Insertion of a Drain

Checklist:

Insertion of a Drain

Is the blood clotting adequate?

Is the material to be drained viscous, does it contain particulate matter, or is it very fluid?

How long is the drain intended to stay?

• Procedure: Mr. Strongarm brings along a strong pain reliever from the ward. Hannah injects the drug slowly as he is positioned on the CT table. Chaban chooses the CT image (Fig. 7.11b) that shows the access route best, injects a local anesthetic, and incises the skin with a pointed scalpel directly ventral of the target area. He advances a thin, long needle toward the fluid collection and aspirates to verify the diagnosis: bloody pus enters the syringe. He gestures toward Hannah—the clinicians were right to be alarmed. He advances a guide-wire into the abscess. The wire is specially designed for this purpose, with a floppy tip so that it curls up in the collection and the rest of the wire stiff enough to provide sufficient "backbone" for later insertion of dilators and the actual drain. The needle is withdrawn over the wire and a number of dilators with increasing diameters are subsequently advanced over the guide-wire and retracted again to widen the path. Finally, he introduces a large-bore drainage catheter with multiple side holes along the tip into the fluid pocket. Now the guide-wire is removed and the contents of the abscess are aspirated. Again creamy pus fills the syringe. After the drain has been fixed to the skin with a few sutures, a bag is connected to it. Using a 3-way-stopcock and a 50 ml syringe (used for perfusors), Chaban withdraws about 150 ml of pus out of the collection (Fig. 7.11c). Mr. Strongarm feels the relief and the drop of tension in his abdomen right away. Chaban sends a sample of the material for microbiological testing. At the end of the procedure another limited CT is performed to ascertain that the drain is in correct position and the collection is well drained. By the time Hannah hands him over to the perfect care of sister Magdalena, who is in charge of the postinterventional monitoring, Mr. Strongarm is cracking jokes again.

Take special care to fix the drainage well to the skin. Abscess drains must be flushed regularly with saline to remain functional.

I Insertion of a Drain

I Insertion of a Drain

Sclerosing Injections Esophagus

This Esophageal Hemorrhage Has Got to be Stopped!

Sandra Woodworth (49) has developed hepatic cirrhosis as a complication of chronic hepatitis that she contracted a few years ago. Portal hypertension has developed over time and the rising pressure in the portal system has led to the formation of venous collaterals along the lesser curve of the stomach and the distal end of the esophagus and has also caused ascites. Now she has had several upper gastrointestinal bleeds in a row due to esophageal varices. One time the problem was solved by endoscopic injection of a sclerosing agent into the varices; another time a band ligation of the varices was performed. Mrs. Woodworth recalls with horror the treatment with a temporary balloon tamponade (Blakemore-Sengstaken balloon). The current bleed, however, is too strong and has been impossible to stop by endoscopy. The gastroenterolo-gists have urgently asked for help. The patient's face is pale with fear. Professor Segner is with Joey as he examines Mrs. Woodworth and briefs her about the intervention to be done: The implantation of a stent creates a shortcut between the portal venous and hepatic venous systems to decompress the portal system. Segner tells her that the risk of further hemorrhages will decrease significantly and that the amount of ascites will also decline. He also mentions the risk of hepatic encephalopathy. As Mrs. Woodworth's bed is pushed into the interventional room she attempts a brave smile. Professor Segner and Joey put on the sterile gowns—Joey wants to help Segner in the procedure. Gregory is currently doing his body intervention time and will hold the ultrasound probe during the intervention.

Fig. 7.11a A large fluid collection (arrows) has formed anterior to the pancreas as a complication of severe acute pancreatitis. It has now become superinfected—an infected pseudocyst. b The noncontrast study before the insertion of the drain shows the same configuration of the pseudocyst. c After the insertion of the drain (arrows), the cyst is emptied and the intestinal loops are rearranged.

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