Principles of Surgical Drain Management

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Principles of Surgical Drain Management

• James H. Paxton, MD MBA
• Ilan Rubinfeld, MD MBA FACS

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Overview

• Indications for Surgical Drains

• Types of Surgical Drains

• Daily Maintenance

• Drain Removal
• Timing
• Preparation
• Methods

• Potential Complications

• Patient Follow-Up / Summary

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Drain Indications

• Drains are used to monitor surgical sites and
  remove accumulated bodily fluids (pus, blood,
  lymph, bile etc) or air from a body cavity,
  wound, or potential space
• Post-Surgical (e.g., Jackson-Pratt)
• Emergent Decompression (e.g., chest tube)
• Definitive Therapy (e.g., percutaneous drainage)
• Medication Delivery (e.g., lavage, antibiotics)
• The use of post-operative drains is declining,
  but they are still often indicated

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Technical Considerations

• Choice of drain depends upon intended use,
  location, and urgency of need
• Example Jackson-Pratt Drain
• Can be used to monitor an anastomosis (check for
  leak), drain a known / anticipated fluid
  collection, or prevent fluid accumulation in a
  post-operative bed
• Tubing may be round or flat
• May be attached to bulb suction or wall suction
• May be cut, but should not be cut on side hole
• Should be cut sharply at an angle, to distinguish
  from fragmented catheter

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Categories by Position

• Superficial
• Soft tissue abscess or seroma
• Under skin flaps, or over Alloderm
• Deep
• Intraperitoneal (e.g., covering anastomosis)
• Hollow Organ / Duct (e.g., biliary T-tube)
• Deep Cavity (e.g., abscess or hematoma)
• Potential Space (e.g., chest tube)
• Abnormal Channel (e.g., fistula)

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Types of Surgical Drains

• Open System
• Drains into a dressing or bag open to air
• e.g., Penrose, Sump, Corrugated Rubber
• Closed System
• Drains into sterilized airtight tubing and
  container
• Involves vacuum-generating device
• Must release vacuum prior to drain removal
• Generally less prone to infection

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Types of Surgical Drains

• CLOSED SYSTEM
• Davol
• Jackson-Pratt
• RediVac / Exudrain
• HemoVac / BaroVac
• Pigtail Drain
• T-tube Drain
• Blake Drain

• OPEN SYSTEM
• Penrose Drain
• Sump Drain

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Anatomy of a Closed System

• Tubing (PVC / Silicon)
• Radiopaque May be siliconized for free flow
• Anti-Reflux Valve
• Rubber valve
• Water Seal (e.g., Chest Tube)
• Drainage Reservoir
• Suction-Generating Device (e.g., bulb or
  spring-loaded device)
• Drain Plug (Vacuum Release)

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Penrose Drain

• Soft, rubber / silicone tube placed in wound to
  prevent closure and facilitate drainage
• Open system (drains into dressings)

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Penrose Drain

• Usually superficial drain
• Remove with gentle traction, unidirectional
• End should appear sharply cut
• If any portion appears torn or degraded, can use
  X-ray of wound to rule out retained drain portion

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Davol / Jackson-Pratt

• Portable, closed drainage system
• Oval-shaped grenade suction device
• To establish suction, must pull plug, squeeze
  bulb, then replace plug
• Bulb should initially be concave
• Suction (100 ml) 80 - 170 mmHg
• Can be flat or round
• Round may be more dependable due to less
  transition of material

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Sump Drains

• Sump drains contain a large central lumen (for
  drainage), with one or more high-flow sump lumens
  (for irrigation)

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Suction Drain Removal

• Release suction prior to removal
• Remove with gentle traction, unidirectional
• Tip should appear to have been sharply cut
• If any portion appears torn or degraded, further
  investigation is warranted to rule out fracture
• More likely to tear at regions of
  weakness (e.g., side holes)
• Never cut drainage catheters through
  side holes, as this is more easily
  mistaken for catheter fracture

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Pigtail Drain

• Placed percutaneously, rarely cut
• Tension on central wire causes pigtail form
  (released when wire is broken)
• Small-caliber drains, with 4-5 holes at end

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Pigtail Drain - Removal

• Be sure to unscrew cap and break central wire
  (releasing pigtail) prior to catheter removal
• Examine end of catheter
• Should not be cut or torn
• If in doubt, obtain x-ray of
  area (or CT Scan) to rule out
  retained drain fragment

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T-Tube Drain

• Placed for biliary drainage (open vs. lap)
• Straight when inserted, T-portion released once
  placed in Common Bile Duct (CBD)
• T-piece is secured in the biliary tree and
  external portion is sutured to the skin
• Require cholangiogram prior to removal to clear
  biliary tree and confirm duct patency
• Not generally removed at bedside

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T-Tube Drain
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T-Tube Drain Removal

• Usually clamped 24 hrs before removal
• Balloon dilatation (in selected units) may be
  performed prior to removal, to separate from
  fibrous sheath
• Complications of T-tube Removal
• Bile leak (1-19)
• Peritonitis
• Failure to remove with manual traction (lt1)
• Catheter fracture (breakage)

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Blake Drain

• White, radiopaque silicone or Teflon drain with
  four 2-mm channels along the sides, surrounding a
  solid core center
• Drains fluid by capillary action
• Does not have side holes, therefore less risk of
  catheter fracture at weak points
• Apt to clog where the channels converge near the
  tip, known as the choke point

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Blake Drain
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Splittable Drain Systems

• Produced by Jackson-Pratt and other leading
  manufacturers
• Increased potential for retained drain segments

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Daily Maintenance

• Surgical drains should be inspected daily
• Daily progress notes should document
• Type of drain (e.g., JP, Penrose etc)
• Amount of drain output (in milliliters)
• Quality of drain output (color, consistency etc)
  
• Drain problems (e.g., loss of suction, torn
  anchoring suture, drain dislodgement etc)
• Appearance of wound (e.g., erythema, discharge or
  drainage, maceration etc)

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Daily Maintenance

• Drains should be kept clean and dry
• To prevent stagnation, with associated clogging
  or reflux wound contamination, good flow should
  be promoted by
• Removing visible clots or tube obstructions, with
  gentle massage or stripping as needed
• Maintaining adequate suction at all times (e.g.,
  keeping suction bulb compressed)
• Excess tubing should be taped / secured to the
  patient or patients dressings

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Drain Stripping

• Causes a transient elevation in intraluminal
  pressure (20 - 95 mmHg)
• This elevation in pressure can be dangerous,
  especially with mediastinal chest tubes (risk of
  pneumothorax)
• Stripping does not significantly increase amount
  of drainage obtained from tubing
• Gentle massage of clotted areas preferred
• Fibrinolytics (e.g., urokinase) may be used

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Daily Maintenance

• Drainage bulbs (collection reservoirs) should be
  emptied on a regularly scheduled basis (e.g.,
  every shift)
• When emptying drainage bulb, take care to avoid
  introducing bacteria or foreign materials to the
  closed drainage system (risk infection)
• Never re-advance a drain that has become
  dislodged (risk infection)

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Timing of Drain Removal

• Drains are removed when they are no longer
  needed! (e.g., output lt 50 ml / day for JP drain)
• Extended duration of drainage may be indicated in
  some patients, up to several weeks!
• General Guidelines
• Peri-Op Hematoma / Bleeding 24-48 hrs
• Serous Collections 3-5 days
• Infection Prevention 1-5 days
• Intestinal Anastomosis 5-7 days
• T-Tube Removal 6-10 days

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Preparation for Drain Removal

• Know your drain! (type, placement, length)
• Review operative notes, talk to surgeon etc
• Inspect drain externally, look for visible breaks
• Examine radiographic evidence (x-rays, CT)
• Know your patient!
• Examine wound, look for evidence of infection,
  fluid collections / drainage
• Is it time for the drain to come out?
• Occlusion? Medically-indicated?

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Preparation for Drain Removal

• Gather your tools!
• Sterile scissors, Skin sterilizing Agent (e.g.,
  DuraPrep)
• Gloves, Sterile Gauze, Tape
• Petrolatum Gauze (if indicated)
• Pick your position!
• Make patient comfortable (supine / in bed)
• Clear obstacles to removal (dressings etc)
• Avoid making a mess keep the nurses happy!
• Discuss plans for removal with patient and nurse
• Pain medication is rarely needed

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Steps in Drain Removal

• Before attempting drain removal, be sure to
  review the patients operative note
• Pay particular attention to the number of drains,
  type of drain, location of drain, and indications
  for drain
• If unsure, ask the surgeon!
• Inspect the external portion of the drain system
  for breaks or damage
• Inspect the wound for evidence of infection

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Steps in Drain Removal

• Remove all dressings covering insertion site, and
  examine wound / patient for signs of infection

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Steps in Drain Removal

• Remove items securing drain in place (e.g.,
  suture, staples, tape), and release suction

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Steps in Drain Removal

• Apply unidirectional traction on the catheter,
  while applying counter-traction to patient

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Steps in Drain Removal

• Examine tip of drainage catheter for
  irregularities or other evidence of breakage

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Steps in Drain Removal

• Cover wound with secure, sterile dressings
• Always perform serial exams of the insertion site

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Anesthesia for Drain Removal

• General anesthesia is seldom indicated
• I.V. pain medication is required in some
  instances depending on drain depth and location
• Local anesthesia (e.g., 10-ml 1 Lidocaine) may
  be helpful
• Pain is due to pressure on nerve fibers in skin
  and underlying innervated structures
• Always sterilize skin prior to needle puncture to
  reduce risk of infection

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Complications of Drain Placement

• Immediate Complications
• Pain, Bleeding, Perforation or injury to adjacent
  structures
• Early Complications
• Occlusion, Leakage around drain, Displacement,
  Infection
• Late Complications
• Pressure / Suction necrosis of bowel or blood
  vessels
• Fistula formation

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Complications of Drain Removal

• Pain
• Drainage from insertion site
• Infection (e.g., cellulitis, abscess)
• Fluid collections (e.g., seroma, hematoma)
• Injury to adjacent structures
• Retained or fragmented catheter

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Managing Retained Drains

• Inform patient and team of the event
• Confirm device retention with appropriate
  radiographic tests (e.g., x-ray, CT scan)
• Antibiotics may be needed to prevent infection
  while removal is planned
• Do not discard portion of device removed
• Needed for FDA reporting
• Discuss event with risk management team

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Patient Follow-Up

• Serial Exams
• Examine wound for evidence of infection
• Examine patient for tachycardia, fever, systemic
  signs of infection
• Monitor Labs
• Unexplained leukocytosis / leukopenia
• Antibiotics used only if signs of infection
• Monitor pain medication usage

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Patient Follow-Up

• Educate patients on signs of infection, with
  instructions to return if they experience
• Persistent fever gt 100.5 F
• Sweats, chills, nausea, vomiting, diarrhea
• Redness, foul-smelling drainage from wound
• Marked or sudden increase in pain at site
• Foreign body in wound
• Let patient know it is normal to have some
  serosanguinous drainage from the wound

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Summary

• Drains should be removed by the person who placed
  them or someone familiar with the patients
  operation (i.e., who has read the operative note)
• Know your patient!
• Is the insertion site infected? Leaking?
• Why was the drain placed initially?
• Is it time to remove it?
• Know your drain!
• How many drains are there?
• What should the tip look like?
• How long should the drain catheter be?
• Do I need to disconnect or deflate anything?

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Summary

• If indicated, drains should be cut sharply and
  not cut through a side hole
• Know your complications!
• Serial examinations are important
• Identify complications early
• If you believe that the drainage catheter may
  have fractured, advise your team (senior
  resident, attending) first, and plan your
  investigation (x-ray, CT scan etc) together
• Talk to your patient (and your team)!
• Communication is the key to identifying and
  preventing problems with drain removal

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Acknowledgements

• Special thanks to the following individuals for
  their assistance in the preparation of this
  educational slideshow
• Deb Flowers, PA-C
• Barbara Joyce, PhD
• Beverly Mihalko, PhD
• Vinod Narra, MD
• Karen Ruwoldt, ACSW
• Ranjodh Singh, MD