In Vitro Evaluation of the Capacity and Nonlinear Efficacy Characteristics of Bulb Suction Drains

Index: WOUNDS. 2013;25(1):15–19.

  Abstract: Objective. Bulb suction drains have long been used in various surgical procedures. The purpose of this study was to evaluate 4 commonly used bulb suction devices in vitro to explore the nonlinear changes in draining ability and efficiency along with the conformation changes of the device throughout the draining processes. Methods. Under a designed simulated scenario using pure water as the desired draining substance, the relative function of the J-VAC 100 cc (JV100) (Ethicon, Inc, Somerville, USA); the EVACUATOR 125cc (EP125) (Pacific Hospital Supply, Taiwan); the Bulb Reservoir 150 cc (BH150) (Hosmed, Inc, Miami, FL); and the HemoVac 400 cc (HV400) (Zimmer, Inc, Warsaw, IN) drains were compared. The maximum collection capacities and the dead space at maximum compression of each bulb drain were recorded and compared. The collected fluid weight was recorded along with time, and collection speeds were calculated and compared. Results. The maximum collected weight of the 4 drains were 110.07 ± 0.54 g (JV100), 122.7 ± 06.51 g (EP125), 140.8 ± 03.78 g (BH150), and 335.07 ± 04.24 g (HV400). The dead spaces under maximum compression were 15.63 ± 01.32 ml, 19.80 ± 03.37 ml, 34.23 ± 06.77 ml, and 82.83 ± 05.51 ml, respectively. The collecting speed-volume curves were generated from the authors’ tested devices. Although slightly different individually, typical characteristics, such as tendency to reach maximum collection speed at the very beginning of the collection phase; rapid decline to about 65% of peak collection speed when approximately 30% of the total collection volume had been achieved; and inefficient collection speed in the later collection phase were noted. Conclusions. Among all the bulb drains tested in this study, all of them performed well in vitro. Although using bulb drains continues to be an effective and economic draining method after operation, clinicians should be aware of the nonlinear features of suction efficiency during the drainage process to avoid unexpected function deterioration.

Introduction

  Surgical drains have been routinely used after operations involving deep compartments throughout the human body for many years.¹ Under most circumstances, surgical drains are placed to prevent the accumulation of fluid or air, and help clinicians assess and characterize the nature of the fluid being drained.^2-4 Therefore, the drainage function and its efficiency become crucial in deciding on the proper drain to use.^4,5   In general, surgical drains can be described as open or closed, and active or passive. In this study, the authors focused on simple bulb-like drains that usually were considered to be closed and active. However, the active draining force originates from the conformational recovering forces generated after being squeezed. In most cases, the energy was simply prestored in a compressed material (eg, silicon) or in springs within the device itself.   It is apparent that this force of reconformation or recoiling is not very consistent. Furthermore, the power of suction is also related to the volume expansion effect caused by this inconsistent force. Therefore, taking this complexity into consideration, true suction efficiency is expected and has been proven to be nonlinear.⁶ In this study, the function and active draining efficiency of 4 commonly used bulb devices were evaluated in vitro under a designed, simulated scenario, using pure water as the desired draining substance.

Materials and Methods

  Four suction bulb devices were evaluated in this study including the J-VAC100 cc (JV100) (Ethicon, Inc, Somerville, USA); the EVACUATOR 125cc (EP125) (Pacific Hospital Supply, Taiwan); the Bulb Reservoir 150 cc (BH150) (Hosmed, Inc, Miami, FL); and the HemoVac 400 cc (HV400) (Zimmer, Inc, Warsaw, IN) as shown in Figure 1. All 4 suction bulb devices were acquired for this study from existing stock at the author’s institution.   Reservoir capacity. After full compression and collection of pure water until each reservoir was fully extended, the weight of each reservoir was recorded and compared to the previously recorded dry weight of each reservoir. The maximum capacity of each device was calculated. The reservoir was then filled with water and compressed with 2 hands to its maximum extent. The fluid remaining in the reservoir after compression represented the dead space, and the weight of the fluid was recorded. The measured pure water weight was converted to volume according to density under room temperature (25°C; 0.9968 g/cm³).   Collecting efficiency. A simulated scenario was constructed. Distilled water was kept in an open reservoir and connected to each bulb device through a 50 cm long silicon tube provide by the original manufacturer of the bulb device (external diameter 5.3 mm; internal diameter 3 mm). Since the size and the arrangements of the side-holes are beyond the scope of this study, the distal side-hole section of the silicon tube was removed. A 3-way flow control was also incorporated into the system at the midpoint of the silicon tube. The bulb device was placed at the same level as the water reservoir to eliminate any siphon effect.   Before each test, the connecting tubes were filled up with water and the test bulb devices were compressed to their maximum extent using 2 hands and then placed on an electronic weight scale for measuring. Once the 3-way flow controller was set open, the recording began. The weight-time data was recorded at 5-second intervals until the bulb stopped collecting fluids. The collection speed was calculated according to the weight collected during these intervals.

Results

  Reservoir capacity. As shown in Table 1, the maximum collection capacities of the JV100, EP125, BH150, and HV400 were 110.07 ± 0.54 ml, 122.7 ± 6.51 ml, 140.8 ± 3.78 ml, and 335.07 ± 4.24 ml, respectively; (Table 1) which was the equivalent to about 110%, 98%, 94%, and 84%, respectively, of the original purported volume. The dead space of each bulb device after maximum compression with 2 hands was 15.63 ± 1.32 ml, 19.8 ± 3.37 ml, 34.23 ± 6.77 ml, and 82.83 ± 5.51 ml, respectively, which was the equivalent to 12.70%, 14.25%, 20.02%, and 16.74%, respectively, of the maximum attainable volume after full water filling (Table 2).   Collection efficiency. The collection speed-volume curves are shown in Figure 2. Although each bulb varied slightly, several typical characteristics could be observed: 1) each bulb device demonstrated a tendency to reach maximum collection speed at the very beginning phase of the collection; 2) for 3 of the bulb devices (JV100, EP125, BH150), the collection speed rapidly declined to approximately 65% of the peak collection speed after only 30% of the total collection volume had been achieved; 3) following the rapid declinations, the collection speed of these 3 bulb devices remained constant until it reached close to the end point; 4) for 3 similar bulb devices (JV100, EP125, BH150), as the bulb device got larger, the collection speed increased proportionally, but the tendency of early decay did not change; and 5) the HV400, in which the collection forces are generated by spring compression, possessed a relatively higher collection speed as compared to the other 3 devices and it also seemed to have the ability to sustain suction force in a more stable manner than the other devices.

Discussion

  Indications for drain placement after an operation are first considered with the intention of preventing the accumulation of fluid or air, and to provide a mechanism to collect, measure, and characterize drainage fluid.^2-4 Secondly, the functions of the drainage device as they can help achieve the previously listed goals are considered. In some cases, choosing between a closed-suction drain or an open drain remains controversial; and in some cases no drain at all is required.^7,8 In some rare cases complications have been reported related to active suction drains.⁹ The importance of the correct usage of surgical drains has been addressed in many surgical specialties including the thoracic cavity, the abdomen, joints, spine, genital organs, and the head and neck region.^8,10-15 In this study, the collection capacities of all tested drains were quite close to the volume claimed by the manufacturer. Interestingly, the authors did not observe drain failure patterns, such as ceasing to pull additional volume despite not being fully expanded, as shown in the study by Whitson et al.⁶ While the maximal attainable volume of these bulb drains does increase proportionally according to the size of the bulb, the dead space under maximal compression also increases. This phenomenon is important and implies that as the size of the bulb drain increases, the efficiency of the compression with hands declines. According to the study by Halfacree et al,¹⁶ compression with 2 hands, rather than 1, produces greater suction.¹⁶ The authors found in this study that even when the 2-handed compression technique was always used, the decay of compression efficiency is still apparent along with the increase of the suction bulb size. Further investigation of this phenomenon might be helpful in the future design of suction bulbs in which the factor of “compressibility under human hands” should be taken into consideration.   Another important characteristic to be investigated is that the draining efficiency changes along with the draining processes. Logically, the draining forces gradually decay as the bulb gradually reforms to its original shape. Although this might be true in a compressed-spring model, the conformational restoration of a compressed simple ball-like bulb drain is more complicated. Factors such as the mechanical properties of the bulb materials and the starting shape of the compressed bulb clearly seem to be involved. Throughout this study, the authors found that as the collection volume increased, the HV400, which is a compressed spring-driven suction bulb drain, performed quite predicatively. The collection speed rapidly increased to the peak in the very beginning and then gradually decayed in a linear fashion. As to the other 3 ball-shaped bulb drains, the collecting speed and volume curves are similar to each other but quite different to the HV400. The collection speed of the ball-shaped drains tended to peak in the beginning and decay more rapidly, to about 65% of the peak collecting speed after 30% of the total collecting volume had been achieved. Following the rapid declination phase, the collection speeds tend to stabilize and remain constant until reaching the maximum attainable volume. The characteristics of collection efficiency for these suction bulb drains differed significantly. From these findings, an important and critical question emerged: What is the critical threshold for the collection speed or pressure? Theoretically, bulb drains can mainly fail for 2 reasons: 1) the collection speed is too slow, or the collection pressure is too low to prevent the blood or body fluid from forming a clot that could obliterate the drainage system; and 2) the collection speed is somehow lower than the accumulation speed of blood or body fluids. The critical collection speed needed for the bulb drain might vary according to different body parts and different surgical procedures. Another limitation of this study is that water was used as a collection substrate. And although the tendencies of the collection speed curve might still be similar, in vivo simulations, such as those using plasma or animal studies, should be further investigated. In conclusion, the drainage performance characteristics of the drains, along with the consideration of body parts and surgical procedures, are all important factors for medical practitioners to consider when selecting and using bulb suction drains.

Conclusion

  All of the bulb drains tested in this study performed well in vitro. Although bulb drains remain an effective and economic method of suction after a surgical procedure, it is important for clinicians to be aware of the nonlinear features of suction efficiency during the drainage process, and to avoid unexpected function deteriorations.

References

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