Drainage of wounds. Methods for draining purulent foci. Indications, technique of execution Drainage of a purulent wound

Lecture No. 11

Plan:

1. The concept of drainage.

2. Types of drainage.

3. Types of drainage.

4. Drainage of the pleural cavity.

5. Drainage abdominal cavity.

6. Bladder drainage.

7. Drainage tubular bones and joints.

8. Drainage care.

Drainage – healing method, which consists in removing contents from wounds, ulcers, contents of hollow organs, natural or pathological body cavities. Complete drainage, ensures sufficient outflow of wound exudate, creates best conditions for the speedy rejection of dead tissue and the transition of the healing process to the regeneration phase. There are practically no contraindications to drainage. The process of purulent surgical and antibacterial therapy revealed another advantage of drainage - the possibility of targeted fight against wound infection.

To ensure good drainage, it has the nature of drainage, the choice is optimal for each case, the method of drainage, the position of the drainage in the wound, the use of certain medications for washing the wound (according to the sensitivity of the microflora), proper maintenance of the drainage system in compliance with the rules of asepsis.

Drainage is carried out using drains. Drains are divided into gauze, flat rubber, tubular and mixed.

Gauze drainage- these are tampons and turundas, which are prepared from absorbent gauze. They are used to tamponade the wound. Wound tamponade can be tight or loose.

Tight tamponade used to stop bleeding from small vessels with dry or moistened in solutions (3% hydrogen peroxide, 5% aminocaproic acid, thrombin) gauze turundas. This turunda is left in the wound for 5 minutes to 2 hours. If there is insufficient growth of granulosa tissue in the wound, a tight Vishnevsky tamponade with ointment is performed. In this case, the turunda is left in the wound for 5-8 days.

Loose tamponade used to clean a contaminated or purulent wound with non-collapsing edges. Gauze drainage is loosely inserted into the wound so as not to interfere with the outflow of discharge. In this case, it is better to insert tampons moistened antiseptic solutions. Gauze saves drainage function only 6-8 hours, then it is saturated with wound discharge and prevents outflow. Therefore, with loose tamponade, gauze drainage should be changed 1-2 times a day.

Flat rubber drains- made from glove rubber by cutting out cavities of various lengths and widths. They promote passive outflow of contents from a shallow wound.

To improve outflow, a napkin moistened with an antiseptic is placed on top of the drainage. Such drains are changed daily.

Tubular drains prepared from rubber, latex, polyvinyl chloride, silicone tubes with a diameter of 0.5 to 2.0 cm. Tubular drainage along the spiral side surfaces has holes no larger than the diameter of the tube itself.

There are single, double, double-lumen, multi-lumen drainages. They drain contents from deep wounds and body cavities; the wound or cavity can be washed with antiseptic solutions. Such drainages are removed from wounds on days 5-8.

Microirrigator- this is a tubular drainage, the diameter of which is from 0.5 to 2 mm without additional holes on the side surface of the tube. It is used for administration medicinal substances in the body cavity.

Mixed drainages- these are rubber gauze drainages. Such drains have suction properties due to a gauze napkin and the outflow of liquid through a rubber flat drainage. They are called “cigar drains” - a finger cut off from a rubber glove with several holes and loosely inserted inside with a strip of gauze or layers of gauze pads and rubber strips of drainage. Mixed drainages are used only in shallow wounds.

Closed drainage- this is a tubular drainage, the free end of which is tied with a silk thread or clamped with a clamp. It is used to introduce medicines or removing the contents of the wound and cavity using a syringe. Closed drainages include microirrigators and drainages from the pleural cavity.

Open drainage- this is a tubular drainage, the free end of which is covered with a gauze cloth or immersed in a sterile vessel with an antiseptic solution.

An extremely important element of physical antisepsis is drainage. This method is used in the treatment of all types of wounds, after most operations on the chest and abdominal cavity and is based on the principles of capillarity and communicating vessels.

There are three main types of drainage: passive, active and flow-flushing.

GOU VPO "Perm State medical Academy Ministry of Health of the Russian Federation"

Department general surgery

Drainage of wounds and body cavities

Teacher: Associate Professor Dyachenko M.I.

Performed by Kravchenko A.I., Savinykh O.Yu.

DRAINAGE AND PAMPING OF WOUNDS AND BODY CAVITIES

Drainage (French Drainer - drainage) is a therapeutic method that involves removing contents from wounds, ulcers, contents of hollow organs, natural or pathological body cavities. Complete drainage ensures sufficient outflow of wound exudate, creates the best conditions for the rapid rejection of dead tissue and the transition of the healing process to the regeneration phase. There are practically no contraindications to drainage. The process of purulent surgical and antibacterial therapy revealed another advantage of drainage - the possibility of targeted fight against wound infection.

To ensure good drainage, it has the nature of drainage, the choice is optimal for each case, the method of drainage, the position of the drainage in the wound, the use of certain medications for washing the wound (according to the sensitivity of the microflora), the proper maintenance of the drainage system in compliance with the rules of asepsis.

Drainage is carried out using rubber, glass or plastic tubes of various sizes and diameters, rubber (glove) outlets, specially made plastic strips, gauze swabs inserted into the wound or drained cavity, soft probes, catheters. The introduction of rubber or plastic drains is often combined with the insertion of gauze swabs, or so-called cigar drains are used, proposed by Spasokukotsky, consisting of a gauze swab placed in the finger of a rubber glove with a cut end. For better outflow of contents, several holes are made in the rubber shell. The use of gauze tampons for drainage is based on the hygroscopic properties of gauze, which creates an outflow of wound contents into the dressing. To treat large deep wounds and purulent cavities, Mikulicz proposed in 1881 a method of drainage with gauze swabs, in which a square piece of gauze stitched in the center with a long silk thread is inserted into the wound or purulent cavity. The gauze is carefully straightened and covered with it the bottom and walls of the wound, after which the wound is loosely packed with gauze swabs moistened with hypertonic solutions of sodium chloride. Tampons are changed periodically without changing the gauze, which prevents tissue damage. If necessary, the gauze is removed by pulling the silk thread. The hygroscopic effect of a gauze swab is extremely short-lived. After 4-6 hours the tampon needs to be changed. Rubber graduates do not have any suction properties at all. Single rubber drains often become clogged with pus and detritus and become covered with mucus, causing inflammatory changes in the surrounding tissues. Consequently, drainage methods such as tamponing, the use of rubber outlets and single rubber tubes should be excluded from the treatment of purulent wounds. These methods lead to difficulty in the outflow of wound exudate, which creates conditions for the progression of wound infection.

Tubular drainages (single and multiple, double, complex, with single or multiple holes) are most adequate for the treatment of purulent wounds. When draining surgical wounds preference is given to silicone tubes, which, in their elastic-elastic characteristics, hardness and transparency, occupy an intermediate position between latex and polyvinyl chloride tubes. They are significantly superior to the latter in terms of biological inertness, which makes it possible to increase the residence time of drainage in wounds. They can be sterilely processed repeatedly by autoclaving and hot air.

Drainage requirement:

1. The requirement for careful adherence to the rules of asepsis (removal or replacement of drainage is indicated when inflammatory changes appear around it, much less often such changes develop in cases where drainage is removed from the wound through healthy tissue). The possibility of infection penetrating into the depths of the wound through the lumen of the drainage is prevented by replacing the entire peripheral part of the drainage system, including the graduated vessels for collecting discharge, with sterile ones twice during the day. An antiseptic solution (furatsilin solution, diocide, rivanol) is usually poured onto their bottom.

2. Drainage should ensure the outflow of fluid throughout the entire period of treatment of the cavity, wound, etc. Loss of drainage can be a serious complication that aggravates the outcome of surgery. This can be prevented by carefully securing the drainage with an outer cover, bandage, adhesive tape or silk suture, preferably with a rubber sleeve placed on the drainage tube close to the skin.

3. The drainage system should not be compressed or bent either inside or outside the wound. The location of the drains should be optimal, i.e. the outflow of fluid should not be caused by the need to place the patient in a forced position in bed.

Only in the presence of poorly treated extensive festering wounds, gunshot fractures of the bones of the extremities, the treatment of which occurs without immobilization. Toxic-resorptive fever, sepsis Purulent infection of wounds is always accompanied by a general reaction of the body, the severity of which is proportional to the prevalence and nature of the process. The degree of the body's general reaction to suppuration depends...

Softens the scab, thereby facilitating the removal of the suture. Such sutures should also be removed before the 8th postoperative day due to the possible formation of scars at the sites where the skin is punctured with a needle. After removing the suture, the edges of the wound are secured with a sterile microporous adhesive plaster. 2. Prevention of tetanus In the United States, 2/3 of new cases of tetanus are the result of receiving lacerations and...

Environment(secondary microbial contamination). Secondary microbial contamination can occur if a protective aseptic dressing on the wound is not applied on time, gets knocked down or is wet with blood and wound discharge. Microbes, once in a favorable environment, begin to multiply. Prevention of wound infection and control of it are among the most pressing problems of surgery. The course of the wound...

Dangerous because the rapid death of microorganisms in this case will lead to a massive release of endotoxins and endotoxic shock. Surgery on damaged organs The nature of surgical intervention for abdominal trauma depends on its type and the damaged organ. Liver. For small linear wounds, U-shaped sutures are used to perform hemostasis, which should be applied transversely...

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Wound drainage plays an important role in creating favorable conditions for the course of the wound process. It is not always carried out, and the indications for this procedure are determined by the surgeon. According to modern concepts, wound drainage, depending on its type, should ensure:

removing excess blood (wound contents) from the wound and thereby preventing wound infection (any type of training);
tight contact wound surfaces helping to stop bleeding from small vessels (vacuum drainage of spaces located under the flaps);
active cleansing of the wound (during its drainage with constant postoperative irrigation).

There are two main types of drainage: active and passive (Fig. 1).

Rice. 1. Types of wound drainage and their characteristics

Passive drainage

It involves removing wound contents directly through the line of skin sutures and is able to provide drainage of only the superficial parts of the wound. This involves the application, first of all, of an interrupted skin suture with relatively wide and leaky suture spaces. It is through them that drainages are installed, for which parts of drainage pipes and other available material can be used. By spreading the edges of the wound, drainages improve the outflow of wound contents. It is quite clear that such drainage is most effective when installing drains taking into account the action of gravity.

In general, passive wound drainage is characterized by simplicity, the downside of which is its low efficiency. It is obvious that passive drainages are not capable of providing drainage to wounds that have a complex shape, and therefore can be used primarily for superficial wounds located in areas where the requirements for the quality of the skin suture can be reduced.

Active drainage

Is the main type of wound drainage complex shape and involves, on the one hand, sealing the skin wound, and on the other, the presence of special drainage devices and tools for inserting drainage tubes (Fig. 2).

Rice. 2. Standard devices for active drainage of wounds with a set of conductors for passing drainage tubes through tissue.

An important difference between the method of active wound drainage is its high efficiency, as well as the possibility of floor-by-floor drainage of the wound. In this case, the surgeon can use the most precise skin suture, the quality of which is completely preserved when the drainage tubes are removed away from the wound. It is advisable to select the exit locations for drainage tubes in “hidden” areas, where additional pinpoint scars do not impair aesthetic characteristics ( hairy part head, armpit, pubic area, etc.).

Active drains are usually removed 1-2 days after surgery, when the volume of daily wound discharge (through a separate tube) does not exceed 30-40 ml.

The greatest drainage effect is provided by tubes made of non-wettable material (for example, silicone rubber). The lumen of a polyvinyl chloride tube can quickly become blocked due to the formation of blood clots. The reliability of such a tube can be increased by preliminary (before installation in the wound) rinsing with a solution containing heparin.

Refusal of drainage or its insufficient effectiveness can lead to the accumulation of a significant amount of wound contents in the wound. The further course of the wound process depends on many factors and can lead to the development of suppuration (Fig. 4). However, even without development purulent complications the wound process in the presence of a hematoma changes significantly: all phases of scar formation are lengthened due to the longer process of organizing the intrawound hematoma. A very unfavorable circumstance is a long-term (several weeks or even months) increase in the volume of tissue in the area of the hematoma. The extent of tissue scarring increases, and the quality of the skin scar may deteriorate.

Rice. 4. Variants of the course of the wound process with intrawound hematoma

Drainage of open purulent lesions necessary if after the operation there are dead tissues, niches and pockets that cannot be removed surgically for anatomical reasons (danger of damage to large vessels, nerves of anatomical cavities, etc.).

For drainage gauze drainage should be used, soaked in one of the hypertonic (5-10%) solutions of medium salts with the addition of up to 3% hydrogen peroxide or up to 2% chloramine, up to 0.5% potassium permanganate, 1: 5000 furatsilin. To accelerate the sequestration of dead tissue, add up to 1: 500-1: 1000 iodine, up to 4% turpentine. 15-20% solutions of urea, liniments of synthomycin and A.V. Vishnevsky deserve to be used. In the presence of large quantity dead tissues are drained with gastric juice, preferably trypsin and trypsin-like enzymes or iruxol ointment. Before introducing drainage, it is necessary to stop the bleeding and cover the wound with a gauze pad according to Mikulicz, generously soaked in 96% ethyl alcohol. Under its influence, the capillaries of lymphatic, arterial and venous vessels narrow, the absorption of exudate decreases while simultaneously having an antiseptic effect on the microbial factor. 10-15 minutes after this treatment, drainage begins. Gauze drainage, moistened with one of the listed solutions, is loosely inserted into each niche or pocket to the bottom. It is more advisable to use wider drainages; narrow ones drain worse and are more likely to lose their drainage properties. In the neck of the wound, drainages must be located freely, otherwise they do not drain well. Properly applied gauze drainages perform a suction function and improve the course of an opened infectious focus or infected wound and help suppress the pathogen. Gauze drainages last for several hours, then they should be removed, as they begin to interfere with the removal of exudate.

Indications for drainage removal: a) the outer end has become dry; b) the cavity of the opened lesion or wound is filled with pus; c) the animal’s condition worsens and the general temperature rises. In cattle, in addition, the indication for removal of the drainage is profuse loss of fibrin, which obstructs the outlet. In connection with this reaction of cattle to drainage, it is advisable to moisten the latter with fibrinolyzing solutions (gastric juice, allantoin, fibrinolysin, 5-10% thiourea solution, etc.).

First dressing and drainage must be removed 24-48 hours after surgery. In the future, the drainage is changed taking into account the indicated signs of drainage disturbance. The drains are removed in compliance with the rules of asepsis and antisepsis without traumatic manipulations. Rough dressing sometimes leads to relapse and generalization of the pathogen. Difficult-to-remove drains must be removed sequentially: first, the drain located in the central part of the wound, then the marginal ones. They are removed after prolonged irrigation with solutions of hydrogen peroxide, 2% chloramine, and ammonium bicarbonate of the same concentration heated to 40 °C.

In cases where after opening and removing dead tissue the cavity of the infected lesion contains relatively little dead substrate; it is advisable to use gauze drainage impregnated with A.V. Vishnevsky’s liniment on fish oil. Dead tissues swollen under its influence undergo enzymatic breakdown. Subsequently, when the purulent focus or wound is cleared of dead tissue, A. V. Vishnevsky’s liniment is used on castor oil, which promotes tissue swelling, protects them from severe irritations, and has a beneficial effect on trophism and the growth of granulations.

B.F. Smetanin established that abundantly impregnated oil-antiseptic drainage A.V. Vishnevsky has negligible capillarity, however, as the liniment flows from the free end, its capillarity increases and conditions are created for the flow of wound contents into the dressing like a large-capillary siphon. In addition, being antiseptic, A. V. Vishnevsky’s drainage prevents the absorption of toxic products of tissue decay and microbial toxins from the infected focus into the body.

In cases where it is necessary to irrigate for a long time opened infected lesion, use drainage from a rubber or synthetic elastic tube of the required length, with a diameter of 3-8 mm. One of the ends of the tube is cut obliquely and the sharp edges of the cut are rounded off. Then, using scissors, small windows are cut out in the wall of the immersed part of the tube so that they are located on all sides. The opposite end of the tube is cut lengthwise over a short distance. The end with the cutouts is carefully inserted into the cavity to its bottom, and the dissected parts are bent and inserted into the neck of the cavity or wound so that they rest against the walls and fix the drainage. In this case, the outer end of the drainage should extend several centimeters beyond the cavity. If the outer end of the drainage tube is not cut, then it is sutured to a bandage or to the edges of the skin. Through drainage, the cavity is systematically irrigated with antiseptic solutions and liniments. If there are pockets, it is advisable to insert a drainage tube into each of them.

Tubular drains removed after 5-6 days or as they become clogged. Washed and boiled, they can be reintroduced into the cavity. If necessary, drainages can be left in the cavities of soft tissues (but not in joints and tendon sheaths) until the latter are filled with granulations. In such cases, the drains are gradually removed and shortened. It is necessary to take into account that tubular drainages can put pressure on the tissues of cavities and cause bedsores (necrosis), especially if trophism is impaired. Therefore, rubber and synthetic tubes must have maximum elasticity and sufficient resistance to compression.

Application of tubular drainages It is contraindicated if neurovascular bundles pass through the wall of the purulent cavity or slight vulnerability of granulations is observed.

Wound with drainage it is left open or bandages are applied to it in order to protect it from contamination, irritation and to enhance the suction of exudate and antisepticism. Dressings soaked in hypertonic solutions enhance drainage, and systematic wetting of them with antiseptic solutions and antibiotics ensures antisepticization of the infectious focus and skin. It is advisable to soak bandages applied to the distal parts of the limbs (hooves) with tar mixed with Vaseline or vegetable oils.

Once the infected wound will be freed from dead tissue, covered with normal granulations and the discharge of pus will decrease, drainage should be stopped. The appearance of normal granulations indicates the elimination of the infectious process. Therefore, further use antiseptics, sulfonamides, antibiotics and hypertonic solutions inappropriate.

Any surgical interventions, especially those related to the removal of pus or exudate from internal cavities, can cause infection of the lesions. Installed drainage in some cases allows you to speed up wound cleansing and facilitate its antiseptic treatment. But with the development of medical technologies, the drainage procedure has already been abandoned in most situations, since removing tubes and systems outside can also cause complications.

Why is drainage placed after surgery?

Unfortunately, many surgeons still use drains as a safety net or out of habit, installing them to prevent re-infection and other common consequences of various procedures. At the same time, even experienced specialists forget why drainage is actually needed after:

evacuation of purulent contents of the cavity;
removal of bile, intra-abdominal fluid, blood;
control of the source of infection;
possibility of antiseptic rinsing of cavities.

Modern doctors adhere to the principles of minimal additional intervention in the healing process. Therefore, drainage is used only in extreme cases. cases where it is impossible to do without it.

When is the drain removed after surgery?

Of course, there is no generally accepted time frame for removing drainage systems. The speed of their removal depends on the complexity surgical intervention, the location of its implementation, the nature of the contents of the internal cavities, the initial purposes of installing drainage devices.

In general, experts are guided by a single rule - the drainage must be removed immediately after it has fulfilled its functions. This usually occurs already 3-7 days after the surgical procedure.