Should I flush a biliary (bile) drain that hasn’t been flushed in two days in a patient with fever?

Management of Biliary Drain in a Febrile Patient

Yes, you should immediately flush the biliary drain in a patient with fever who has not had the drain flushed in two days, as this is critical to prevent progression to severe cholangitis and sepsis. 1

Rationale for Immediate Flushing

Fever in a patient with a biliary drain suggests possible cholangitis, which requires prompt intervention. The American College of Radiology recommends immediate flushing of biliary drains in febrile patients to prevent progression to severe cholangitis and sepsis 1. This is particularly important when the drain hasn't been flushed for two days, as biliary obstruction is the most important predisposing factor for cholangitis 2.

Proper Flushing Technique

When flushing the biliary drain:

• Use sterile technique to prevent introducing infection
• Use normal saline (typically 10-20 mL)
• Apply gentle irrigation to avoid excessive pressure that could cause cholangio-venous reflux
• Observe the return fluid for color, consistency, and presence of debris
• Consider obtaining bile samples for culture and sensitivity testing before or during the flush procedure 1

Additional Management Steps

After flushing the drain:

1. Continue regular flushing: Establish a schedule of flushing every 8-12 hours
2. Evaluate drain function: Consider drain upsizing if output remains poor after flushing
3. Assess for additional collections: Look for other fluid collections that may require drainage
4. Initiate antibiotics: Start empirical antibiotic therapy promptly
   • For immunocompetent patients: Amoxicillin/Clavulanate 2g/0.2g q8h IV
   • Alternative options: Piperacillin/Tazobactam, Meropenem, Doripenem, or Imipenem/Cilastatin
   • For beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose, then 50 mg q12h 1

Monitoring and Follow-up

• Monitor temperature response after flushing
• Assess for clinical improvement (reduction in fever, pain, and other symptoms)
• Consider additional imaging if symptoms persist despite drainage
• Adjust antibiotic therapy based on culture results when available

Potential Complications to Watch For

• Cholangio-venous reflux: Can occur with high-pressure flushing, potentially worsening sepsis
• Persistent fever: May indicate inadequate drainage or need for additional interventions
• Bilomas or bile leaks: May develop and require additional drainage procedures 1, 3

When to Consider Additional Interventions

If the patient doesn't improve after initial flushing:

• Consider alternative or additional biliary drainage procedures (ERCP or PTBD)
• Evaluate for undrained biliary segments that may require additional intervention
• Assess for biliary stones or strictures that may need definitive treatment 2, 1

Remember that establishing successful biliary drainage is critical in the treatment of biliary sepsis, and prompt action can significantly reduce morbidity and mortality 2.