Chapter 11: Postoperative Monitoring

LINES, DRAINS, AND TUBES

NASOGASTRIC AND OROGASTRIC TUBES

1. Indications:

   1. Management of bowel obstruction

   2. Symptom relief in patients with nausea and/or emesis (e.g., acute pancreatitis).

2. Types of tubes:

   1. Salem sump – standard double-lumen gastric tube. The larger lumen allows for evacuation of air and fluid. The smaller-vent lumen allows for air to be drawn into the stomach to equalize pressures. Available in multiple sizes from 6 to 18 Fr.

   2. Andersen – very soft, comfortable double-lumen tube made from vinyl.

   3. Replogle – used most commonly for evacuating proximal esophageal pouch in unrepaired esophageal atresia.

3. Management: Can be placed to gravity drainage or to low intermittent wall suction. Suction provides better decompression but risks gastric irritation. Ventilation port must remain unoccluded for proper function. If occluded, the drainage port should be flushed with water and the ventilation port with air.

4. Removal: Generally removed when gastric output is nonbilious and output volume is decreased. Some surgeons opt to continue nasogastric/orogastric (NG/OG) decompression until return of bowel function.

5. EBM Pearl: Routine nasogastric drainage after abdominal surgery is not indicated. A Cochrane review demonstrated that NG tubes are associated with delayed return of bowel function, with no difference in anastomotic leak, wound infection, or other complications.¹

SURGICAL DRAINS

1. Indications:

   1. Prevention of seroma or hematoma under flaps

   2. Monitoring and control of biliary or pancreatic leak following biliary or pancreatic anastomosis, liver resection, or pancreatic resection

   3. Monitoring and control of chyle leak following extensive retroperitoneal dissection

   4. Monitoring and control of urine leak following partial nephrectomy, bladder augmentation, and other urologic procedures

   5. Drainage of abscess cavity

   6. Monitoring and drainage following esophageal or duodenal perforation +/− repair

   7. Drainage of neonatal perforation in extremely low-birth-weight (ELBW) infants (<1 kg) with Penrose drain

2. Types of drains:

   1. Jackson-Pratt – closed suction drain with suction provided by compressed bulb. Often used intra-abdominally or under skin flaps.

   2. Hemovac – closed suction drain with suction provided by spring-loaded accordion-type container.

   3. TLS – small-caliber closed suction drain with suction provided by Vacutainer. Often used in head and neck surgery or other times when output is expected to be low.

   4. Penrose – open drain. Tube provides passive route of egress for fluid and air.

3. Management:

   1. Stripping and flushing – closed suction drains may require stripping and/or flushing to maintain patency, especially when drainage is thicker (blood or abscess). Flushing must be performed using sterile technique. Drains are flushed with saline to maintain patency. Tissue plasminogen activator (tPA) can also be used if the drain is clotted or if trying to break up loculations in an abscess cavity.

   2. Drains should be emptied and output volume recorded at least every shift and more frequently if needed.

4. Removal:

   1. Timing – dependent on indication. Drains placed to monitor for bile, pancreatic, or chyle leak should remain until patient is on a general diet. If monitoring for a leak following a biliary, pancreatic, or urologic procedure, it is sometimes helpful to ...