Surgical drains are catheters placed near the surgical wound to remove blood, pus, or other fluid and prevent it from accumulating in the body. They are active drains that maintain a negative pressure gradient. The collection reservoir of an active drain collects fluid by exchanging negative pressure, and the drain may become ineffective if the vacuum is lost. The activity describes suction drains and highlights the role of the interprofessional team in the care of drain.
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Suction drains are appliances used to collect blood, pus, or body fluids. They are active drains that maintain a negative pressure gradient. The collection reservoir of an active drain collects fluid by exchanging negative pressure, and the drain may become ineffective if the vacuum is lost. The type of drainage system is based on the needs of a patient, type of surgery, type of wound, expected amount of drainage, and surgeon preference. [1]
Two commonly used suction drains are a low negative pressure bulb vacuum used to drain small amounts of fluid and a high negative pressure bottle drain used for more significant draining amounts of fluid. Its compressed green nozzle ascertains the negative pressure on the bottle. [2]
How to Insert a Drain Catheter
The drain catheter has a sharp end (trocar) to go through the skin and has multiple perforations on another end for fluid to come through. It is important to know anatomy while inserting the drain to avoid puncturing vital structures such as vessels or nerves. Insert the drain with trocar piercing under the skin with counterpressure applied above the skin surface. Pull it through the skin and insert the safety rubber on the pointed end of the trocar to avoid accidental injury. Pull the catheter till all holes are just inside and trim the perforated catheter to the length needed.
Securing the Drain Catheter with Suture
Skin suture is taken near the drain site, and a loose square knot is applied (i.e., hanging knot). Then come around the drain catheter to tie a double knot, and this can be repeated several times with throw behind and front of the catheter.[3]
Securing Drain in the Microvascular Procedure
The drain catheter should avoid crossing over vascular repair site. Before securing the drain as described above, one or two additional sutures were applied to immobilize the drain catheter placed inside a flap. The additional suture passed through the skin through the nearest catheter hole and then back through the skin, where a loose knot is fashioned on the skin side. This method of securing avoids displacement of the drain. The nursing staff must be shown where the anchoring suture has been placed for extra care.[4][5]
Completing the Circuit
The catheter trocar is cut and attached to a clamped plastic tubing accompanied by a drain. The other end of plastic tubing is connected to the provided reservoir, a bulb in the low-pressure drain, and a negative pressure bottle in the high-pressure drain. Once the skin wound is closed, and the dressing is done, clamp-on plastic tubing is released.
Monitor Drainage
The reservoir collects blood immediately after surgery. The collections gradually become less red over time. The fluid then becomes yellow with occasional blood clots. The surgeon has to be informed if the reservoir fluid suddenly changes to blood with clots or becomes milky white.
Milking the Drain Tube
Milking prevents clogging of the tube. Before milking, perform hand hygiene with soap and water. First, hold the tube at the skin insertion site with the non-dominant hand. Then milk the tube with the dominant hand by gently squeezing between thumb and index finger and moving along the reservoir. Hand sanitizer or alcohol rub can be used for smooth gliding along the tube. The fluid should run along the tube with the finger into the reservoir. It is not necessary to remove all fluid from the tube during milking but remove as much as possible. The tube needs to be milked twice a day for each drain. If milking of the tube does not restore flow, inform the surgeon, it probably means obstruction of the tube inside the body. Do not disconnect, puncture, or kink the drain tubing.
Removing Collection From Low-Pressure Bulb
The bulb is emptied at least three times per day or whenever the bulb is more than 50% full. The drain care needs to be sterile, and the hands must be washed thoroughly with soap and water. Unplug the stopper from the emptying port located at the top of the bulb. Turn the reservoir upside down over the measuring cup. Gently squeeze all fluid from the bulb into a measuring cup. Enter the chart date, time, and volume collected in a measuring cup. Discard the fluid in the measuring cup in a basin or toilet. Caution: Never disconnect drain tubing from the bulb.
Creating Negative Pressure in Low-Pressure Bulb
First, wipe the port opening with an alcohol swab to clean it. Next, gently squeeze the bulb by hand and flatten it as much as possible. With a flattened bulb, plug the stopper into an emptying port as far as possible. Release the bulb and check the bulb is flattened. The bulb expands slowly as the fluid gets filled inside. Constant suction generated by the bulb pulls collected fluid out of the body. Use a plastic tag on the bulb secure to clothing or belt so that bulb lies below the drain insertion site for better drainage.
Changing High-Pressure Reservoir
Change the high-pressure bottle once it is half-full or when the vacuum has weakened as indicated by an expanded nozzle. Before beginning to change the bottle, perform proper hand hygiene by washing with soap water or using hand sanitizer. Ensure that the new high-pressure bottle has been clamped and has a compressed nozzle. Lock both clamps on the bottle planned to be removed. Clean around the connector with an alcohol swab and unscrew the connector to detach the tubing from the bottle. Clean the tube connector with a new alcohol swab. Attach the new bottle without touching the connector. Finally, release both clamps of the new bottle. Measurement is done by keeping the drain on a flat surface, preferably at the same time each day. Observe the fluid reading at eye level and draw a line on a white label, and indicate the date of measurement. Document drainage amount on the given chart.[6]
Care of Drain Insertion Site
It is normal to have little swelling and tenderness at the drain insertion site for a few days. The patient can take a shower 48 hours after surgery in most cases. During the shower, allow the soapy water to flow on the drain site. Pat the skin area with a clean towel and allow it to dry for a few minutes. If unable to shower, clean the drain site with soap and water towel at least once a day. Before cleaning the drain insertion site, perform hand hygiene with soap and water.
The dressing at the insertion site is changed daily. The dressing is usually removed before a shower and after the shower check for signs of infection. Then a new dressing is applied. The conventional method of dressing is to keep a folded gauze below the drain site and secure it with adhesive tape. Another folded gauze is placed above the drain site and secured with adhesive tape.
Look for signs of infection at the drain insertion site like pain, increasing swelling, redness, pus discharge, foul-smelling discharge, or systemic signs like fever. If any of the signs are present, inform the surgeon.
Removal of Drain
Routine practice is to measure the drainage every 24 hours and remove the drain when daily drainage falls below 30 ml/day for two consecutive days.[7] Before cutting suture, do a final milking procedure to check for residual collections. The tube then clamped, and the suture holding the catheter is cut. The catheter is slowly pulled out, and any clots attached to the perforated end of the catheter are gently removed.
Dressing after Drain Removal
After the drain is removed, a folded gauze is applied to the puncture skin hole on the drain site and secured with adhesive tape. The dressing can be removed after 24 hours, and the patient may ask to shower. The further dressing is usually not advised, and an antibiotic ointment may be given twice daily application for a week.
Drains systems are a common feature of post-operative surgical management and are used to remove drainage from a wound bed to prevent infection and the delay of wound healing. A drain may be superficial to the skin or deep in an organ, duct, or a cavity such as a hematoma. The number of drains depends on the extent and type of surgery. A closed system uses a vacuum system to withdraw fluids and collects the drainage into a reservoir. Closed systems must be emptied and measured at least once every shift and cleaned using sterile technique according to agency protocol.
Drainage tubes consist of silastic tubes with perforations to allow fluid to drain from the surgical wound site, or separate puncture holes close to the surgical area. The drainage is collected in a closed sterile collection system/reservoir (Hemovac or Jackson-Pratt) or an open system that deposits the drainage on a sterile dressing. Drainage may vary depending on location and type of surgery. A Hemovac drain (see Figure 4.3) can hold up to 500 ml of drainage. A Jackson-Pratt (JP) drain (see Figure 4.4) is usually used for smaller amounts of drainage (25 to 50 ml). Drains are usually sutured to the skin to prevent accidental removal. The drainage site is covered with a sterile dressing and should be checked periodically to ensure the drain is functioning effectively and that no leaking is occurring.
Checklist 39 outlines the steps to take when emptying a closed wound drainage system.
Checklist 39: Emptying a Closed Wound Drainage SystemDisclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:
Check room for additional precautions
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Introduce yourself to patient.
Confirm patient ID using two patient identifiers (e.g., name and date of birth).
Explain process to patient and offer analgesia, bathroom etc.
Listen and attend to patient cues.
Ensure patient’s privacy and dignity.
Maintain the plug’s sterility.
The vacuum will be broken and the reservoir (drainage collection system) will expand.
5. Gently tilt the opening of the reservoir toward the measuring container and pour out the drainage. Pour away from yourself to prevent exposure to body fluids. 6. Place drainage container on bed or hard surface, tilt away from your face, and compress the drain to flatten it with one hand.With the other hand, swab the surface of the port, then insert the plug to close the drainage system.
Gently squeezing the drain to flatten and remove all the air prior to closing the spout will establish the vacuum system. 7. Place the plug back into the pour spout of the drainage system, maintaining sterility. This establishes vacuum suction for drainage system. 8. Secure device onto patient’s gown using a safety pin; check patency and placement of tube.Ensure that enough slack is present in tubing, and that reservoir hangs lower than the wound.
Proper placement of the reservoir allows gravity to facilitate wound drainage. Providing enough slack to accommodate patient movement prevents tension of the drainage system and pulling on the tubing and insertion site. 9. Note character of drainage: colour, consistency, odour, amount.Discard drainage according to agency policy.
Drainage counts as patient fluid output and must be documented on patient chart as per hospital protocol.Monitor drains frequently in the post-operative period to reduce the weight of the reservoir and to monitor drainage.
10. Remove gloves and perform hand hygiene. Hand hygiene must be performed after removing gloves. Gloves are not puncture-proof or leak-proof, and hands may become contaminated when gloves are removed.11. Document procedure and findings according to agency policy.
Report any unusual findings or concerns to the appropriate health care professional.
This allows for an accurate recording of drainage.Record the number the drains if there is more than one, and record each one separately.
If the amount of drainage increases or changes, notify the appropriate health care provider according to agency policy.
If amount of drainage significantly decreases, the drain may be ready to be assessed and removed.
Data source: BCIT, 2010b; Perry et al., 2014Removal of a drain must be ordered by the physician or NP. A drain is usually in place for 24 to 48 hours, and removal depends on the amount of drainage over the last 24 hours.
Checklist 40 outlines the steps for removing a wound drainage system.
Checklist 40: Drain RemovalDisclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:
Check room for additional precautions
Introduce yourself to patient.
Confirm patient ID using two patient identifiers (e.g., name and date of birth).
Explain process to patient and offer analgesia, bathroom, etc.
Listen and attend to patient cues.
Ensure patient’s privacy and dignity.
Assess ABCCS/suction/oxygen/safety
Analgesia provides comfort and achieves the goal of an acceptable pain level for the procedure.
3. Assemble supplies at patient’s bedside: dressing tray, sterile suture scissors or a sterile blade, cleansing solution, extra gauze, tape, garbage bag. Organizing supplies helps the procedure occur as efficiently as possible for the patient. 4. Apply a waterproof drape/pad for depositing the drain once it has been removed. This provides a place to put the drain once it is removed. 5. Perform hand hygiene. Hand hygiene reduces the risk of infection. 6. Apply non-sterile gloves and face shield according to agency policy. Personal protective equipment reduces the potential for accidental exposure to blood or body fluids. 7. Release suction on reservoir and empty; measure and record drainage if >10 ml. Releasing suction reduces potential for tissue damage as drain is removed. 8. Remove tape and dressing from drain insertion site. Remove tape to allow for ease of drain removal. 9. Cleanse site according to simple dressing change procedure. This step prevents infection of the site and allows the suture to be easily seen for removal. 10. Carefully cut and remove suture anchoring drain with sterile suture scissors or a sterile blade.Snip beneath the suture knot to ensure contaminated suture is not brought into the tissue. Pull suture out. Snip or cut knot away from yourself.
11. Stabilize skin with non-dominant hand. Applying counterpressure to skin near the drain decreases discomfort to patient. 12. Ask patient to take a deep breath and exhale slowly; remove the drain as the patient exhales. This step helps the patient prepare for removal of the drain. 13. Firmly grasp drainage tube close to skin with dominant hand, and with a swift and steady motion withdraw the drain and place it on the waterproof drape/pad (other hand should stabilize skin with 4 x 4 sterile gauze around drain site). Slight resistance may be felt.If there is strong resistance, stop, cover site, and call physician.
Ensure the drainage tip is intact. The end of the drainage tip should be smooth. Some agencies require that the tip be sent for lab analysis for microorganisms.
When pulling out drain, gather up the drain tubing in your hand as it’s being removed.
14. Place drain and tube on waterproof pad or in garbage bag to be disposed of after procedure is complete. This step prevents the drain and tube from contaminating bed or floor. 15. Remove gloves and apply new non-sterile gloves. This prevents contamination of the drain site. 16. Cleanse old drain site using aseptic technique according to simple dressing change procedure. This step prevents contamination of the drain site. 17. Cover drain site with sterile dressing. 18 Assist patient back to comfortable position and lower bed. This ensures patient safety and comfort after the procedure. 19. Discard drain in biohazard waste as per hospital policy. This prevents the spread of microorganisms. 20. Perform hand hygiene. Hand hygiene prevents the spread of infection. 21. Document output and drain removal. Record drainage according to agency policy. 22. Assess dressing 30 minutes after drain removal. Monitor for excessive drainage from the drainage site. 23. Document procedure and findings according to agency policy.Report any unusual findings or concerns to the appropriate health care professional.
Accurate and timely documentation and reporting promote patient safety. Data source: BCIT, 2010b; Perry et al., 2014; Saskatoon Health Region, 2012Critical Thinking Exercises
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