Clinical Guidelines (Nursing)

Pleural and mediastinal drain management after cardiothoracic surgery

    • Introduction

      Drainage of fluid, or evacuation of air, from the pericardial and pleural spaces after cardiothoracic surgery is necessary to prevent effusions, tamponade or pneumothoraces and to also detect hemorrhage. Therefore negative pressure drains are placed in the mediastinum and pleural cavities. The type of drain inserted are closed systems and include:  the Atriumᵀᴹ underwater sealed drain (UWSD) (Atrium Ocean, Atrium Medical, Hudson, USA), the Redon Redivacᵀᴹ drain (PFM Redon system, Mepro, Koln Germany), the Jackson-Prattᵀᴹ drain (Cardinal Health, Waukegan, Illinois) and/or the ConvaTec Minivacᵀᴹ drain (ConvaTec, NewZealand)
       
      NB: Passive drainage systems with an attached collection bag (such as a urine or bile bag) are not used following cardiothoracic surgery.

      Aim

      To provide a description of the types of drains available and to describe the safe and competent nursing management of Redivacᵀᴹ and Jackson-Prattᵀᴹ drains in the post-operative cardiac surgical patient. Management of UWSD can be found in the following link: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/ Definition of terms

      Definition of Terms

      • Cardiac surgical procedures: Please refer to the cardiology intranet site
      • Mediastinum: The region between the pleural sacs, containing the heart and all of the thoracic viscera except the lungs
      • Pleural Cavity: The potential space between the two pleurae (visceral and parietal) of the lungs
      • Pleural Effusion: Increased fluid in the pleural space
      • Pericardial Space: The space between the layers of the pericardium that contains fluid that lubricates the membrane surfaces of the heart and allows easy heart movement
      • Sternotomy: Surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided to provide access to the heart
      • Thoracotomy: Incision into the chest wall either made on the side or under the arm to gain access to the heart for certain cardiac procedures.
      • Tamponade: Is an acute effusion caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise

      The following terms are defined in the Chest Drain Management Clinical Guideline

      • Chylothorax
      • Haemothorax
      • Pneumothorax
      • Tension Pneumothorax
      • Pleural effusion

      Types of Drains inserted in the pleural and mediastinal space

      Children with multiple drains following cardiac surgery will have each drain labelled appropriately, for example a child with 3 drains will have on the tubing or drain itself if the insertion is in the “left pleural”, “right pleural” or “mediastinal” space.

      Atriumᵀᴹ Underwater Seal Drain (UWSD) (Atrium Ocean, Atrium Medical, Hudson, USA) (Figure 1)

      • This is considered a conventional drainage system that is attached to low-pressure wall suction to maintain a negative pressure of between -5cmH20 and -20cmH2O (1.96kPa); unless stated otherwise suction should be applied at all times. (see chest drain management CPG)
      • The tubing is soft silicone, however semi-rigid tubing can be attached to the silicone tubing and inserted into the patient. The drainage system allows collection of fluid up to 2L
      • UWSD is preferred  if a significant drop in mean arterial pressure is a concern which can occur after surgery of single ventricle anomalies
      • Pigtail tubing maybe attached to an UWSD if pneumothorax or pleural effusion develops after cardiac surgery
      • These drainage systems are preferred in situations where there may be an ongoing air leak (eg open chest/delayed sternal closure) or when accurate measurement of losses are required or large volumes of drainage are expected (eg chylothorax)
      • Figure 1. Atriumᵀᴹ Underwater Seal Drain (UWSD)
        Pleural and Mediastinal Drain Figure 1


      Redon Redivacᵀᴹ Drain (PFM Redon system, Mepro, Koln Germany) (Figure 2)

      • This drainage system maintains a consistent high negative pressure of up to 90KPa without the need for wall suction
      • The tubing is semi-rigid and two canister sizes are available which allows a drain capacity of either 200ml or 600ml
      • This high vacuum drain has been found to result in lower incidence of residual pleural and mediastinal effusions requiring drainage, are easier to care for, allow for earlier mobilization of patients and are most cost effective than conventional UWSD.
      • Redivac drains are usually inserted in the superficial mediastinum in neonates or following delayed sternal closure to minimise risk of infection
      • Redivac drain canisters may be changed to UWSD collecting system in particular circumstances such as significant air leak and/or drainage.
      • Figure 2. Redon Redivacᵀᴹ Drain
        Pleural and Mediastinal Drain Figure 2

      Jackson-Prattᵀᴹ Drain (Cardinal Health, Waukegan, Illinois) (Figure 3)

      • This drainage system maintains low negative pressure without the need for wall suction. The soft canister is squeezed to create suction.
      • The tubing inserted into the patient is flat or round and soft, two canister sizes are available which allows a drain capacity of either 100ml or 400ml.
      • Jackson-Pratt drains, if used, are inserted in the mediastinal space in the cardiac transplant patients.
      • The Jackson-Pratt drain maybe changed to a redivac drain as per surgeon’s preference
      • Figure 3. Jackson-Prattᵀᴹ Drain
        Pleural and Mediastinal Drain Figure 3

      ConvaTec Minivacᵀᴹ Drain (ConvaTec, NewZealand) (Figure 4)

      This drainage system maintains low negative pressure without the need for wall suction. The concertina drain is squeezed to create suction

      Minivac drains maybe inserted in the superficial mediastinum in neonates or following delayed sternal closure to minimise risk of infection. The decision for the drain to be redivac or minivac in the mediastinum is as per surgeon’s preference.

      Figure 4. ConvaTec Minivacᵀᴹ Drain
      Pleural and Mediastinal Drain Figure 4

      Patient Group

      The patient group will have undergone cardiac or thoracic surgery and will have had a median sternotomy or thoracotomy wound incision. Patients attending cardiac preadmission clinic will receive the following resource informing parents of the post-operative course, including chest drain management, ward staff should check such information has been received:
      http://www.rch.org.au/uploadedFiles/Main/Content/cardiology/Cardiac_Surgery_Manual_parent_info.pdf

      Management

      Start of shift checks

      • Patient assessment
      • Chest drain assessment

      Patient assessment

      Patient monitoring 

      • Patients in Rosella returning from cardiac theatre should be on continuous cardiac monitoring
        • HR, SaO2, BP, RR
        • A systems approach to assessment is undertaken on admission, then hourly or more frequently if necessary and documented accordingly
      • Patients transferred to the wards undergo a full primary assessment and are assessed 1-4 hourly as indicated by patient condition. 

      Pain and Patient Positioning

      • Chest drains are painful as the parietal pleura is very sensitive. Patients require regular pain relief for comfort and to allow them to ambulate and participate in physiotherapy.
      • Post-operative cardiac patient’s with a chest drain insitu will have a narcotic infusion continued on transfer from Rosella to Koala ward.
      • In addition to assessing patient’s rating of pain, it should also include assessing positions that are comfortable for the child, and ensuring the drains are well secured during movement. 
      • Parents should be encouraged to participate in their child’s activities of daily living such as hygiene and comfort needs (eg: nappy changes and cuddling) but emphasis should be placed on monitoring to ensure the drain is well secured.
      • Patients who are ambulant post operatively will have fewer complications and shorter length of stay
      • Patients on strict bed rest should have regular position changes to promote drainage and prevent pressure areas.

      Drain Insertion Site 

      • Observe for signs of infection, inflammation or pressure sores and document findings
      • Ensure drains are anchored appropriately so as to minimise pressure areas and pulling of drains. Anchoring of drains can be found in the Chest Drain Management Clinical Guideline: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/
      • Check dressing is clean and intact. Dressing should be changed if:
        • No longer dry and intact or signs of infection eg: redness, swelling. Exudate
        • infected drain sites require daily changing or when wet or soiled
        • no evidence for routine dressing change after 3 or 7 days 
      • Observe sutures remain intact and secure. 
      • Redivacs are less likely to be utilised in a long term drainage situation but observe for the erosion of sutures over time.

      Chest Drain Assessment

      Safety Equipment

      • Two chest drain clamps per drain should be readily available, in close proximity to the patient, to use in an emergency such as an accidental disconnection.
      • Note: Drains should not be routinely clamped for transport

      Vacuum

      • The presence of vacuum suction should be assessed hourly and documented on the EMR fluid balance chart
      • Ensure all connections between drainage tube and suction unit are tight and secure
      • Vacuum on the Redivac system
        • The system consists of a solid clear plastic canister, with a green plastic concertina on top to monitor the presence of vacuum pressure. If vacuum pressure is present in the system the concertina is tightly compressed. When suction is lost the concertina is extended.
        • Provided the suction is “on” then there is continuous suction which is facilitating drainage despite the unit and tubing being above or below the patient’s chest level. The higher the negative pressure the greater the vacuum and so it is acceptable for the drain to be above the chest. However, for safety the unit and tubing should be equal to or below the patient’s chest.
        • The black lines on the redivac drain tubing are radiolucent, meaning x-ray can confirm position. Therefore the black lines on the tubing should not be visible outside the patient
      • Vacuum on the Jackson-Pratt system
        • The system consists of a soft clear canister which can be compressed to create suction.
        • The white silicon tube that is placed internally is radiolucent, allowing x-ray to confirm position.

      Drainage

      • Ensure slide clamps on drain tubing are open to allow for drainage
      • Care should be taken to ensure there are no kinks or obstruction of the tubing that may inhibit drainage. Avoid unnecessary loops in tubing.
      • Document hourly the amount of fluid in the drainage chamber on the fluid balance chart. 
        • Calculate and document total hourly output if multiple drains.
        • Calculate and document cumulative total output
      • Notify medical staff if there is sudden increase in the amount of drainage 
        • Greater then 5ml/kg in 1hr
        • Greater then 3ml/kg consistently for 3 hours.
      • Blocked drains are a major concern and Redivac and Jackson-Pratt drains have a smaller internal diameter than a UWSD
      • Notify medical staff if a drain with ongoing losses suddenly stops draining
      • Monitor colour/type of drainage. If there is a change, eg: haemoserous to bright red, or serous to creamy, notify medical staff.

      Specimen Collection

      • The Redivac and Jackson-Pratt drainage tubing cannot be accessed with a needle, it is not self-sealing. 
      • To collect a sample from a redivac the whole canister must be changed and sent to the lab (see below)
      • To collect a sample from a Jackson-Pratt a leur lock syringe can be attached to the port to aspirate a sample (see below)

      Changing the redivac chamber

      • The Redivac chamber needs changing when the chamber is ≥¾ full, when the vacuum is not maintained, or if the sterility of the system has been compromised (i.e accidental disconnection)
      • This procedure should be using a surgical aseptic technique.
      • Equipment:
        • Eye protection
        • New Redivac chamber
        • Dressing pack
        • Sterile gloves
        • Chlorhexidine 0.5% in 70% alcohol
      • Procedure:
        • Prepare patient
        • Don  eye protection to protect eyes from possible body fluid exposure
        • Clean trolley/work surface with detergent and water or impregnated wipe
        • Perform hand hygiene
        • Open dressing pack by using corners to protect aseptic field
        • Peel open sterile equipment and drop onto sterile field, including new redivac chamber on to dressing pack, ensure chamber is clamped and green concertina is compressed
        • Close the clamps on the old bottle and on the drain tubing. This ensures no air can escape back into the patient.
        • Perform hand hygiene
        • Don sterile gloves
        • Disinfect key part connections (attached to old bottle) using gauze soaked in Chlorhexidine 0.5% in 70% alcohol and allow to dry for 30 seconds, dispose of used gauze into waste
        • Remove drain tubing from old bottle
        • Connect tubing to new bottle
        • Release clamp at new bottle
        • Release clamp slowly on drain tubing
        • Check for suction and free flow
        • Discard old bottle, or as ordered obtain specimen to send to pathology
        • Dispose of waste, remove gloves and perform hand hygiene
        • Document change of chamber on Fluid Balance Chart.

      Taking a sample from a Jackson-Pratt Drain

      • This procedure should be using a standard aseptic technique.
      • Equipment:
        • Eye protection
        • One drain clamp
        • Clean tray
        • 10mL leur lock syringe
        • Non-sterile gloves
        • Sterile gauze
        • Chlorhexidine 0.5% in 70% alcohol
        • Eye protection
      • Procedure:
        • Don eye protection to protect eyes from possible body fluid exposure
        • Clean tray
        • Perform hand hygiene
        • Open leur lock syringe and gauze onto tray, leave the equipment in the clear packaging (micro aseptic field)
        • Pour chlorhexidine onto gauze using non touch technique
        • Clamp Jackson-Pratt tubing
        • Perform hand hygiene and don non-sterile gloves
        • Clean the port of the canister with the gauze soaked in chlorhexidine and allow to dry for 30 seconds
        • Once port is dry attach 10mL leur lock syringe and aspirate sample
        • Squeeze the canister and close the port
        • Release the clamp
        • Dispose of waste, remove gloves and perform hand hygiene, clean tray.

      Troubleshooting

      Loss of high vacuum suction on redivac drain

      • If the vacuum is lost, the drain will not function, so the drain tubing must be connected to a new chamber or the vacuum must be reinstated.
      • It is the preference of the cardiology team to connect the drain tubing to a new chamber. Please refer to “Changing the Redivac Chamber” above.

      Converting a redivac to an underwater seal drain (UWSD):

      • It may be necessary to convert the redivac drainage bottle to an UWSD. Incidents where this may be necessary include increased drainage, large pneumothorax causing continuous loss of suction and/or unsuccessful attempts at re-establishing vacuum. 
      • Consultation with the cardiac surgical team must be made prior to converting to an UWSD
      • This procedure should be using a surgical aseptic technique
      • Equipment:
        • Clean trolley
        • Eye protection
        • Two drain clamps 
        • Clear Tube Adaptor – small/large (Code: TA410PP-S)
        • UWSD
        • Sterile towel
        • Sterile dressing pack
        • Sterile scissors or scalpel
        • Sterile gloves
        • Chlorhexidine 0.5% in 70% alcohol
        • Eye glasses
        • Cable ties and cable gun
      • Procedure: 
        • Don eye protection to protect eyes from possible body fluid exposure
        • Clean dressing trolley
        • Perform hand hygiene
        • Onto the trolley open the UWSD and spread open blue wrapping by using corners so it can act as an aseptic field
        • Open sterile dressing pack onto this blue wrapping with UWSD to one side
        • Peel open sterile scissors or scalpel and drop onto aseptic field
        • Peel open sterile towel and drop onto aseptic field
        • Clamp Redivac drain tubing close to patient but below any existing tube connections (the tube inserted into the patient may also be connected to tubing with the redivac bottle, leave these two tubes
          connected and clamp below connection)
        • Perform hand hygiene and don sterile gloves
        • Perform procedure ensuring all key parts are protected
        • Place sterile towel under redivac tubing (Figure 5)
        • With chlorhexidine 0.5% in 70% alcohol and disinfect the area 5cm above and below the key part tubing site you will cut and allow to dry for 30 seconds
        • Cut the Redivac tubing using scissors or scalpel.
        • This tubing with redivac drain will be thrown away or as ordered sample collected and sent to pathology 
        • Insert the thin end of Clear Tube Adaptor into tubing as far as possible (this is a tight fit) (Figure 6)
        • There is a connector attached to the UWSD – cut this off
        • Insert the other end of the Clear Tube Adaptor into the tube of the UWSD (Figure 7)
        • With cable ties and cable gun (Figure 8a), cable tie over connections (Figure 8b)
        • Ensure suction is on UWSD as per order, thn remove drain clamps from tubing.
        • Refer to the following guideline to manage UWSD:  http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/

      Figure 5

       Pleural and Mediastinal Drain Figure 5

      Figure 6

      Pleural and Mediastinal Drain Figure 6

      Figure 7

      Pleural and Mediastinal Drain Figure 7

       Figure 8a

      Pleural and Mediastinal Drain Figure 8a

      Figure 8b

      Pleural and Mediastinal Drain Figure 8b


      Removal of redivac drain

      • Medical documentation is required in EPIC by the cardiac team for the removal of a chest drain
        Prior to removal of the drain, clamp tubing as the drain must not be removed under suction
      • Consider pain management
      • Perform hand hygiene
      • Removal of Redivac and post-procedure care follows the same steps as removal of UWSD: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/
      • Inspect end of drain in order to ensure entire drainage tube has been removed. Jagged or torn appearance could be signs of the tube fracturing.
      • If this is the concern contact the cardiac surgical fellow and treating team, a chest x-ray should be performed immediately once ordered by the surgical fellow, the patient should be kept nil by mouth in anticipation for surgical removal of the tube that has been left in the patient, 
        keep the whole redivac unit in the patient’s room until surgical review and collection for quality review. 
      • A VHIMS must be completed by the nurse delegated to remove the drain.
      • For further information on managing missing or non intact drains refer to the following link: https://www.rch.org.au/policy/policies/Surgical_Wounds_-_Procedure_for_Missing_or_Non_Intact_Drains/
      • Staff involved in reinserting the drain on the ward or surgical staff involved in removing the retained drain tube please see the following guideline: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/

      Futher complications and troubleshooting

      Refer to the following guideline: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/

      Special Considerations

      • A VHIMS report should be made for any adverse events such as accidental disconnection or piece of tubing left in during removal of drain

      Documentation 

      • The presence of vacuum suction should be assessed hourly and documented on the EMR fluid balance chart
      • Document hourly in the fluid balance chart the amount of fluid in each drainage chamber 
      • Each shift observe key sites for signs of infection, inflammation or pressure sores and document findings in EMR-> LDA
      • Document change of drain site dressings 
      • Document change of chamber on Fluid Balance Chart
      • Document when drain sutures need to come out post drain removal to prevent risk of embedded suture or infection, usually sutures are removed 5 days post drain removal.

      Links

      Evidence Table 

      Evidence Table: Pleural and Mediastinal Drain Management after Cardiothoracic Surgery

      References

      • Agati, S; Mignosa, C; Gitto, P; Santo Trimarchi, E et al (2006). A method for chest drainage after pediatric cardiac surgery: A prospective randomized trial. The Journal of Thoracic and Cardiovascular Surgery, 131 (6); 1306-1309.
      • Berg, H; Brands WG; Van Geldorp TR; Kluytmans-VandenBergh FQ; Kluytmans JA. (2000). Comparison between closed drainage techniques for the treatment of postoperative mediastinitis. The Annals of Thoracic Surgery. 70; 924-929.
      • Durai, R, and Philip, C. (2010). Surgical Vacuum Drains: Types, uses and complications. AORN. 91 (2); 266-271.
      • Meyerson, J.M (2016). A Brief History of Two Common Surgical Drains. Annals of Plastic Surgery, 77 (1); 4-5.
      • Newcomb, A; Alphonso N; Norgaard M; Cochrane A; Karl T; Brizard C. (2005) High-vacuum drains rival conventional underwater-seal drains after pediatric heart surgery. European Journal of Cardiothoracic Surgery. 27:395-400
      • Paddle, A; Elahi, M and Newcomb, A (2010). Retained foreign body following pleural drainage with a small-bore catheter. General Thoracic Cardiovascular Surgery, 58: 42-44.
      • Salvatore, A; Mignosa, C; Gitto, P; Santo Trimachi, E; Ciccarello, G; Salvo, D; Trimarchi, G (2006). A method for chest drainage after pediatric cardiac surgery: A prospective randomized trial. The Journal of Thoracic and Cardiovascular Surgery, 131(6): 1306-1309
      • Shalli, S; Saeed, D; Kiyotaka, F; Gillinov, A.M; Cohen, W.E; Perrault, L.P; Boyle, E.M (2009). Journal of Cardiac Surgery, 24: 503-509
        Pfm medical Redon Drains – Low Vacuum and High Vacuum Drainage. www.pfmmedical.com


      Please remember to read the disclaimer.


      The development of this nursing guideline was coordinated by Annabelle Santos, CSN, Koala, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2017.