How do you manage drainage and decompression devices, such as chest tubes, abdominal drains, and intracranial pressure (ICP) monitors, as an Adult-Gerontology Acute Care Nurse Practitioner (AGACNP)?

Management of Drainage and Decompression Devices as an AGACNP

Intracranial Pressure Monitoring Devices

For patients with severe traumatic brain injury (GCS ≤8) and abnormal CT findings, place an ICP monitor immediately—preferably an intraparenchymal probe over a ventricular catheter due to lower infection and hemorrhage risk. 1, 2

Indications for ICP Monitor Placement

• Traumatic Brain Injury: Insert in patients with GCS ≤8 and abnormal CT scan, or in those with normal CT but hemodynamic instability requiring evaluation on a case-by-case basis 2
• Post-Hematoma Evacuation: Monitor ICP if any of the following exist: preoperative motor response ≤5, anisocoria or bilateral mydriasis, hemodynamic instability, compressed basal cisterns, midline shift >5mm, intraoperative cerebral edema, or new postoperative intracranial lesions 1, 2
• Intracerebral Hemorrhage: Consider monitoring in patients with GCS ≤8, clinical evidence of transtentorial herniation, or significant intraventricular hemorrhage with hydrocephalus 1

Device Selection and Technical Considerations

• Prefer intraparenchymal probes over ventricular catheters when CSF drainage is not required—infection rate is 2.5% versus 10%, and hemorrhage risk is 0-1% versus 2-4% 1, 2
• Use ventricular catheter (external ventricular drain) when hydrocephalus requires CSF drainage, particularly in patients with decreased level of consciousness 1
• Correct coagulopathy before insertion: Reverse warfarin, consider platelet transfusion if patient was on antiplatelet agents 1
• Place reference point for mean arterial pressure measurement at the external ear tragus 1

ICP Management Targets and Interventions

Maintain cerebral perfusion pressure (CPP) between 60-70 mmHg and ICP <20 mmHg. 1, 2, 3

Stepwise approach when ICP exceeds 20 mmHg:

1. Immediate non-pharmacologic measures: Elevate head of bed 20-30 degrees to enhance venous drainage 3
2. Ensure adequate sedation and analgesia to prevent agitation-induced ICP spikes 1
3. Osmotherapy: Administer mannitol 20% (0.25-2 g/kg over 30-60 minutes) or hypertonic saline (250 mOsm over 15-20 minutes)—maximum effect occurs at 10-15 minutes, lasting 2-4 hours 1, 3
4. Moderate hyperventilation (PaCO2 26-30 mmHg) only as temporizing measure—avoid prolonged hypocapnia as it worsens outcomes through cerebral ischemia 1, 3, 4
5. Consider neurosurgical intervention if refractory to medical management 4

Critical Pitfalls to Avoid

• Never maintain CPP >70 mmHg routinely—values >90 mmHg worsen outcomes by aggravating vasogenic edema 1, 2
• Do not allow CPP <60 mmHg—associated with poor neurological outcomes 1, 2
• Avoid aggressive hyperventilation—prolonged hypocapnia causes cerebral vasoconstriction and ischemia 3
• Do not use corticosteroids for elevated ICP in intracerebral hemorrhage 1

Special Considerations for ECMO Patients

• External ventricular drain insertion is high-risk in ECMO patients due to coagulopathy and systemic anticoagulation 1
• Consider EVD only in selected patients at imminent risk of death from intraventricular hemorrhage with hydrocephalus 1
• Invasive ICP monitoring has not shown improved long-term outcomes and increases parenchymal hemorrhage risk in ECMO patients 1

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Chest Tube Management

Insert chest tubes using blunt dissection with digital exploration of the pleural space—never use trocars—and direct the tube posteriorly and superiorly to prevent complications. 5

Indications for Chest Tube Placement

• Pneumothorax: Hemodynamically unstable patients with tension pneumothorax require immediate decompression 5
• Hemothorax: Drainage of blood from pleural space in trauma or post-cardiac surgery 1
• Pleural effusions: Symptomatic effusions requiring drainage 6
• Post-cardiac surgery: Routine placement to drain shed mediastinal blood and prevent retained blood syndrome 1

Insertion Technique and Device Selection

• Blunt dissection and digital decompression through the pleura is the essential first step—decompression is the primary goal, tube insertion is secondary 5
• Avoid trocars completely—use aseptic technique and guide tube posteriorly and superiorly during insertion 5
• Consider silicone-rubber drains (19F Blake drains) over traditional 32F PVC drains—associated with 71% more drainage, 49% decrease in pericardial effusion, reduced atrial fibrillation (11.3% vs 23.8%), and shorter hospital stay 1

Monitoring and Maintenance

• Assess drainage system hourly for patency, volume, and character of drainage 6
• Maintain water-seal integrity—the container allows one-way movement of air and liquid from pleural cavity 6
• Do not clamp chest tubes unnecessarily—clamping can cause tension pneumothorax 6
• Change drainage container only when full—unnecessary changes increase infection risk 6
• Monitor for air leaks by observing water-seal chamber for bubbling 6

Removal Criteria

• Remove when drainage is minimal (<100-200 mL/24 hours depending on indication), no air leak present, and lung is fully expanded on chest radiograph 1
• Obtain chest radiograph after removal to confirm no pneumothorax or reaccumulation of fluid 5

Critical Pitfalls to Avoid

• Never use needle thoracocentesis as primary decompression in unstable patients—it is unreliable and should only be used as last resort 5
• Do not insert chest tube without digital exploration—blind insertion increases risk of organ injury 5
• Avoid dependent loops in tubing—impairs drainage and increases retained fluid risk 6

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Abdominal Drains (Jackson-Pratt, Blake Drains)

Manage surgical drains by assessing output every 4-8 hours, stripping the tubing to maintain patency, and removing when output is <30 mL/24 hours. 7

Monitoring and Maintenance

• Empty and measure drainage every 4-8 hours or when bulb is half-full 7
• Strip tubing regularly to prevent clot formation and maintain patency—blood clotting is the primary cause of drain failure 7
• Maintain negative pressure by compressing bulb after emptying 7
• Assess drain site for signs of infection, skin breakdown, or inadvertent dislodgement 7

Removal Criteria

• Remove when output decreases to <30 mL/24 hours and character changes from serosanguinous to serous 7
• Ensure no signs of ongoing bleeding, infection, or fluid collection requiring continued drainage 7

Common Complications

• Tube clogging from blood clots—prevented by regular stripping 7
• Inadvertent removal—secure drain with suture and transparent dressing 7
• Infection at insertion site—use aseptic technique during care 7

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Transport and Patient Mobility Considerations

• Never clamp chest tubes during transport unless specifically ordered for air leak assessment 6
• Keep drainage systems below level of insertion site to prevent backflow 6
• Secure all drainage devices to prevent dislodgement during patient movement 6
• Maintain continuous monitoring of ICP during transport if critically elevated 4