e n t s , and is a s s e m b l e d w h e n the initial d r a i n a g e p r o c e d u r e is p e r f o r m e d . The s y s t e m e m p h a s i z e s the use o f the s i p h o n effect to m a i n t a i n c o n s t a n t s u c t i o n a n d a closed irrigation and drainage c o n f i g u r a t i o n that p r e v e n t s spread of infection to others and m i n i m i z e s ' c o n t a m i n a t i o n of the drained cavity. This m e t h o d of irrigation and drainage also m a k e s patient care c o n s i d e r a b l y easier, and e n s u r e s c a t h e t e r p a t e n c y . Key words: A b s c e s s , p e r c u t a n e o u s d r a i n a g e , OF--Catheters, catheterization, technology
P e r c u t a n e o u s d r a i n a g e of a b s c e s s e s using c o m p u t e d t o m o g r a p h y (CT), u l t r a s o u n d {US). or f l u o r o s c o p i c g u i d a n c e is in w i d b s p r e a d clinical p r a c t i c e and has been welt d e s c r i b e d in the literature [1-3]. t t o w e v e r , very little has b e e n written c o n c e r n i n g the m a i n t e n a n c e of c a t h e t e r p a t e n c y o n c e the c a t h e t e r has b e e n placed in the a b s c e s s , and the m e t h o d of s u c t i o n to p r o m o t e drainage.
Materials and Methods Fifty consecutive patients had abscesses drained percutaneously. Informed consent for the procedure, blood coagulation profile, and blood count was obtained for all patients. All ab,,cesses were drained with 5.5, 7. or 8.5 French trocar type drainage catheters using CT in conjunction with a CT guidance device 141. After
Address reprint requests to: Aubrey M. Palestrant, M .D., Department of Radiology, Good Samaritan Medical Cen,'er. I I I I E.
McDowell Road, Phoenix, Arizona 85(106. USA
placement of the catheter, as much fluid as possible was aspirated to decomprcsx the cavily. The catheter was sutured to the skin and connected to the irrigation and drainage system as shown in Figure I. The elements of the irrigation drainage system are standard items available in most hospitab, or may be obtained as a set (NAMIC. Glens Falls, NY). For drainage to be optimal, the drainage bag must be below the patient at all times to promote suction created by the siphon effect. If stronger suction is necessary, the drainage tubing may be connected to wall suction. To irrigate the catheter, the :,,yringe is first filled with 5-10 cc of saline, the voh,me depends on the size of the cavity but never exceeds half the initial volume aspirated from the cavity. The two stopcocks are then set to allow the irrigant from the syringe to be Itushed into the draimtge catheter. The irrigant is injected rapidly to clear debris from the drainage holes in the catheter and the stopcock attached to the drainage catheter is then turned to alh:.w flow into the drainage tubing. At the time of initial drainage catheter placement, the abscess is thoroughly irrigated and drained until there is substantial clearing of the fluid ttowing down the drainage tubing. No complications occurred during insertion of any catheters. Patients are usually seen daily by the physician who inserted the catheter. Nursing staff'are instructed to flush the catheter every 4-8 h and to observe flow through lhe drainage tubing after turning the stopcock to drainage.
Results In all patients, the c a t h e t e r s r e m a i n e d patent until r e m o v e d . N o n e of the p a t i e n t s e x p e r i e n c e d a n y e p i s o d e s o f b a c t e r e m i a or s e p t i c e m i a a t t r i b u t a b l e to irrigation of d r a i n a g e c a t h e t e r s . A major be.nefit was the u n a n i m o u s a p p r o v a l by the n u r s i n g stat'f, who felt that it m a d e irrigation and care of p e r c u t a n e o u s drainage c a t h e t e r s c o n s i d e r a b l y easier and cleaner.
Discussion For an a b s c e s s to be a d e q u a t e l y d r a i n e d by a percut a n e o u s l y placed d r a i n a g e c a t h e t e r , it is n e c e s s a r y for these catheters to be irrigated at fi-equent intervals [3]. T y p i c a l l y , s e v e r a l steps are i n v o l v e d , inchiding o b t a i n i n g a s y r i n g e , filling it with irrigant
120
~
A.M. Paleslrant et al.: Closed Irrigation and Drainage System
A
J
U Fig. 1. Closed irrigation and drainage system. A IV bag containing 100 cc of saline or other irrigant, B regular Iu set, C one-way valve connection or three-way stopcock, 13 three-way sh~pcock. E 75 cm IV extension tuTbing, g drainage cmhe~er, G drainage tubing, tt drainage bag.
from a sterile source, disconnecting the catheter from the drainage bag, connecting the syringe and flushing the catheter, and finally, reconnecting the catheter to the drainage bag. Alternately, a threeway stopcock is sometimes used between the drainage catheter and the drainage tubing. To flush the catheter, an irrigating syringe is connected to the third port of the stopcock, fluid is injected, and the syringe is removed. Three-way stopcocks have frequently been shown to be contaminated with microorganisms which may come from the hands of personnel during frequent stopcock manipulations, or
from the syringe used for irriszation. A further source of contamination is from failure to treat the stopcock with strict aseptic techniques or to keep a sterile cap on the stopcock when not in use [5]. Therefore, each time a connection is undone, there is a potential for contamination of the abscess by outside microorganisms. It is likely that the larger the number of connections and disconnections, the higher the risk of contamination. When using this irrigation and drainage system, none of the connections are removed or changed with the exception of periodically changing the flushing solution when the bag is empty. Hence, the possibility of cross-contamination is theoretically eliminated. This is especially important at the time of initial drainage when it may not be known whether a fluid collection is sterile or infected. A Gram's stain may not reliably exclude infection and a complete culture of the fluid may take two days. During this time, the cavity can be irrigated and drained by this closed system with minimal risk of corttamination. Using the siphon effect to generate continuous, gentle suction has not been emphasized in the past. By placing the drainage bag below the mattress, the siphon effect generates suction equivalent to 40 cm of water without the need for the patient to be connetted to wall suction. If the patient wishes to ambulate, the drainage bag is attached to the bottom of the patient's gown and suction is maintained even when the patient is not in bed. This system offers a substantial saving in nursing time and cost of materials. In most hospitals, a drainage catheter is flushed two or three times a day using new syringes, needles, and bottles of irrigant each time; this is costly. Additional time must be allocated by nursing staff to procure these items, draw up the irrigant, and flush the catheter. Hospital policy may dictate that nursing staff use gloves if drainage catheters are manipulated to prevent cross-contamination. With the closed irrigation and drainage system, these items are not necessary, thus materials and nursing time are saved. The system can be used with all types of single htmen drainage catheters. Sump catheters cause air to be drawn into the drainage tubing resulting in cessation of suction from the siphon'effect. If sump catheters are used, the drainage tubing can be connected directly to wall suction. 1,1 summary, a closed irrigation and drainage system has been used in 50 patients to assess its effectiveness in maintaining patency and function of drainage catheters. We have found that the system makes patient care considerably easier,
A.M. Palestrant et at.: Closed Irrigation and I)rmn-tge System prevents contamination, provides continuous suction, and maintains patency of the drainage catheter.
References I. vanSonnenberg E, Ferrucci JT Jr, Mueller PR. Wittenberg J, Simcone Jl-; (1982) Percutane(ms drainage of abscesses and fluid collections: Techniqucs. results and applicalions. Radiology 142:1-10
121 2. Lung EK. Springer RM. Oloriose l.W Ill. Cammaratu CA (1986) Abdominal abscess drainage under radiologic guidance: Causes of failure, Radiology 159:329--336 3. Pruett TL. Simmons RL (1988J Status of percutaneous catheter drainage of abscesse,s. Surg Clin North Am 68:89-105 4. Palestrunt AM (1990) A comprehensive approach to CT-guided procedures using a hand-held guidance device. Radiology 174:270-272 5. Kaye W (1982) Catheter and infusion-related sepsis: The nature of the problem and its prevention, tteart t,ung I 1:221-228
CardioVascular andInterventional (c') Springer-Verlag New York Inc. 1990
A Closed Irrigation and Drainage System for Use with Percutaneous Abscess Drainage: Technical Note A u b r e y M. P a l e s t r a n t , Cordell A. E s p l i n , and G a r y T. Shaw Department of Radiology. Good Samaritan Medical Center. Phoenix, Arizona, USA
Abstract. A closed irrigation a n d d r a i n a g e s y s t e m has b e e n used in 50 c o n s e c u t i v e p a t i e n t s to assess its effectiveness in m a i n t a i n i n g c a t h e t e r p a l e n c y and draining fluid collections. It c o n s i s t s of an irrigation fluid s o u r c e , flushing syringe, d r a i n a g e bag, a n d tubing to c o n n e c t the c o m p o n e n t s , and is a s s e m b l e d w h e n the initial d r a i n a g e p r o c e d u r e is p e r f o r m e d . The s y s t e m e m p h a s i z e s the use o f the s i p h o n effect to m a i n t a i n c o n s t a n t s u c t i o n a n d a closed irrigation and drainage c o n f i g u r a t i o n that p r e v e n t s spread of infection to others and m i n i m i z e s ' c o n t a m i n a t i o n of the drained cavity. This m e t h o d of irrigation and drainage also m a k e s patient care c o n s i d e r a b l y easier, and e n s u r e s c a t h e t e r p a t e n c y . Key words: A b s c e s s , p e r c u t a n e o u s d r a i n a g e , OF--Catheters, catheterization, technology
P e r c u t a n e o u s d r a i n a g e of a b s c e s s e s using c o m p u t e d t o m o g r a p h y (CT), u l t r a s o u n d {US). or f l u o r o s c o p i c g u i d a n c e is in w i d b s p r e a d clinical p r a c t i c e and has been welt d e s c r i b e d in the literature [1-3]. t t o w e v e r , very little has b e e n written c o n c e r n i n g the m a i n t e n a n c e of c a t h e t e r p a t e n c y o n c e the c a t h e t e r has b e e n placed in the a b s c e s s , and the m e t h o d of s u c t i o n to p r o m o t e drainage.
Materials and Methods Fifty consecutive patients had abscesses drained percutaneously. Informed consent for the procedure, blood coagulation profile, and blood count was obtained for all patients. All ab,,cesses were drained with 5.5, 7. or 8.5 French trocar type drainage catheters using CT in conjunction with a CT guidance device 141. After
Address reprint requests to: Aubrey M. Palestrant, M .D., Department of Radiology, Good Samaritan Medical Cen,'er. I I I I E.
McDowell Road, Phoenix, Arizona 85(106. USA
placement of the catheter, as much fluid as possible was aspirated to decomprcsx the cavily. The catheter was sutured to the skin and connected to the irrigation and drainage system as shown in Figure I. The elements of the irrigation drainage system are standard items available in most hospitab, or may be obtained as a set (NAMIC. Glens Falls, NY). For drainage to be optimal, the drainage bag must be below the patient at all times to promote suction created by the siphon effect. If stronger suction is necessary, the drainage tubing may be connected to wall suction. To irrigate the catheter, the :,,yringe is first filled with 5-10 cc of saline, the voh,me depends on the size of the cavity but never exceeds half the initial volume aspirated from the cavity. The two stopcocks are then set to allow the irrigant from the syringe to be Itushed into the draimtge catheter. The irrigant is injected rapidly to clear debris from the drainage holes in the catheter and the stopcock attached to the drainage catheter is then turned to alh:.w flow into the drainage tubing. At the time of initial drainage catheter placement, the abscess is thoroughly irrigated and drained until there is substantial clearing of the fluid ttowing down the drainage tubing. No complications occurred during insertion of any catheters. Patients are usually seen daily by the physician who inserted the catheter. Nursing staff'are instructed to flush the catheter every 4-8 h and to observe flow through lhe drainage tubing after turning the stopcock to drainage.
Results In all patients, the c a t h e t e r s r e m a i n e d patent until r e m o v e d . N o n e of the p a t i e n t s e x p e r i e n c e d a n y e p i s o d e s o f b a c t e r e m i a or s e p t i c e m i a a t t r i b u t a b l e to irrigation of d r a i n a g e c a t h e t e r s . A major be.nefit was the u n a n i m o u s a p p r o v a l by the n u r s i n g stat'f, who felt that it m a d e irrigation and care of p e r c u t a n e o u s drainage c a t h e t e r s c o n s i d e r a b l y easier and cleaner.
Discussion For an a b s c e s s to be a d e q u a t e l y d r a i n e d by a percut a n e o u s l y placed d r a i n a g e c a t h e t e r , it is n e c e s s a r y for these catheters to be irrigated at fi-equent intervals [3]. T y p i c a l l y , s e v e r a l steps are i n v o l v e d , inchiding o b t a i n i n g a s y r i n g e , filling it with irrigant
120
~
A.M. Paleslrant et al.: Closed Irrigation and Drainage System
A
J
U Fig. 1. Closed irrigation and drainage system. A IV bag containing 100 cc of saline or other irrigant, B regular Iu set, C one-way valve connection or three-way stopcock, 13 three-way sh~pcock. E 75 cm IV extension tuTbing, g drainage cmhe~er, G drainage tubing, tt drainage bag.
from a sterile source, disconnecting the catheter from the drainage bag, connecting the syringe and flushing the catheter, and finally, reconnecting the catheter to the drainage bag. Alternately, a threeway stopcock is sometimes used between the drainage catheter and the drainage tubing. To flush the catheter, an irrigating syringe is connected to the third port of the stopcock, fluid is injected, and the syringe is removed. Three-way stopcocks have frequently been shown to be contaminated with microorganisms which may come from the hands of personnel during frequent stopcock manipulations, or
from the syringe used for irriszation. A further source of contamination is from failure to treat the stopcock with strict aseptic techniques or to keep a sterile cap on the stopcock when not in use [5]. Therefore, each time a connection is undone, there is a potential for contamination of the abscess by outside microorganisms. It is likely that the larger the number of connections and disconnections, the higher the risk of contamination. When using this irrigation and drainage system, none of the connections are removed or changed with the exception of periodically changing the flushing solution when the bag is empty. Hence, the possibility of cross-contamination is theoretically eliminated. This is especially important at the time of initial drainage when it may not be known whether a fluid collection is sterile or infected. A Gram's stain may not reliably exclude infection and a complete culture of the fluid may take two days. During this time, the cavity can be irrigated and drained by this closed system with minimal risk of corttamination. Using the siphon effect to generate continuous, gentle suction has not been emphasized in the past. By placing the drainage bag below the mattress, the siphon effect generates suction equivalent to 40 cm of water without the need for the patient to be connetted to wall suction. If the patient wishes to ambulate, the drainage bag is attached to the bottom of the patient's gown and suction is maintained even when the patient is not in bed. This system offers a substantial saving in nursing time and cost of materials. In most hospitals, a drainage catheter is flushed two or three times a day using new syringes, needles, and bottles of irrigant each time; this is costly. Additional time must be allocated by nursing staff to procure these items, draw up the irrigant, and flush the catheter. Hospital policy may dictate that nursing staff use gloves if drainage catheters are manipulated to prevent cross-contamination. With the closed irrigation and drainage system, these items are not necessary, thus materials and nursing time are saved. The system can be used with all types of single htmen drainage catheters. Sump catheters cause air to be drawn into the drainage tubing resulting in cessation of suction from the siphon'effect. If sump catheters are used, the drainage tubing can be connected directly to wall suction. 1,1 summary, a closed irrigation and drainage system has been used in 50 patients to assess its effectiveness in maintaining patency and function of drainage catheters. We have found that the system makes patient care considerably easier,
A.M. Palestrant et at.: Closed Irrigation and I)rmn-tge System prevents contamination, provides continuous suction, and maintains patency of the drainage catheter.
References I. vanSonnenberg E, Ferrucci JT Jr, Mueller PR. Wittenberg J, Simcone Jl-; (1982) Percutane(ms drainage of abscesses and fluid collections: Techniqucs. results and applicalions. Radiology 142:1-10
121 2. Lung EK. Springer RM. Oloriose l.W Ill. Cammaratu CA (1986) Abdominal abscess drainage under radiologic guidance: Causes of failure, Radiology 159:329--336 3. Pruett TL. Simmons RL (1988J Status of percutaneous catheter drainage of abscesse,s. Surg Clin North Am 68:89-105 4. Palestrunt AM (1990) A comprehensive approach to CT-guided procedures using a hand-held guidance device. Radiology 174:270-272 5. Kaye W (1982) Catheter and infusion-related sepsis: The nature of the problem and its prevention, tteart t,ung I 1:221-228
