Ultrasound guided percutaneous drainage

Last revised by Andrew Murphy on 23 Mar 2023

Ultrasound guided percutaneous drainage is one form of image guided procedure, allowing minimally invasive treatment of collections that are accessible by ultrasound study.

It has several advantages and disadvantages over CT, which include:

  • is a dynamic study, allowing greater precision to control needle insertion

  • does not expose patients to ionizing radiation

  • does not require as wide a range of staff, compared to CT-guided procedures

  • deeper targets may not be as well-visualized on ultrasound (e.g. retroperitoneal nodes)

  • bowel gas may obscure visualization

  • attenuation of the sound beam on larger patients

Indications for percutaneous drainage are broad: essentially any abnormal fluid collection in the patient which can be accessible. Examples include:

  • complicated diverticular abscess

  • Crohn's disease related abscess

  • complicated appendicitis with appendicular abscess

  • tuboovarian abscess

  • post-surgical fluid collections

  • hepatic abscess (e.g. amoebic or post-operative)

  • renal abscess or retroperitoneal abscess

  • splenic abscess

The only common contraindications are:

  • biopsy target is not accessible

  • patient has a bleeding diathesis

Interventional procedures like percutaneous drainage require special attention to coagulation indices. There are widely divergent opinions about the safe values of these indices for percutaneous biopsies. The values suggested below were considered based on a literature review.

Complete blood count: platelet count > 50000/mm3  (Some institutions determine other values between 50000-100000/mm3) 1

Coagulation profile:

  • international normalized ratio (INR) ≤1.5 1

  • normal prothrombin time (PT), partial thromboplastin time (PTT)

Some studies show that having a normal INR or prothrombin time is no reassurance that the patient will not bleed after the procedure 2.

Review other diagnostic studies first to clarify the collection that is requested to be drained. An ultrasound study should be done prior to the procedure to decide the access angle and check the relationship of the collection to adjacent structures. In general, the shortest possible route is preferred, as long as it does not traverse other structures.

Ultrasound guided percutaneous drainage may be performed with a single or multiple stage technique.

In the single stage technique, the fluid collection is entered directly with a catheter, typically either 8F or 12F in size.

The multiple step technique utilizes the modified Seldinger technique, whereby the abscess is entered with an introducer needle, through which a stiff wire is passed. The track is then expanded with a dilator or serial dilators, before the catheter is passed over the wire to gain the final position within the abscess. A locking drain is typically used to ensure a secure position.

The catheter is then connected to a vaccum drainage system (for peritoneal or retroperitoneal space collections) or external drainage bags (for draining urinary, digestive and biliary tracts).

Post-procedure care

The patient's basic vital signs should be monitored for 4 hours post procedure (pulse, blood pressure, SpO2), or as long as deemed necessary.

The patient should remain in bed for 2 hours. After this period, mobilization and oral intake are permitted.

The entry site should be reviewed on a daily basis. If output from the collection ceases, it may mean that the collection is no longer present or that the drain is clogged. Re-imaging and/or flushing the drain should be considered before removing the drainage catheter.

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Cases and figures

  • Figure 1: two Seldinger technique
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  • Case 1: perinephric abscess
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  • Figure 2: typical 3 part drainage catheter
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  • Case 2: ultrasound guidance (combined with fluroscopy)
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  • Figure 3: US-guided drainage being performed
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  • Case 3: aspiration from joint
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  • Case 4: appendiceal abscess
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