Abscess/Collection Drainage Procedures.

Dr.Denis Kinsella Royal Devon and Exeter Hospital.

Drainage Procedures

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

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 ?

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 ?

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

IV access Fasted for > 2 hours Coagulopathy excluded Informed consent

Procedure 1

Consider conscious sedation Clean skin Anaesthetise skin Skin incision large enough for passage of catheter Consider tract dissection

Procedure 2-Trocar technique

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

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

Aspirate fluid Re-image:?need for 2nd drain Secure drain-it is always more difficult to re-puncture a partially drained collection

After Care

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

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

Catheter displacement Catheter/tubing blocked or kinked Upsizing catheter Septation/loculation

If Collection Persists with high flows

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 PAD

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

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

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

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

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

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.