SURGEON AT WORK
Surgical Drainage of a Small Tissue Volume with Butterfly Infusion and Vacuum Phlebotomy Tube Sets Jeffrey L Kaufman,
MD, FACS
been marketed in the past, but it comes with largerdiameter drains than the one described here. Initially, butterfly drains were created by retaining the 19-gauge needle, which was used directly to puncture the vacuum tube. Unfortunately, nursing personnel have sometimes experienced difficulty with puncturing the stoppers, and there have been instances where they have been stuck by the needle. The novel aspect of this article is the use of the phlebotomy adaptor and sleeve as protective devices, where the needle is sheathed and the vacuum tube supported. Whether to drain a wound is often controversial. If a surgeon chooses to drain a small cavity or potential space, commercially available drains, such as the Jackson-Pratt type, are bulky or heavy, not really suitable for use in ambulatory patients at home. They are suboptimal in a nonhospital environment because emptying or priming them can be daunting for the general public. The primary use of the vacuum drain by the author has been for foot surgery, amputations, and bone resections, where the small size of the drain has been a key advantage in an experience of >1,000 procedures. It has proven easy to manage for both medical personnel and by patents and their families.
Surgeons commonly encounter the need to drain a small tissue volume. Often the area to be drained is in an extremity, and the drain must function in a home or nursing facility environment (Fig. 1). Here I will describe a convenient drain fashioned out of commonly available intravenous and phlebotomy equipment. The drain is fashioned by removing the needle from a standard 19-gauge butterfly catheter (Fig. 2). The tubing is fenestrated with multiple small side holes cut with fine scissors. From a Vacutainer-type phlebotomy needle kit, the vacuum tube puncture adaptor is retained, connected to the 19-gauge hub, and the vacuum tube protective sleeve is used to hold a standard red-top vacuum collection tube as the reservoir. The aspiration tubing from smaller butterfly catheters (21 or 23 gauge) usually fails. The catheter tubing is sutured to skin carefully, usually with a 4-0 suture, to prevent constriction and thrombosis. Vacuum tubes are changed when half full.
DISCUSSION The concept of using a butterfly needle set to fashion a small-parts drain is very old. I used this drain when I was a resident in the 1970s. Many surgeons have used this type of drain, but surprisingly, few publications in the general medical literature have described this type of drain during the last 40 years.1-3 However, phlebotomytube drainage has been widely adopted in veterinary practice and is well described.4,5 In all previous publications, the obvious benefits of this drain have been noted: nearuniversal availability, low cost, effectiveness, small size, and low mass. A commercial version of a vacuum collection tube system (TLS; Stryker Craniomaxillofacial) has Disclosure Information: Nothing to disclose. Disclosures outside the scope of this work: Dr Kaufman has been paid as a member of the HMO clinical oversight board of Health New England, Springfield, MA. He has received payment for medicolegal review of 3 cases during the last 2 years, with no testimony. Received December 14, 2014; Revised February 16, 2015; Accepted February 16, 2015. From Baystate Vascular Services, Springfield, MA. Correspondence address: Jeffrey L Kaufman, MD, FACS, Baystate Vascular Services, 3500 Main St, Suite 201, Springfield, MA 01107. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
Figure 1. Drain in clinical use 1 week after right fifth metatarsal head resection for chronic plantar ulceration. Drain remained in place for a total 3 weeks.
e79
http://dx.doi.org/10.1016/j.jamcollsurg.2015.02.017 ISSN 1072-7515/15
e80
Kaufman
Surgical Drainage of Small Tissue Volumes
Figure 2. Components of the drain. The butterfly needle is divided from the catheter and discarded. Inset shows the fenestrations in the catheter end.
The disadvantages of this drain system are common to any closed suction drain: the potential of the tubing to clot, the potential for the tubing to fall out, and the potential for constriction of the tubing when it is sutured in place. This system has not been studied in a comparison with larger-diameter drain systems because they are so different in nature. There is also the potential that the differences in tubing plasticdsilicone in the larger drains vs polypropylene for the butterfly tubingdcould create a performance difference, but that has never been studied. This type of smalldiameter drain does not work well with established hematomas, which should be treated by proper incision, irrigation, and drainage, with large-diameter suction drains if necessary.
J Am Coll Surg
There is a requirement for any surgeon using this type of drain to teach nurses when to change the vacuum tubes and how to manage them. Usually, it is best to change the tube when it is half full. Nurses must be instructed to discard the tube appropriately, and never to pull the stopper, empty the fluid, and replace that nonvacuum tube. Teaching also includes methods to secure the drain to a dressing and to avoid cutting the drain tubing when the dressing is removed. Drains of this small diameter are easily avulsed, but in the majority of instances, when they accidentally fall out, there is no consequence. This is also the situation for the drain that clots, especially when the recent amount of drainage has been small. These drains have been successfully maintained in place for as long as a month in circumstances where drainage has continued, to avoid a closed fluid accumulation, but all drains can become a source for wound infection, so they are best removed as soon as possible. REFERENCES 1. Josephs RL. Vacudrain system for foot surgery. J Foot Surg 1977;16:97. 2. Kim CW, Oh SJ, Rho YS, Oh JI. Postoperative drainage with a Vacutainer tube after excision of the preauricular sinus. Clin Otolaryngol 2009;34:82e83. 3. Agarwala S, Mulay S. Use of mini-vacuum drains in small surgical wounds. Plast Reconstr Surg 1998;101:1421e1422. 4. Seibert R, Tobias KM. Surgical treatment for aural hematoma. Clinician’s Brief 2013, Mar, 2932. Available at: http://www. cliniciansbrief.com/sites/default/files/attachments/Surgical% 20Treatment%20for%20Aural%20Hematoma.pdf. Accessed December 13, 2014. 5. Hosgood G, Surgery STAT: using active drains in wound management. Available at: http://veterinarynews.dvm360.com/ surgery-stat-using-active-drains-wound-management?rel¼canonical. Accessed December 13, 2014.
Surgical Drainage of a Small Tissue Volume with Butterfly Infusion and Vacuum Phlebotomy Tube Sets Jeffrey L Kaufman,
MD, FACS
been marketed in the past, but it comes with largerdiameter drains than the one described here. Initially, butterfly drains were created by retaining the 19-gauge needle, which was used directly to puncture the vacuum tube. Unfortunately, nursing personnel have sometimes experienced difficulty with puncturing the stoppers, and there have been instances where they have been stuck by the needle. The novel aspect of this article is the use of the phlebotomy adaptor and sleeve as protective devices, where the needle is sheathed and the vacuum tube supported. Whether to drain a wound is often controversial. If a surgeon chooses to drain a small cavity or potential space, commercially available drains, such as the Jackson-Pratt type, are bulky or heavy, not really suitable for use in ambulatory patients at home. They are suboptimal in a nonhospital environment because emptying or priming them can be daunting for the general public. The primary use of the vacuum drain by the author has been for foot surgery, amputations, and bone resections, where the small size of the drain has been a key advantage in an experience of >1,000 procedures. It has proven easy to manage for both medical personnel and by patents and their families.
Surgeons commonly encounter the need to drain a small tissue volume. Often the area to be drained is in an extremity, and the drain must function in a home or nursing facility environment (Fig. 1). Here I will describe a convenient drain fashioned out of commonly available intravenous and phlebotomy equipment. The drain is fashioned by removing the needle from a standard 19-gauge butterfly catheter (Fig. 2). The tubing is fenestrated with multiple small side holes cut with fine scissors. From a Vacutainer-type phlebotomy needle kit, the vacuum tube puncture adaptor is retained, connected to the 19-gauge hub, and the vacuum tube protective sleeve is used to hold a standard red-top vacuum collection tube as the reservoir. The aspiration tubing from smaller butterfly catheters (21 or 23 gauge) usually fails. The catheter tubing is sutured to skin carefully, usually with a 4-0 suture, to prevent constriction and thrombosis. Vacuum tubes are changed when half full.
DISCUSSION The concept of using a butterfly needle set to fashion a small-parts drain is very old. I used this drain when I was a resident in the 1970s. Many surgeons have used this type of drain, but surprisingly, few publications in the general medical literature have described this type of drain during the last 40 years.1-3 However, phlebotomytube drainage has been widely adopted in veterinary practice and is well described.4,5 In all previous publications, the obvious benefits of this drain have been noted: nearuniversal availability, low cost, effectiveness, small size, and low mass. A commercial version of a vacuum collection tube system (TLS; Stryker Craniomaxillofacial) has Disclosure Information: Nothing to disclose. Disclosures outside the scope of this work: Dr Kaufman has been paid as a member of the HMO clinical oversight board of Health New England, Springfield, MA. He has received payment for medicolegal review of 3 cases during the last 2 years, with no testimony. Received December 14, 2014; Revised February 16, 2015; Accepted February 16, 2015. From Baystate Vascular Services, Springfield, MA. Correspondence address: Jeffrey L Kaufman, MD, FACS, Baystate Vascular Services, 3500 Main St, Suite 201, Springfield, MA 01107. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
Figure 1. Drain in clinical use 1 week after right fifth metatarsal head resection for chronic plantar ulceration. Drain remained in place for a total 3 weeks.
e79
http://dx.doi.org/10.1016/j.jamcollsurg.2015.02.017 ISSN 1072-7515/15
e80
Kaufman
Surgical Drainage of Small Tissue Volumes
Figure 2. Components of the drain. The butterfly needle is divided from the catheter and discarded. Inset shows the fenestrations in the catheter end.
The disadvantages of this drain system are common to any closed suction drain: the potential of the tubing to clot, the potential for the tubing to fall out, and the potential for constriction of the tubing when it is sutured in place. This system has not been studied in a comparison with larger-diameter drain systems because they are so different in nature. There is also the potential that the differences in tubing plasticdsilicone in the larger drains vs polypropylene for the butterfly tubingdcould create a performance difference, but that has never been studied. This type of smalldiameter drain does not work well with established hematomas, which should be treated by proper incision, irrigation, and drainage, with large-diameter suction drains if necessary.
J Am Coll Surg
There is a requirement for any surgeon using this type of drain to teach nurses when to change the vacuum tubes and how to manage them. Usually, it is best to change the tube when it is half full. Nurses must be instructed to discard the tube appropriately, and never to pull the stopper, empty the fluid, and replace that nonvacuum tube. Teaching also includes methods to secure the drain to a dressing and to avoid cutting the drain tubing when the dressing is removed. Drains of this small diameter are easily avulsed, but in the majority of instances, when they accidentally fall out, there is no consequence. This is also the situation for the drain that clots, especially when the recent amount of drainage has been small. These drains have been successfully maintained in place for as long as a month in circumstances where drainage has continued, to avoid a closed fluid accumulation, but all drains can become a source for wound infection, so they are best removed as soon as possible. REFERENCES 1. Josephs RL. Vacudrain system for foot surgery. J Foot Surg 1977;16:97. 2. Kim CW, Oh SJ, Rho YS, Oh JI. Postoperative drainage with a Vacutainer tube after excision of the preauricular sinus. Clin Otolaryngol 2009;34:82e83. 3. Agarwala S, Mulay S. Use of mini-vacuum drains in small surgical wounds. Plast Reconstr Surg 1998;101:1421e1422. 4. Seibert R, Tobias KM. Surgical treatment for aural hematoma. Clinician’s Brief 2013, Mar, 2932. Available at: http://www. cliniciansbrief.com/sites/default/files/attachments/Surgical% 20Treatment%20for%20Aural%20Hematoma.pdf. Accessed December 13, 2014. 5. Hosgood G, Surgery STAT: using active drains in wound management. Available at: http://veterinarynews.dvm360.com/ surgery-stat-using-active-drains-wound-management?rel¼canonical. Accessed December 13, 2014.
