Percutaneous transhepatic biliary drain

Using fluoroscopy, your provider will be able to locate the appropriate dilated bile duct in your liver. Using a thin needle, your provider will access the dilated duct through your skin. Following confirmation of appropriate access under x-ray guidance, the tract formed through your skin to the bile duct will be dilated using a system of wire and dilators to a certain size to accommodate the appropriate drain size chosen by your provider. After the drain is successfully placed, the external portion of the drain will be secured to your skin using a nonabsorbable suture +/- additional securement device. There are different types of adhesive securement devices on the market including: stay fix, statlock, uresil fixation system, and cathgrip

Images 3a-d. Different adhesive securement devices you may see.

Image 4. A non dissolvable suture securing your drain to your skin

The final component of the drain is the 3-way stopcock and drainage bag. The 3-way stopcock has 3 points of attachment and a tap that can be turned to control the flow of bile (see image 5). The drainage bag will be connected to the attachment point opposite to the catheter. The third attachment point is where saline flushes can be injected. Typically there is a needleless connector attached to this third attachment point.

Image 5. The stop cock that will be attached to your biliary drain on one end and the drainage bag on the other.

https://www.mskcc.org/cancer-care/patient-education/how-cap-your-biliary-drainage-catheter

Image 6. Drainage bag which is called a “600 ml drainage bag.

Daily drain care task checklist

• Check the dressing to make sure it is clean, dry, and intact. If the dressing is soiled/wet/or falling off, it needs to be changed.
• Examine skin around the catheter site when changing the dressing. Note if there are any areas of significant redness or broken skin. Check to make sure no fluid is leaking around the catheter.
• Inspect the catheter daily from the insertion site at the skin to the drainage bag.
• • Ensure your suture is still in place and the tube has not partially dislodged.
  • Check the connections at the stop cock and the drainage bag to make sure the connections are secure and not leaking.
  • Ensure the stop cock is open to the drainage bag.
  • Make sure there are no kinks or holes in the external portion of the tubing.
  • Inspect the drainage bag. Bile should be flowing freely into the bag.
  • Evaluate the drainage bag for any hole or tear with leakage of bile.
• Flush the catheter with 10 ml sterile saline and record daily total volume of saline flushes in your MDC account. Biliary drains are generally flushed once a day to keep them patent, however your provider may have asked you to flush your drain more often.
• Empty drainage from the bag. Do not wait until the bag is completely full or the weight of the drainage bag may dislodge the tube.
• Record the amount and color of drainage in your MDC account.

Flushing the catheter

• Gather supplies:
  • (10 mL) prefilled normal saline syringe
  • alcohol wipes
• Wash hands
• Take a normal saline syringe and adjust volume to the amount your doctor recommended by squirting extra saline out: typical volumes include 3 mL, 5 mL, or 10 mL.
• Turn the stopcock toward the drainage bag in order to close the circuit off to the drainage bag

• Using the alcohol wipes, clean the needless connector for 15-30 secs rubbing vigorously
• Place saline syringe onto the needless connector and turn the syringe clockwise to lock it in place
• Push the plunger of the syringe to flush saline into the drain in 1/3rd increments. Never pull back on the saline syringe plunger. Flushing the syringe should be smooth without much resistance.
• When the syringe is empty, turn the syringe counterclockwise to loosen and remove and toss the syringe.
• Turn the stopcock back to the direction of the needless connector. You should see fluid draining into the bag at this point.
• Problems with flushing (link to troubleshooting) may include:
  • Pain while flushing
  • Feel resistance against the pushing. The pushing of saline should be smooth
  • See leaking around the catheter
• Do not forget to record your daily total volume of saline flushes in the MDC account under “total mL saline flush”. For example if you used 2 full 10 mL saline flushes in one day, record 20 mL in the “total mL saline flush” for that particular day.

You will have a drainage bag attached to your catheter. You will see bile (yellow-green fluid) flowing into the bag. The fluid may appear bloody for the first day or 2 after the procedure. The color will eventually be golden yellow or green.

• Gather supplies:
  • Measuring container
  • Nonsterile gloves
  • Alcohol wipes
• Wash hands
• Put on nonsterile gloves
• Using alcohol wipe, clean the cap at the bottom of the drainage bag

• Depending on the type of bag you have, either twist cap open or turn valve counterclockwise while holding cap over the measuring container and allow fluid to drain into the container

• Once all the fluid has drained, twist the cap close or turn the valve clockwise to lock the bag drain cap.
• Clean the cap again with an alcohol wipe.
• Measure the amount of fluid in the container and note the color of the fluid. Record amount and color of fluid in your MDC tracker.
• Pour fluid into toilet and flush.
• Wash measuring container with soap and water and allow it to air dry.
• Throw mt-25 gloves away and wash hands.

Supplies needed:

• Non-sterile gloves
• 1 needleless connector
• 1 sterile 3 way stopcock
• 1 drainage bag
• Safety pin or strap
• Gauze
• Skin friendly tape such as micropore paper tape
• Waste basket
• Empty drainage bag and record amount and color of drainage in MDC database.
• Wash hands
• Gather new drainage bag, 3 way stopcock, and needless connector.
• Attach new needless connector to center port of new stopcock.
• Connect tubing from drainage bag to new stopcock with a twisting motion.
• Ensure drainage port of the new drainage bag is closed by turning it clockwise.
• Wash hands
• Put on non sterile gloves
• Twist off old stopcock and drainage bag from your catheter and throw it away.
• Quickly attach new stopcock and drainage bag to catheter.
• Turn tap of stopcock in the direction of the needless connector to make sure catheter drains into the drainage bag.
• Place any new securement device according to provided instructions.
• Secure drainage bag with strap, bag holder, or safety pin.
• Ensure the bag is below the level of the catheter to allow drainage by gravity.

You can shower with your drain but it is important to keep your dressing dry. Be sure to cover your dressing when taking a shower. A hand-held showerhead can also help direct water away from your dressing.

If your dressing becomes damp/wet from shower, you will need to change the dressing. Wet dressings can lead to skin problems.

There are many methods to cover your dressing/drain before taking a shower. You can tape a plastic wrap or a gallon size bag over the dressing to keep it dry. You can also cover the dressing using AquaGuard which is a 1 time use waterproof cover. When taping a cover over your dressing, be sure to avoid taping directly onto the dressing to avoid lifting the dressing once the covering is removed.

Everyday activities with a catheter

You may resume work and exercise with your catheter securely in place. Movements that should be minimized to help reduce risk of catheter dislodgement include stretching from side to side or continual bending.

One way a catheter can get kinked or dislodged is when getting dressed. Be sure to not to tug on the catheter while getting dressed. Avoid tight clothing including pantyhose or belt around the catheter to avoid kinking. When sleeping , avoid lying on the side your catheter is on to avoid kinking.

Do not swim, take a bath, or submerge your catheter in water.

Typically biliary drains will be exchanged every 8 to 12 weeks. However, the frequency can vary from patient to patient. The physician who placed your drain should inform you of your next followup visit when they will check and exchange or possibly remove your drain.

Typically a capping trial is reserved for patients with an internal-external biliary drainage catheter. If you do not know which kind of catheter you have, please ask your provider. Only attempt a capping trial if you have been instructed by your provider to do so. For specific instructions on frequency and timing of your capping trial, please talk to your doctor.

A capping trial is a test to see if your body can handle the normal route of bile emptying from the liver into the small intestines by removing the external emptying through the drainage bag. It is a safe test because you still have your catheter in place just in case your body is not ready yet to tolerate a capping trial.

Capping Trial Steps:

• Remove the stopcock and drainage bag row mt-25entirely and place the needleless connector cap on the catheter hub.
• When your catheter is capped, you no longer need a drainage bag. At this point, bile will flow internally inside your liver through the existing internal component of your catheter and empty into the intestines
• You can continue to flush through the needleless connector cap per schedule

Symptoms Listed Below are Important to be Aware of While You Have Your Catheter Capped.

• Leaking around the catheter insertion site at the skin
• New or worsening belly pain pain around the catheter
• Fever higher than 100.4 °F (38 °C) or chills

Development of these symptoms may indicate your body is not ready for a capping trial. If you develop any of these symptoms, call your doctor and uncap the catheter. To uncap, remove the needleless connector cap from the catheter and attach the 3 way stopcock and drainage bag. Be sure the catheter is emptying into the drainage bag by turning the tap of the stopcock in the direction of the middle port.

When To Call Your Provider

• Fever of 100.4 °F (38 °C) or chills
• Worsening nausea/vomiting
• New or increasing jaundice
• New or worsening pain/leakage/swelling/redness around the catheter insertion site
• No drainage from your catheter or if the amount of drainage is significantly less than usual
• Bloody drain output
• You cannot flush the catheter or leaking around catheter site when flushing (be sure to make sure the 3 way stopcock tap is turned towards the mid port to open the catheter to flushing)
• Dislodgement of catheter
• Catheter is kinked that you cannot straighten out leading to blockage
• Catheter is broken