1. Abscess/Collection Drainage Procedures. Dr.Denis Kinsella Royal Devon and Exeter Hospital.

2. Drainage Procedures Defined as a core skill Structured Training in Clinical Radiology document Defined as a core skill Structured Training in Clinical Radiology document Marked growth in last 20 years Marked growth in last 20 years All types of simple and complex collections drained in the chest,abdomen and pelvis All types of simple and complex collections drained in the chest,abdomen and pelvis Requires ability to assess CT and US images and familiarity with drainage equipment Requires ability to assess CT and US images and familiarity with drainage equipment

3. Collection Assessment- Imaging Aim-shortest,safest route to site drain in the most dependent position Aim-shortest,safest route to site drain in the most dependent position Avoid major vessels Avoid major vessels Avoid transgressing bowel Avoid transgressing bowel Assessment of nature of fluid- echogenicity;septations Assessment of nature of fluid- echogenicity;septations

4. Imaging-US or CT CT-good visualisation opacified bowel opacified bowel not limited by ileus or depth not limited by ileus or depth US-real time portable portable operator dependent operator dependent Size+site of collection;operator preference

5. Which Needle ? 22g as in Accustick set 22g as in Accustick set 18g-has 5% of the resistance to fluid flow of a 22g needle 18g-has 5% of the resistance to fluid flow of a 22g needle If fail to aspirate fluid -check needle position If good position-flush with saline If no aspirate - consider biopsy If fail to aspirate fluid -check needle position If good position-flush with saline If no aspirate - consider biopsy

8. Which Catheter ? 6F-24F catheters 6F-24F catheters Locking or non-locking-VIP at removal Locking or non-locking-VIP at removal Sump or non-sump-2 nd lumen containing air which prevents cavity collapsing around catheter tip Sump or non-sump-2 nd lumen containing air which prevents cavity collapsing around catheter tip

12. Patient Preparation IV access IV access Fasted for > 2 hours Fasted for > 2 hours Coagulopathy excluded Coagulopathy excluded Informed consent Informed consent

13. Procedure 1 Consider conscious sedation Consider conscious sedation Clean skin Clean skin Anaesthetise skin Anaesthetise skin Skin incision large enough for passage of catheter Skin incision large enough for passage of catheter Consider tract dissection Consider tract dissection

14. Procedure 2-Trocar technique Reference needle in collection Reference needle in collection Catheter assembly advanced to the same depth,in the same plane Catheter assembly advanced to the same depth,in the same plane Remove stylet and aspirate Remove stylet and aspirate Advance catheter over stationary stiffener Advance catheter over stationary stiffener

15. Procedure 3-Seldinger technique 18g needle in collection 18g needle in collection Pass 0.035 wire into collection Pass 0.035 wire into collection Dilate tract Dilate tract Pass catheter and stiffener over wire Pass catheter and stiffener over wire When inside collection pass catheter alone When inside collection pass catheter alone

16. Post Insertion of Drain Aspirate fluid Aspirate fluid Re-image:?need for 2 nd drain Re-image:?need for 2 nd drain Secure drain-it is always more difficult to re-puncture a partially drained collection Secure drain-it is always more difficult to re-puncture a partially drained collection

17. After Care Chart fluid drained Chart fluid drained Aspirate 8hrly with a 50ml. Syringe Aspirate 8hrly with a 50ml. Syringe Irrigate with 10ml. of saline Irrigate with 10ml. of saline Dependent position of bag Dependent position of bag Removal-clinical improvement and drainage of <10ml. per day or collection resolved on re-imaging Removal-clinical improvement and drainage of <10ml. per day or collection resolved on re-imaging

18. Tips –insertion Ensure adequate skin incision Ensure adequate skin incision Avoid kinking wire(no fluoroscopy) Avoid kinking wire(no fluoroscopy) Ideal wire-stiff enough to allow passage of dilators and catheter but will coil within abscess and not perforate posterior wall Ideal wire-stiff enough to allow passage of dilators and catheter but will coil within abscess and not perforate posterior wall Cut thread flush with catheter hub Cut thread flush with catheter hub 3-way tap 3-way tap

19. Click this box AND WAIT to play movie clip of a drainage procedure

20. If Collection Persists with low flows- Catheter displacement Catheter displacement Catheter/tubing blocked or kinked Catheter/tubing blocked or kinked Upsizing catheter Upsizing catheter Septation/loculation Septation/loculation

21. If Collection Persists with high flows- Expect to find a fistula Expect to find a fistula Can occur from bowel,bile and pancreatic duct,renal tract Can occur from bowel,bile and pancreatic duct,renal tract Exclude distal obstruction;underlying bowel disease;proximal diversion;parenteral feeding Exclude distal obstruction;underlying bowel disease;proximal diversion;parenteral feeding Bile leak postlap.chole.-drain plus cbd stent Bile leak postlap.chole.-drain plus cbd stent

22. Minimising Complications at PAD- Broad spectrum antibiotics Broad spectrum antibiotics Correct coagulopathy Correct coagulopathy Adequate sedation + analgesia-beware the restless patient Adequate sedation + analgesia-beware the restless patient Good bowel opacification at CT Good bowel opacification at CT Post procedure catheter management Post procedure catheter management Beware collections adjacent to implants- aspirate>drain Beware collections adjacent to implants- aspirate>drain Discuss cases with clinical team Discuss cases with clinical team

23. Subphrenic Abscess Drainage Traditional to use an extrapleural approach Traditional to use an extrapleural approach Pleural reflections-12 th rib posteriorly;10 th rib laterally;8 th rib anteriorly Pleural reflections-12 th rib posteriorly;10 th rib laterally;8 th rib anteriorly Anterior subcostal approach recommended Anterior subcostal approach recommended Lowest possible intercostal approach used-no empyema due to pleural adhesions Lowest possible intercostal approach used-no empyema due to pleural adhesions Vascular and Interventional Radiology-J.Kaufman;M.J.Lee-Mosby

28. The Inaccessible or Undrainable Abscess:How to drain it Detailed account of TV and PR US guided drains in low pelvic abscesses Detailed account of TV and PR US guided drains in low pelvic abscesses Tilting of CT gantry to access high pelvic abscesses Tilting of CT gantry to access high pelvic abscesses Transgluteal approach-close to sacrum to avoid sciatic nerve + gluteal vesels;below pyriformis to avoid sacral plexus Transgluteal approach-close to sacrum to avoid sciatic nerve + gluteal vesels;below pyriformis to avoid sacral plexus Radiographics[2004] 24,717-735

31. Percutaneous abscess drainage in the U.K How actively involved should radiologists be in drain management post P.A.D? How actively involved should radiologists be in drain management post P.A.D? Postal survey of 117 departments Postal survey of 117 departments 70%-managed by clinical team 70%-managed by clinical team 5%-formally managed drain 5%-formally managed drain Radiologist?clinical team?specialist nurse? Clinical Radiology [2006] 61,55-64

32. Percutaneous abscess drainage in the U.K Single centre study Single centre study Drains for abdominal sepsis-63 in 45 patients Drains for abdominal sepsis-63 in 45 patients 70% curative/successful 70% curative/successful 12% of drains displaced 12% of drains displaced 15% radiological input at time of removal 15% radiological input at time of removal 60% removed by nursing staff 60% removed by nursing staff Complication rate low Complication rate low Clinical Radiolgy [2006] 61,55-64

33. SUMMARY Assess pre-procedure imaging Assess pre-procedure imaging Minimise complications related to PAD Minimise complications related to PAD Involvement in post procedure catheter management Involvement in post procedure catheter management Practical knowledge of needles,wires and catheters Practical knowledge of needles,wires and catheters

35. Transgastric Pancreatic Pseudocyst Drain.