Residency · Residency · General Surgery

Principles of Surgical Drains, Tubes, and Access

Overview

Surgical drains, tubes, and vascular access devices are fundamental tools in surgical practice. Understanding their indications, insertion techniques, management principles, and the evidence for or against their use is essential for safe perioperative care. Importantly, the trend in modern surgery has moved toward selective rather than routine use of many of these devices, driven by evidence that routine placement often adds risk without benefit.

Nasogastric Tubes

Types

Three main types of nasogastric tubes are used in surgical practice. The Salem sump is a double-lumen tube with a sump port (the blue pigtail) that prevents mucosal suction injury and is designed for gastric decompression. The Levin tube is a single-lumen device suitable for feeding or medication administration but not ideal for continuous suction. The Dobhoff tube is a small-bore, weighted-tip tube designed for enteral feeding, ideally placed in a post-pyloric position.

Indications

Nasogastric tubes are indicated for gastric decompression in bowel obstruction, ileus, or after upper GI surgery; for decompression of acute gastric dilation; for gastric lavage in GI bleeding or poisoning; and for enteral access when oral intake is not possible.

Placement and Management

Position must be confirmed with a chest or abdominal X-ray before use, as air insufflation with auscultation is unreliable. The sump port (blue pigtail) on a Salem sump must be kept open to air and should never be clamped or used for fluid injection. The tube should be secured to the nose and cheek to prevent migration. Low intermittent suction is used for Salem sump tubes because continuous suction damages the gastric mucosa. Output volume and character (bilious, bloody, or feculent) should be monitored regularly.

Complications

Prolonged nasogastric tube use can cause sinusitis, esophageal erosion or stricture, and aspiration. Inadvertent tracheal placement is a particular risk in obtunded patients. The loss of gastric acid through continuous drainage can produce hypochloremic, hypokalemic metabolic alkalosis.

Evidence for NG Tube Use

A critical point for surgical trainees is that routine nasogastric decompression after elective abdominal surgery is not recommended. Multiple randomized controlled trials and meta-analyses have demonstrated no benefit and an increased rate of pulmonary complications with routine placement. Enhanced Recovery After Surgery (ERAS) protocols advocate for selective rather than routine nasogastric tube use.

Chest Tubes (Thoracostomy Tubes)

Indications

Chest tubes are indicated for pneumothorax (traumatic, iatrogenic, or spontaneous), hemothorax, empyema, therapeutic drainage of pleural effusions, and after thoracotomy or cardiac surgery.

Tube Selection

Tube size is selected based on the indication.

Large bore tubes (28 to 36 French) are needed for hemothorax and empyema, where viscous fluid or blood must be drained. Medium bore tubes (20 to 28 French) are appropriate for pneumothorax and pleural effusions. Small bore or pigtail catheters (8 to 14 French) can be placed using the Seldinger technique and are suitable for simple pneumothorax and free-flowing effusions.

Insertion Technique

For open chest tube insertion, the patient is positioned in the lateral decubitus or supine position with the arm raised above the head. The insertion site is the 4th or 5th intercostal space, anterior to the mid-axillary line, within the "safe triangle." The skin is incised, and blunt dissection is carried through the intercostal muscles above the rib to avoid the neurovascular bundle that runs along the inferior margin of each rib. After entering the pleural space, a finger sweep confirms entry and checks for adhesions. The tube is directed posteriorly and superiorly for pneumothorax or posteriorly and inferiorly for fluid collections. It is connected to an underwater seal drainage system (such as a Pleur-evac) at -20 cmH2O suction, secured with suture, and confirmed with a chest X-ray.

Management

Output volume and character (serous, sanguineous, or chylous) are monitored, and the water seal chamber is assessed for air leak (bubbling with respiration or cough). Criteria for chest tube removal include output less than 150 to 200 mL per 24 hours for fluid drainage, no air leak for 24 hours for pneumothorax, and full lung expansion on chest X-ray. The tube is removed at end-expiration or during a Valsalva maneuver, and an occlusive petroleum gauze dressing is applied immediately.

Indications for Thoracotomy in Hemothorax

Operative exploration is mandated when the initial chest tube output exceeds 1500 mL, when ongoing output exceeds 200 mL per hour for 2 to 4 hours, when the patient remains hemodynamically unstable despite resuscitation, or when a retained hemothorax persists despite adequate chest tube placement.

Surgical Drains

Classification

Surgical drains are classified by mechanism.

Open drains such as the Penrose drain (a flat latex device) provide passive drainage by gravity and capillary action but carry a risk of ascending infection. Closed-suction drains -- including the Jackson-Pratt (JP), Blake, and Hemovac -- apply active suction to reduce dead space and carry a lower infection risk. Sump drains are double-lumen devices with an air vent, designed for large cavities with high output such as the pancreatic bed.

Common Indications

Drains are placed to manage dead space (after mastectomy, thyroidectomy, or lymph node dissection), to monitor for postoperative hemorrhage, to drain established or anticipated fluid collections (bile, pancreatic fluid, lymph), and to provide controlled drainage of anastomotic leaks or fistulae.

Evidence Against Routine Drain Use

The evidence against routine drain placement is strong for several common operations. After cholecystectomy, multiple RCTs show no benefit; drains do not prevent bile leak or detect it earlier. After thyroidectomy, routine drainage does not reduce hematoma complications, as most life-threatening hematomas present before a drain would be effective. After colectomy, meta-analyses show no benefit for routine drainage of colorectal anastomoses. After appendectomy, there is no benefit even in complicated (perforated) cases. For hepatectomy, drains may be selectively useful for major resections but are not routine for minor ones. After splenectomy, drains are not routinely indicated.

When Drains ARE Indicated

Drains have a clear role after pancreatic surgery, where a JP drain after pancreaticoduodenectomy allows monitoring of drain amylase for fistula detection. The Bassi criteria support early removal if drain amylase is below 5000 U/L on postoperative day 1. After esophagectomy, surgical field drainage facilitates anastomotic leak detection. For abscess drainage, percutaneous or surgical drains are essential for managing established collections.

Drain Management

Output volume and character should be recorded. The principle of "drain the drain, not the patient" guides removal -- drains should be removed when output decreases to an acceptable level. Drains can be used to perform sinograms or fistulography. After pancreatic surgery, drains should not be removed early without first checking drain fluid amylase.

Urinary Catheters

Urinary catheters are indicated for intraoperative monitoring of urine output, postoperative urinary retention, accurate intake and output monitoring in critically ill patients, pelvic or urologic surgery, and short-term management of incontinence in immobilized patients. The most important management principle is early removal, as catheter-associated urinary tract infection risk increases 3 to 7% per day of catheterization. ERAS protocols recommend removal on postoperative day 1 for most abdominal surgeries, with the exception of low anterior resection where removal on postoperative day 2 to 3 is appropriate. Suprapubic catheters may be preferable for longer-term drainage due to lower UTI rates and improved patient comfort.

Central Venous Access

Indications

Central venous access is indicated for vasopressor and inotrope administration, TPN administration (when osmolality exceeds 900 mOsm/L), inadequate peripheral access, central venous pressure monitoring, transvenous pacing, hemodialysis access, and frequent blood sampling.

Sites

Three primary sites are used.

The internal jugular vein is the most commonly accessed, benefits from ultrasound guidance, and carries a low pneumothorax risk. The subclavian vein has the lowest infection rate but is contraindicated in coagulopathy, carries a risk of pneumothorax, and is difficult to compress if arterial puncture occurs. The femoral vein offers the easiest landmark-based access but has the highest infection rate and should be avoided in ambulatory patients.

Insertion Technique

For ultrasound-guided internal jugular cannulation, the patient is positioned in Trendelenburg to distend the vein and prevent air embolism. Full barrier precautions (cap, mask, gown, gloves, and a large drape) are mandatory. The IJ vein is identified by ultrasound as a compressible structure lateral to the carotid artery. The Seldinger technique is employed: needle insertion under real-time ultrasound guidance, guidewire advancement, dilation, and catheter placement. Position is confirmed with a chest X-ray, with the catheter tip at the cavoatrial junction. The catheter is secured and a sterile dressing applied.

Complications

Complications include pneumothorax (especially with subclavian access), arterial puncture or cannulation, air embolism (prevented by Trendelenburg positioning), thrombosis, central line-associated bloodstream infection (CLABSI), arrhythmia (if the guidewire or catheter irritates the right atrium), and thoracic duct injury (with left-sided IJ or subclavian access).

CLABSI Prevention Bundle

The evidence-based CLABSI prevention bundle includes hand hygiene, full barrier precautions during insertion, chlorhexidine skin antisepsis, optimal site selection (avoiding the femoral vein when possible), daily review of line necessity with prompt removal when the line is no longer needed, and chlorhexidine-impregnated dressings.

<image>Anatomical illustration of chest tube insertion showing the safe triangle (bounded by anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at the level of the nipple/5th intercostal space). Include cross-sectional view of the intercostal space showing proper insertion above the rib to avoid the neurovascular bundle. Show the tube directed posteriorly and apically for pneumothorax drainage, with connection to an underwater seal drainage system.</image>

<image>Comparison diagram of common surgical drains: Penrose (open, flat latex), Jackson-Pratt (closed-suction, bulb with fluted drain), Blake drain (closed-suction, channeled silicone), and Hemovac (closed-suction, spring-loaded reservoir). Show each drain type with its mechanism of action, advantages, and typical clinical applications. Include cross-sectional views of drain lumens.</image>

<image>Step-by-step illustration of ultrasound-guided internal jugular central venous catheter placement using Seldinger technique. Show: (1) patient positioning in Trendelenburg, (2) ultrasound probe placement with short-axis view identifying IJ vein and carotid artery, (3) needle insertion under real-time guidance, (4) guidewire advancement, (5) dilator insertion, (6) catheter placement, and (7) final confirmation with catheter tip at cavoatrial junction on chest X-ray.</image>

Clinical Pearls

Routine nasogastric decompression after elective abdominal surgery is not supported by evidence and increases pulmonary complications. Chest tube output exceeding 1500 mL initially or exceeding 200 mL per hour for 2 to 4 hours mandates operative exploration for hemothorax. Chest tubes must always be inserted over the top of the rib to avoid the intercostal neurovascular bundle that runs along the inferior rib margin. Routine drain placement after cholecystectomy, thyroidectomy, and colectomy is not supported by evidence. After pancreaticoduodenectomy, drain amylase should be checked on postoperative day 1; if below 5000 U/L, early drain removal is safe and reduces the pancreatic fistula rate. Central line infection risk by site follows the pattern: femoral greater than internal jugular greater than subclavian. Ultrasound guidance for central venous access reduces complications and is now the standard of care for internal jugular access. The blue pigtail on a Salem sump tube is the air vent and must never be clamped or used for fluid injection. Urinary catheters should be removed as early as possible, as each day of catheterization increases UTI risk by 3 to 7%. A chest tube that suddenly stops draining may indicate tube obstruction by clot rather than resolution of the effusion, and the patient should be assessed both clinically and radiographically.

References

• Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995;221(5):469-478.
• Bassi C, Molinari E, Malleo G, et al. Early versus late drain removal after standard pancreatic resections. Ann Surg. 2010;252(2):207-214.
• Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58(Suppl 2):ii53-ii59.
• Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.

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