Transcript Abscess/Collection Drainage Procedures.

Abscess/Collection
Drainage Procedures.
Dr.Denis Kinsella
Royal Devon and Exeter Hospital.
Drainage Procedures
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Defined as a core skill Structured Training in
Clinical Radiology document
Marked growth in last 20 years
All types of simple and complex collections
drained in the chest,abdomen and pelvis
Requires ability to assess CT and US images
and familiarity with drainage equipment
Collection AssessmentImaging
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Aim-shortest,safest route to site drain
in the most dependent position
Avoid major vessels
Avoid transgressing bowel
Assessment of nature of fluidechogenicity;septations
Imaging-US or CT
CT-good visualisation
opacified bowel
not limited by ileus or depth
US-real time
portable
operator dependent
Size+site of collection;operator preference
Which Needle ?
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22g as in Accustick set
18g-has 5% of the resistance to fluid
flow of a 22g needle
If fail to aspirate fluid -check needle
position
If good position-flush with saline
If no aspirate - consider biopsy
Which Catheter ?
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6F-24F catheters
Locking or non-locking-VIP at removal
Sump or non-sump-2nd lumen
containing air which prevents cavity
collapsing around catheter tip
Patient Preparation
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IV access
Fasted for > 2 hours
Coagulopathy excluded
Informed consent
Procedure 1
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Consider conscious sedation
Clean skin
Anaesthetise skin
Skin incision large enough for passage
of catheter
Consider tract dissection
Procedure 2-Trocar
technique
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Reference needle in collection
Catheter assembly advanced to the
same depth ,in the same plane
Remove stylet and aspirate
Advance catheter over stationary
stiffener
Procedure 3-Seldinger
technique
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18g needle in collection
Pass 0.035 wire into collection
Dilate tract
Pass catheter and stiffener over wire
When inside collection pass catheter
alone
Post Insertion of Drain
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Aspirate fluid
Re-image:?need for 2nd drain
Secure drain-it is always more difficult
to re-puncture a partially drained
collection
After Care
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Chart fluid drained
Aspirate 8hrly with a 50ml. Syringe
Irrigate with 10ml. of saline
Dependent position of bag
Removal-clinical improvement and
drainage of <10ml. per day or
collection resolved on re-imaging
Tips –insertion
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Ensure adequate skin incision
Avoid kinking wire(no fluoroscopy)
Ideal wire-stiff enough to allow
passage of dilators and catheter but
will coil within abscess and not
perforate posterior wall
Cut thread flush with catheter hub
3-way tap
Click this box AND WAIT to play
movie clip of a drainage procedure
If Collection Persists with
low flows
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Catheter displacement
Catheter/tubing blocked or kinked
Upsizing catheter
Septation/loculation
If Collection Persists with
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Expect to find a fistula
Can occur from bowel,bile and pancreatic
duct,renal tract
Exclude distal obstruction;underlying
bowel disease;proximal
diversion;parenteral feeding
Bile leak postlap.chole.-drain plus cbd
stent
Minimising Complications at
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Broad spectrum antibiotics
Correct coagulopathy
Adequate sedation + analgesia-beware
the restless patient
Good bowel opacification at CT
Post procedure catheter management
Beware collections adjacent to implantsaspirate>drain
Discuss cases with clinical team
Subphrenic Abscess
Drainage
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Traditional to use an extrapleural approach
Pleural reflections-12th rib posteriorly;10th rib
laterally;8th rib anteriorly
Anterior subcostal approach recommended
Lowest possible intercostal approach used-no
empyema due to pleural adhesions
Vascular and Interventional Radiology-J.Kaufman;M.J.Lee-Mosby
The Inaccessible or
Undrainable Abscess:How to
drain it
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Detailed account of TV and PR US
guided drains in low pelvic abscesses
Tilting of CT gantry to access high
pelvic abscesses
Transgluteal approach-close to sacrum
to avoid sciatic nerve + gluteal
vesels;below pyriformis to avoid sacral
plexus
Radiographics[2004] 24,717-735
Percutaneous abscess
drainage in the U.K
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How actively involved should radiologists be
in drain management post P.A.D?
Postal survey of 117 departments
70%-managed by clinical team
5%-formally managed drain
Radiologist?clinical team?specialist nurse?
Clinical Radiology [2006] 61,55-64
Percutaneous abscess
drainage in the U.K
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Single centre study
Drains for abdominal sepsis-63 in 45 patients
70% curative/successful
12% of drains displaced
15% radiological input at time of removal
60% removed by nursing staff
Complication rate low
Clinical Radiolgy [2006] 61,55-64
SUMMARY
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Assess pre-procedure imaging
Minimise complications related to PAD
Involvement in post procedure
catheter management
Practical knowledge of needles,wires
and catheters
Transgastric Pancreatic Pseudocyst Drain.