Access and Abcess Drainage Procedures - Dr Denis Kinsella

Abscess/Collection Abscess/Collection Drainage Procedures.Drainage Procedures.Dr.Denis KinsellaDr.Denis KinsellaRoyal Devon and Exeter Royal Devon and Exeter Hospital.Hospital.

Drainage ProceduresDrainage Procedures Defined as a core skill Structured Defined as a core skill Structured

Training in Clinical Radiology documentTraining in Clinical Radiology document Marked growth in last 20 yearsMarked growth in last 20 years All types of simple and complex All types of simple and complex

collections drained in the collections drained in the chest,abdomen and pelvischest,abdomen and pelvis

Requires ability to assess CT and US Requires ability to assess CT and US images and familiarity with drainage images and familiarity with drainage equipmentequipment

Collection Assessment-Collection Assessment-ImagingImaging Aim-shortest,safest route to site Aim-shortest,safest route to site

drain in the most dependent drain in the most dependent positionposition

Avoid major vesselsAvoid major vessels Avoid transgressing bowelAvoid transgressing bowel Assessment of nature of fluid-Assessment of nature of fluid-

echogenicity;septationsechogenicity;septations

Imaging-US or CTImaging-US or CTCT-good visualisationCT-good visualisation opacified bowelopacified bowel not limited by ileus or depthnot limited by ileus or depth

US-real timeUS-real time portableportable operator dependentoperator dependent

Size+site of collection;operator Size+site of collection;operator preferencepreference

Which Needle ?Which Needle ? 22g as in Accustick set22g as in Accustick set 18g-has 5% of the resistance to 18g-has 5% of the resistance to

fluid flow of a 22g needlefluid flow of a 22g needle If fail to aspirate fluid -check If fail to aspirate fluid -check

needle position needle position If good position-flush If good position-flush with saline If no with saline If no aspirate - consider biopsyaspirate - consider biopsy

Which Catheter ?Which Catheter ? 6F-24F catheters6F-24F catheters Locking or non-locking-VIP at Locking or non-locking-VIP at

removalremoval Sump or non-sump-2Sump or non-sump-2ndnd lumen lumen

containing air which prevents containing air which prevents cavity collapsing around catheter cavity collapsing around catheter tiptip

Patient PreparationPatient Preparation IV accessIV access Fasted for > 2 hoursFasted for > 2 hours Coagulopathy excludedCoagulopathy excluded Informed consentInformed consent

Procedure 1Procedure 1 Consider conscious sedationConsider conscious sedation Clean skinClean skin Anaesthetise skinAnaesthetise skin Skin incision large enough for Skin incision large enough for

passage of catheterpassage of catheter Consider tract dissectionConsider tract dissection

Procedure 2-Trocar Procedure 2-Trocar techniquetechnique Reference needle in collectionReference needle in collection Catheter assembly advanced to Catheter assembly advanced to

the same depth ,in the same the same depth ,in the same planeplane

Remove stylet and aspirateRemove stylet and aspirate Advance catheter over stationary Advance catheter over stationary

stiffenerstiffener

Procedure 3-Seldinger Procedure 3-Seldinger techniquetechnique 18g needle in collection18g needle in collection Pass 0.035 wire into collectionPass 0.035 wire into collection Dilate tractDilate tract Pass catheter and stiffener over Pass catheter and stiffener over

wirewire When inside collection pass When inside collection pass

catheter alonecatheter alone

Post Insertion of DrainPost Insertion of Drain Aspirate fluidAspirate fluid Re-image:?need for 2Re-image:?need for 2ndnd drain drain Secure drain-it is always more Secure drain-it is always more

difficult to re-puncture a partially difficult to re-puncture a partially drained collectiondrained collection

After CareAfter Care Chart fluid drainedChart fluid drained Aspirate 8hrly with a 50ml. SyringeAspirate 8hrly with a 50ml. Syringe Irrigate with 10ml. of salineIrrigate with 10ml. of saline Dependent position of bagDependent position of bag Removal-clinical improvement and Removal-clinical improvement and

drainage of <10ml. per day or drainage of <10ml. per day or collection resolved on re-imagingcollection resolved on re-imaging

Tips –insertionTips –insertion Ensure adequate skin incisionEnsure adequate skin incision Avoid kinking wire(no fluoroscopy)Avoid kinking wire(no fluoroscopy) Ideal wire-stiff enough to allow Ideal wire-stiff enough to allow

passage of dilators and catheter passage of dilators and catheter but will coil within abscess and but will coil within abscess and not perforate posterior wallnot perforate posterior wall

Cut thread flush with catheter hubCut thread flush with catheter hub 3-way tap3-way tap

Click this box AND WAIT to play movie clip of a drainage procedure

If Collection Persists If Collection Persists with low flows-with low flows- Catheter displacementCatheter displacement Catheter/tubing blocked or kinkedCatheter/tubing blocked or kinked Upsizing catheterUpsizing catheter Septation/loculationSeptation/loculation

If Collection Persists with If Collection Persists with high flows-high flows-

Expect to find a fistulaExpect to find a fistula Can occur from bowel,bile and Can occur from bowel,bile and

pancreatic duct,renal tractpancreatic duct,renal tract Exclude distal obstruction;underlying Exclude distal obstruction;underlying

bowel disease;proximal bowel disease;proximal diversion;parenteral feedingdiversion;parenteral feeding

Bile leak postlap.chole.-drain plus Bile leak postlap.chole.-drain plus cbd stentcbd stent

Minimising Complications Minimising Complications at PAD-at PAD-

Broad spectrum antibioticsBroad spectrum antibiotics Correct coagulopathyCorrect coagulopathy Adequate sedation + analgesia-Adequate sedation + analgesia-

beware the restless patientbeware the restless patient Good bowel opacification at CTGood bowel opacification at CT Post procedure catheter managementPost procedure catheter management Beware collections adjacent to Beware collections adjacent to

implants-aspirate>drainimplants-aspirate>drain Discuss cases with clinical teamDiscuss cases with clinical team

Subphrenic Abscess Subphrenic Abscess DrainageDrainage

Traditional to use an extrapleural approachTraditional to use an extrapleural approach Pleural reflections-12Pleural reflections-12thth rib posteriorly;10 rib posteriorly;10thth rib rib

laterally;8laterally;8thth rib anteriorly rib anteriorly Anterior subcostal approach recommendedAnterior subcostal approach recommended Lowest possible intercostal approach used-Lowest possible intercostal approach used-

no empyema due to pleural adhesionsno empyema due to pleural adhesions

Vascular and Interventional Radiology-J.Kaufman;M.J.Lee-Mosby

The Inaccessible or The Inaccessible or Undrainable Abscess:How Undrainable Abscess:How to drain itto drain it Detailed account of TV and PR US Detailed account of TV and PR US

guided drains in low pelvic guided drains in low pelvic abscessesabscesses

Tilting of CT gantry to access high Tilting of CT gantry to access high pelvic abscessespelvic abscesses

Transgluteal approach-close to Transgluteal approach-close to sacrum to avoid sciatic nerve + sacrum to avoid sciatic nerve + gluteal vesels;below pyriformis to gluteal vesels;below pyriformis to avoid sacral plexusavoid sacral plexus

Radiographics[2004] 24,717-735

Percutaneous abscess Percutaneous abscess drainage in the U.Kdrainage in the U.K How actively involved should radiologists How actively involved should radiologists

be in drain management post P.A.D?be in drain management post P.A.D? Postal survey of 117 departmentsPostal survey of 117 departments 70%-managed by clinical team70%-managed by clinical team 5%-formally managed drain5%-formally managed drain

Radiologist?clinical team?specialist nurse?Radiologist?clinical team?specialist nurse?

Clinical Radiology [2006] 61,55-64

Percutaneous abscess Percutaneous abscess drainage in the U.Kdrainage in the U.K Single centre studySingle centre study Drains for abdominal sepsis-63 in 45 Drains for abdominal sepsis-63 in 45

patientspatients 70% curative/successful70% curative/successful 12% of drains displaced12% of drains displaced 15% radiological input at time of removal15% radiological input at time of removal 60% removed by nursing staff60% removed by nursing staff Complication rate lowComplication rate low

Clinical Radiolgy [2006] 61,55-64

SUMMARYSUMMARY Assess pre-procedure imagingAssess pre-procedure imaging Minimise complications related to Minimise complications related to

PADPAD Involvement in post procedure Involvement in post procedure

catheter managementcatheter management Practical knowledge of Practical knowledge of

needles,wires and cathetersneedles,wires and catheters

Transgastric Pancreatic Pseudocyst Drain.