23.2 Surgical Drains, Chest Tubes, Gastrostomy/Enteral Tubes, Paracentesis, Thoracentesis & Urinary Catheterization

Surgical Drains, Chest Tubes, Gastrostomy/Enteral Tubes, Paracentesis, Thoracentesis & Urinary Catheterization

Quick Answer: Track surgical drain output and remove the drain only when the operative team confirms readiness. After chest tube trouble, assess the child first and restore a closed system that lets air escape. Hold feeds after G-tube dislodgement until the care team confirms a safe gastric position. Use ultrasound to select a safe fluid pocket for thoracentesis or paracentesis. Blood at the meatus after male pelvic trauma requires urethral evaluation before blind catheter passage.

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Surgical Drains and Neurosurgical CSF Catheters

Closed-Suction vs. Open Passive Drains

Assess the child, site, seal and tubing before interpreting a change in output. Document volume and appearance over time and avoid routine stripping or flushing unless ordered for the specific drain. For removal, confirm the order and the operative team's output and wound criteria. Provide analgesia, use aseptic technique, release reservoir suction as appropriate, and identify the securing suture or locking mechanism. Release a locking pigtail according to its device instructions. Withdraw with steady traction. Stop and contact the treating team if the drain will not come free. Inspect the removed drain for completeness, dress the site, and monitor for bleeding, leakage, infection or reaccumulation. Pediatric surgical drain management

External Ventricular Drains (EVDs) and VP Shunts

The EVD drains cerebrospinal fluid (CSF) at the height prescribed by neurosurgery. In a supine child, use the tragus as the external reference approximating the foramen of Monro. Relevel after position changes. Follow the setup-specific stopcock procedure for a valid ICP reading and the separate order for CSF drainage. Interpret the amount and trend with the prescribed height, the waveform, the circuit and the child's neurologic exam.

New headache, vomiting, reduced alertness, a bulging fontanelle or a new ocular motor deficit can accompany impaired drainage. A sudden change in output prompts a check of leveling, clamps, stopcocks and external kinks and immediate communication with neurosurgery. Hypertension with bradycardia and irregular breathing is a late emergency. Avoid aspirating, flushing or otherwise manipulating the ventricular catheter without neurosurgical direction. Suspected VP shunt malfunction or infection also needs urgent neurosurgical evaluation. Reservoir sampling or tapping requires an indication, sterile technique and a team authorized to access the particular shunt. Pediatric EVD management · IDSA healthcare-associated ventriculitis guidance

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Chest Tube Insertion, Mechanics and Removal

Select the Tube and Site

A tube evacuates pleural air, blood, pus or other fluid when the indication warrants drainage. In an unstable child with clinical tension pneumothorax, decompress immediately with the pediatric trauma technique and proceed to definitive drainage. For a child aged 3 months to 18 years with pneumonia-associated empyema that requires drainage, the 2026 IDSA/PIDS guideline conditionally favors a small-bore tube (12 Fr or smaller) and tube drainage with intrapleural fibrinolysis as first-line therapy in most cases. It suggests alteplase alone when a fibrinolytic is used. Selected children may need operative drainage. IDSA/PIDS 2026 pediatric CAP recommendations

For planned placement, confirm the indication and side, obtain appropriate monitoring, plan analgesia and sedation, and prepare a sterile field and drainage system. A common approach for pneumothorax is the fourth or fifth intercostal space near the anterior to midaxillary line in the safe triangle. For fluid, use ultrasound to choose an accessible pocket and avoid underlying organs. Enter immediately over the upper border of the lower rib. A trained operator may use a guidewire for a small-bore tube or blunt dissection for a larger trauma tube. Confirm pleural entry and ensure the tube's drainage holes lie within the pleural space. Secure the tube, connect to the closed unit, reassess and confirm position and effect with appropriate imaging. Pediatric thoracocentesis and chest drain insertion

Interpret the System and Respond to Trouble

Keep the collection unit upright and below the chest. Identify the water seal separately from the suction-control chamber or regulator. Set suction as ordered for the device and indication. Tidaling reflects transmission of respiratory pressure. Its disappearance can follow lung re-expansion or tube obstruction. Check the child, the tube and circuit, and obtain imaging when needed to distinguish these possibilities. Intermittent water-seal bubbling can accompany air evacuation. Continuous bubbling may come from the patient, tube exit site or circuit. Inspect the dressing, connections and tubing. New subcutaneous crepitus calls for evaluation of tube position, including an exposed side hole, obstruction and adequacy of drainage.

• Disconnection: Assess oxygenation, ventilation and circulation, summon help, and promptly restore sterile closed drainage with the unit or a replacement. Some pediatric protocols place the free end of the patient-side tubing in sterile water temporarily while a new circuit is prepared. Follow the unit's emergency procedure and maintain air egress when an active pleural leak is suspected. Pediatric emergency disconnection example
• Tube pulled out: Cover the exit site promptly with a sterile occlusive dressing per the pediatric emergency protocol and call for help. Reassess for recurrent pneumothorax or tension. The treating team decides whether a new drain is needed. Leave the displaced tube out.
• Planned removal: Confirm the indication has resolved sufficiently. Consider lung expansion, absence of an air leak for pneumothorax, and the amount and nature of residual fluid output for an effusion. Give analgesia and coordinate withdrawal with breathing or ventilation according to local practice. Seal the site immediately. Monitor for respiratory change or bleeding and use post-removal imaging according to the indication, symptoms and local protocol. Pediatric observational studies support selective imaging in some asymptomatic populations. Pediatric chest drain management · Pediatric post-removal imaging study

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Enteral Tube Verification and Gastrostomy Emergencies

NG and NJ Placement

A gastric aspirate pH of 1–5.5 supports nasogastric (NG) placement when the pediatric policy accepts bedside testing. Use radiography for uncertain or high-risk placement, such as after blind placement in a sedated or intubated child. Follow the tube's full course and verify the gastric tip before use. A nasojejunal (NJ) tube requires confirmation that its tip is in the intended postpyloric position. An external depth mark helps detect migration. Auscultation after air injection cannot establish enteral location. ASPEN NOVEL pediatric NG recommendations

Dislodged G-Tube, Buried Bumper and Migrated GJ Tube

A tract can narrow quickly, so hold feeds and medications, assess hydration and medication needs, and establish the insertion date, device type and first-change history promptly. For a new or uncertain tract or first tube change, contact the placing team urgently for a stoma-preservation plan, supervised replacement and confirmation. For example, the CHOP pathway treats a tract younger than six weeks or without a completed first tube change as requiring the placing service for replacement, with contrast confirmation. Any temporary catheter in a new tract should follow the hospital's explicit protocol and team direction.

For an established balloon gastrostomy tract, prompt replacement by a trained clinician or caregiver may preserve patency. A temporary catheter may be used to hold the tract open under local policy. The 2026 ASPEN guideline recommends gastric aspiration as first-line confirmation after a mature balloon tube is dislodged. If placement remains uncertain or symptoms suggest a false tract, keep the tube out of use and escalate to the tube team and imaging. A tract that required dilation needs particular attention to possible false passage. Where the local team has the required expertise, ultrasound can help verify position and an inconclusive study should be followed by contrast imaging.

Suspect a buried bumper with leakage, increased resistance or loss of expected tube mobility in a device with an internal bumper. Hold use and seek GI or surgical review. Formula returning from the gastric port or new feed intolerance can indicate gastrojejunostomy (GJ) migration. Hold jejunal feeds until the jejunal position is confirmed or restored, typically with imaging and specialist help. CHOP G/GJ displacement pathway · ASPEN 2026 pediatric balloon gastrostomy replacement guideline

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Thoracentesis, Paracentesis and Urinary Catheterization

Thoracentesis

Use ultrasound to select a safe fluid pocket for diagnostic sampling or therapeutic relief. Identify the diaphragm and nearby organs. Enter above the upper edge of the lower rib to reduce the risk of striking the intercostal neurovascular bundle, which usually runs along the lower edge of the rib above. Plan the volume and rate of therapeutic drainage with the pediatric team for the child's size, symptoms and clinical indication. Monitor for persistent cough, chest pain, dyspnea, hypoxemia or hypotension, stop drainage and reassess for complications such as pneumothorax, bleeding or re-expansion pulmonary edema. Pediatric thoracocentesis procedure

Paracentesis

Use ultrasound to choose a safe pocket away from vessels, bowel, solid organs and the bladder. Plan analgesia or sedation and monitoring. In a child with cirrhosis and ascites, fever, abdominal pain or clinical deterioration prompts diagnostic sampling. Tense, symptomatic refractory ascites may warrant therapeutic drainage.

• Portal hypertension: Calculate the serum–ascites albumin gradient (SAAG) from the serum albumin minus the ascitic albumin. A gradient of at least 1.1 g/dL supports a portal hypertensive cause.
• Suspected spontaneous bacterial peritonitis (SBP): In a child with cirrhotic ascites, an ascitic neutrophil count above 250 cells/µL meets the criterion stated in AASLD’s pediatric text and warrants empiric treatment while evaluating for a secondary intra-abdominal source. Some pediatric studies use 250 or greater. If SBP is clinically suspected, including at the cutoff or when sampling cannot be obtained, treat promptly. Obtain cell count, differential and cultures, ideally inoculating culture bottles at the bedside before antibiotics when feasible. Start prompt empiric IV treatment covering gram-positive and gram-negative organisms, taking acquisition setting, severity and local resistance into account.
• Albumin after large-volume paracentesis: AASLD pediatric guidance describes 25% IV albumin at 0.5–1 g/kg or 6–8 g per liter removed. Pediatric evidence on removal thresholds and rate is limited. Use the hepatology protocol to choose one dosing method and monitor hemodynamics and renal function. AASLD practice guidance, pediatric section · Pediatric ascitic fluid cohort

Pediatric Urinary Catheterization

Use an age- and size-appropriate catheter and aseptic technique for inpatient insertion. Lubricate and advance gently, and stop if resistance is encountered. Confirm urine return and sufficient advancement according to the device and pediatric procedure before inflating a retention balloon. Secure the device without traction, maintain closed dependent drainage and reassess the indication daily.

Blood at the urethral meatus after male pelvic trauma warrants retrograde urethrography before blind urethral catheterization. Consult pediatric urology promptly when injury is suspected, including suspected female urethral injury, for the appropriate evaluation and drainage plan. A suprapubic route may be needed if the urethra is disrupted. AUA urotrauma guideline, statement 19 · CDC urinary catheter indications and technique