Clinical Guidelines (Nursing)

Surgical Drains (Non Cardiac)

  • Introduction 

    Aim

    Definition of Terms

    Assessment

    Troubleshooting

    Removal

    Evidence Table

    References


    Introduction

    Surgical drains are tubes placed near surgical incisions in the post-operative patient, to remove pus, blood or other fluid, preventing it from accumulating in the body. The type of drainage system inserted is based on the needs of patient, type of surgery, type of wound, how much drainage is expected and surgeon preference.  

    Aim

    This guideline is designed to ensure a standard approach to care and management of surgical drains (as listed below) through evidence based practice. 

    Note:This guideline does not relate to the care and management of Chest Drains (UWSD), for further information on these drains please follow this link to Chest Drain Management Nursing Guideline.  

      Definition of Terms

      • Jackson-Pratt™ – a soft pliable tube with multiple perforations with a bulb that can recreate low negative pressure vacuum, designed so that body tissues are not sucked into the tube, decreasing risk of bowel perforation
      • Redivac™ – a high negative pressure drain
      • Pigtail™– Small lumen with a coil in the shape of pigtail, used for draining a single cavity, passive drains, easily blocked, patency can be maintained by flushing 1-2 times daily. Self retaining (no suture). Please see note regarding removal of these drains.
      • Penrose™– flat ribbon-like drain, gauze is applied to external end to absorb drainage, can be colonized by bacteria if left in situ for an extended period of time

        Assessment

        Initial

        Assess drain insertion site for signs of leakage, redness or signs of ooze. Document site condition and notify treating team and AUM if any concerns.
        Assess if drain is secured with suture or tape, document.
        Assess patency of drain. Ensure drain is located below the insertion site and free from kinks or knots. Note and document amount and type of fluid in drain bottle/receptacle.

        If additional suction/wall suction is required for a Redivac™, treating team must document amount of suction needed and expected output in the patients progress notes.

        Ongoing


        Monitor patient for signs of sepsis; if the patient is febrile, has redness, tenderness or increased ooze at the drain site, this could be a sign of infection, the treating team must be notified and blood cultures may need to be obtained.

        Drain patency and insertion site should be observed at the beginning of your shift and before and after moving a patient. If applicable, ensure suction is maintained. A blocked drain tube can lead to formation of haematoma and increased pain and risk of infection.

        Drainage needs to be documented at a minimum 4 hourly and more frequently if output is high.

        Drains should be removed as soon as practicable, the longer a drain remains in situ, the higher risk of infection as well as development of granulation tissue around the drain site, causing increased pain and trauma upon removal.

        Pain Assessments should be completed and documented at regular intervals whilst drain is insitu. Appropriate analgesia should be provided when necessary. Please refer to the pain assessment and management guideline for more information. 

        Investigations

        If suspecting infection, notify treating medical team and obtain a swab of the insertion site or sample of any ooze for pathological investigation.


        Education

        Educate patient/parent to ensure the drain is below the site of insertion but not pulling on the patient. Educate the patient/parent that there is a risk of dislodgement, requiring increased care when moving. Patient should be aware that moving whilst drain is in situ will cause some pain, but this can be minimised with regular analgesia and the patient should be encouraged to mobilise with supervision when appropriate.

        Troubleshooting

        Reinstating Suction

        Should suction be lost when using vacuum drainage systems (i.e. Redivac), the treating doctor should be notified.
        If suction is to be reapplied, ensure “standard aseptic technique” is utilised, please refer the Aseptic Technique Policy for more information: 

        1. Attach a Yankauer™ suction catheter to suction and turn it on
        2. Clamp the drain tubing closest to the patient, using forceps/clamps
        3. Disconnect tubing from the drain bottle
        4. Hold Yankauer™ suction catheter tight against the plastic attachment of the vacuum bottle, until an adequate vacuum pressure is achieved
        5. Clamp the drainage device and reattach to the drain
        6. Then unclamp/remove forceps from drain tubing.

        Moving a patient with a drain tube

        Assess the patient and all drains and attachment sites prior to mobilising, ensuring drains are secured and will not dislodge/pull on patient. 

        When appropriate, patient mobilisation with a drain should be encouraged to reduce risk of DVT.

        Reassess drains post mobilising to ensure dislodgement of drains has not occurred.

        At all times, ensure drainage tube is not entangled with other leads (IV tubing, O2 leads, etc) as this could lead to inadvertent removal of the tube.


        Leakage

        If leakage occurs at a surgical drain site, please notify the AUM and treating team and consider the following:

        • Reinforcing or retaping the surgical drain dressing
        • Placing a Coloplast™ drainage bag (2245) over the surgical drain tubing
        • Review the wound care nursing guideline for further information
        • Refer patient to Stomal Therapy for further input if necessary

        Blockage

        If drainage is minimal, ensure the drain is not blocked, if blocked, notify the treating team and AUM.

        Inadvertent removal/Drain dislodgement

        If the drain is suspected to have been moved, the drain should be secured and the treating team notified.
        In the event a drain has been removed or dislodged, a sterile dressing should be applied and the treating team notified.
        If the drain is suspected to have receded into the patient, the treating team should be notified and imaging (x-ray, etc.) should be performed. Link to Policy & Procedure: Surgical Wounds – Procedure for Missing/Non Intact Drains

        Removal

        Ensure plan for removal of drain tube is discussed with and documented by the treating team in the patient’s progress notes.

        Inform patient/parent about removal and possible associated pain. Explain the removal process to the patient and carer. 
        Discuss and plan for procedural pain management and non-pharmalogical interventions to minimise pain and distress throughout procedure, assess analgesic requirements first and then consider the need for procedural sedation; please refer to the procedural sedation ward and ambulatory areas at RCH procedure for more information. If using analgesia ensure it is given 45-60 minutes prior to procedure to ensure it has taken peak effect. Please refer to the procedural pain management guideline for more information.


        The following should be completed using a “Standard Aseptic technique” please refer the Aseptic Technique Policy for more information:

        Using standard aseptic technique clean around the site and remove any sutures. Pinching the edges of the skin together, rotate tubing from side to side gently to loosen, then remove the drain using a smooth, but fast, continuous traction. Tie off any purse-string sutures and apply occlusive dressing.


        NB. Pigtail drains must be uncoiled prior to removal, failure to uncoil a pigtail drain can cause severe pain and/or tissue damage. To uncoil the pigtail drain the catheter/string should be cut to release the string that creates the pigtail coil. 


        If required, cut the tip of the tube for cultures.
        Document removal of drain and that it is intact/not intact in progress notes as well as amount of drainage on fluid balance chart.

        Unable to remove surgical drain

        If there is resistance and no movement of the drain tube despite gentle side-to-side rotation and a firm pull do not proceed further and notify the treating team/surgeon. 
        There should be no excessive force when pulling the drain tube, doing so can lead to serious complications such as drain tube fractures or internal tissue damage.

        Drain Tube Fractures

        If the tube fractures during drain removal and remnants of the tubing is left within the patient contact the treating team.
        The surgical fellow should order an immediate Xray of the drain tube site.
        The patient should be prepared for theatre, inform the parents and consider the need to keep the child nil by mouth in anticipation for surgical removal of the remaining drain tube.
        The whole drain unit should be kept in the patient’s room until surgical review and will need to be kept for collection to enable quality review.
        The piece of drain tubing that remains in the patient will also be kept once surgically removed to allow for appropriate follow up of the incidents cause.
        A VHIMS must be completed by the nurse delegated to remove the drain.

        For Theatre Staff involved in the surgical removal retained drain tube of the:

        In theatre, previous surgery is checked on EPIC regarding the LDA’s flowsheet of the drain that was inserted at that operation. NB. There can be multiple drains.
        After removal of retained drain, instrumentation nurse to superficially clean visible blood /serous fluid off the retained drain.
        Instrumentation nurse to measure length of retained drain before placing in a yellow top container. -Surgery is completed as planned.
        Scout RN to record length of retained item on patient’s UR label on container.
        Retained item's lot number and expiry that has been recorded in EPIC is to be transcribed onto the yellow top container with patient’s UR label
        Scout RN to record in EPIC retained items details.  Also check LDA's flow sheet for removal of drain/line details and update in comments section that residual item has been removed and record length with date and time stamp.
        Yellow top container to be kept together with the remaining drains until critical review process is completed and VHIMs documentation finalised.
        Post op X ray to be reviewed by surgeons and open disclosure to family to be undertaken by surgeons. 
        Link to surgical Wounds – Procedure for Missing/Non Intact Drains
        Link to aseptic technique policy and procedure

        Post removal

        Monitor site for signs of infection, obtain swabs or samples if required.
        Monitor and mark dressings to ensure minimal leakage, replace dressings as required to minimise risk of infection. Excessive leakage should be reported to AUM or surgeon.
        Dressing should be removed when wound has healed (3-5 days).

        Evidence Table

        Click here to view the evidence table

        References

        Procedure Surgical Wounds – Procedure for missing Non Intact Drains
        Wound Care Nursing Guidelines
        Chest Drain Nursing Guidelines

        Pain assessment and management guideline
        Aseptic Technique Policy
        Procedural sedation ward and ambulatory areas at RCH prcedure
        Procedural pain management guideline


        Please remember to read the disclaimer.

         

        The development of this nursing guideline was coordinated by Stacey Richards, Nurse Educator, Undergraduate Nurses, and approved by the Nursing Clinical Effectiveness Committee. Updated September 2016.