Drains and Brains

 

The Video Transcript

In this video, we have a drain that is tunneled out through a hole and placed at the bedside with a suction device to pull out fluid. The white drains are barium impregnated, allowing us to see their location. You can observe the drain extending all the way to the tip. Any questions about this case?

One question I had was regarding the number of drains used during the initial cranial plastic procedure. Initially, we did not use any drains. The case went smoothly, and there was no need for a drain. However, I apologize for the confusion. We did put one external drain above the flap to account for oozing from the scalp. I removed that drain in the operating room. But I didn't place a drain underneath because there was no oozing, and drains can also act as conduits for infection. So, we always have to balance the risk of infection. I decided to place a sub galeal drain on top of the flap instead. It's essential to note that the flaps or prosthesis used have holes in them, allowing any slight oozing to come out from the inside to the outside, which can be pulled off by the outer drain. However, in this case, there was an acute clot, so it wasn't going to come through. But thank you for the question.

Someone asked about the duration for which the drains were left in place and the post-op instructions given. The drains are like little grenades that can be squeezed and closed. The negative expansion of the grenade creates a suction effect. Typically, we use half pressure for the grenades, which means half suction, and they are left in place until the drainage is low. Usually, if there are around 10 to 20 CCs every eight hours, the drains can be removed. But if there's a higher amount, like 50 or 60 or 70 CCs, we may leave them in for another day.

I have another question. We often talk about what appears bright on a CT scan. Can drains also appear bright? Absolutely, yes. When we remove a drain, it's important to ensure that everything has come out, so we examine the tip and check for any foreign bodies left behind.

One more question, please. Sure.

Initially, the patient presented as confused, but once you operated, did his mental status return to normal? Yes, he returned to his baseline mental status after the operation. He is awake now, and his left arm is functioning. When I took him to the operating room, he was confused and had weakness in his left arm. However, the following morning after the re-evacuation, he was doing well. So far, there are no permanent neurological deficits. He had some mild left arm weakness from his original subdural, but currently, he is back to his baseline.

It's important to be cautious when performing these procedures, as they are cosmetic in nature. In this case, the patient did not have any serious underlying conditions. He simply wanted to look normal cosmetically, which is a legitimate desire. However, it's crucial to remember that there are risks associated with such procedures. Additionally, it's important to consider the differences between an 85-year-old patient's brain and that of a younger person. The brain of an elderly individual is more compliant, like a saturated sponge. It doesn't fill the space as a younger person's brain would, which can lead to recurrent subdurals in older patients. Fluid can fill up or cause pressure due to the brain's inability to completely fill the space.

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