Overview
Definition:
Surgical drains are tubes or devices used to remove accumulated fluid (blood, pus, seroma, lymph, ascites, bile) from a surgical site or body cavity
They can be active (requiring suction) or passive (utilizing capillary action or gravity)
Effective drain management is crucial for preventing complications like infection, hematoma, and seroma formation, and for promoting wound healing.
Clinical Significance:
Proper selection and placement of surgical drains significantly impact patient outcomes by: reducing the risk of infection and abscess formation
facilitating early detection of anastomotic leaks or hemorrhage
minimizing dead space that can lead to seroma or hematoma
preventing pressure on surrounding tissues
and aiding in the assessment of fluid output, which can indicate complications
Incorrect management can lead to prolonged hospital stays, reoperations, and increased morbidity.
Types Of Drains:
Drains are broadly classified by mechanism of action and design
Passive drains include Penrose drains (open, soft rubber), corrugated drains, and T-tubes
Active drains include Jackson-Pratt (JP) drains (closed suction), Hemovac drains (closed suction), and Pleur-evac systems (chest drains)
The choice depends on the volume and character of expected drainage, the surgical site, and the need for suction.
Indications For Drainage
General Indications:
Drainage is indicated when there is a high likelihood of significant fluid accumulation that could compromise healing, increase infection risk, or cause pressure effects
This includes cavities created by extensive dissection, tissue resection with raw surfaces, or where there is a risk of anastomotic leak
Procedures involving contaminated fields also necessitate drainage.
Specific Scenarios:
Common indications include: after radical oncologic resections (e.g., mastectomy, colectomy, thyroidectomy) to prevent seroma/hematoma
following abdominal surgeries with bowel resections or potential leaks
in deep abscess cavities post-drainage
after complex orthopedic procedures (e.g., joint replacements)
in thoracic surgery to evacuate pleural space fluid or air
and after reconstructive plastic surgery to prevent flap necrosis due to hematoma
Certain neurosurgical procedures also benefit from drains.
Contraindications:
Absolute contraindications are rare but include situations where drain placement might directly injure vital structures or worsen a specific pathology
Relative contraindications may include conditions that significantly impair healing or increase infection risk, though often the benefits of drainage outweigh these risks
In cases of generalized peritonitis without localized collections, drains may not be beneficial and could seed infection.
Drain Selection Criteria
Fluid Characteristics:
The viscosity, volume, and nature of the expected fluid are key
Thin, serous fluid may be managed with passive drains or low-suction active drains
Thick pus or viscous fluid might require larger bore drains or drains less prone to blockage
High-volume output may necessitate efficient active suction systems.
Anatomical Location And Depth:
The depth of the cavity and proximity to vital structures influence drain choice
Deeper cavities often require drains with a channel for suction
Drains placed through stab incisions are preferred to avoid wound dehiscence
Consideration must be given to the path of the drain to prevent kinking or pressure sores.
Desired Drainage Mechanism:
Passive drains rely on capillary action or gravity, suitable for low-volume, thin fluid
Active drains use negative pressure to continuously aspirate fluid, more effective for high-volume or viscous drainage and for preventing dead space
Closed suction systems (JP, Hemovac) are generally preferred for reducing infection risk and facilitating monitoring.
Patient Factors:
Patient comorbidities (e.g., coagulopathy, malnutrition, immunosuppression) and the potential for patient compliance with drain care are also considered
Active drains may require more nursing care and patient education.
Placement Techniques And Principles
Insertion Site:
Drains should ideally emerge through a separate stab incision, away from the primary surgical wound, to minimize the risk of wound dehiscence and ascending infection
The exit site should be in a dependent position if gravity is to be utilized.
Drain Type Specifics:
Penrose drains are placed in the dead space and brought out through the incision
Closed suction drains (JP, Hemovac) are inserted into the cavity and connected to a vacuum-sealed reservoir, ensuring constant negative pressure
Chest tubes are placed into the pleural or mediastinal space and connected to an underwater seal system, often with suction.
Securing The Drain:
Drains must be securely sutured to the skin to prevent accidental dislodgement
Silk or non-absorbable sutures are commonly used
The drain channel should be sealed with a dressing to prevent retrograde contamination.
Flushing And Irrigation:
In some cases, particularly with thick secretions or at risk of blockage, drains may be intermittently flushed with sterile saline
However, this should be done judiciously to avoid introducing infection and is generally less common with closed suction systems
Irrigation is more often used in abscess cavities post-drainage than prophylactically in clean surgical fields.
Drain Management And Removal
Monitoring Output:
Daily output should be recorded, noting volume, color, consistency, and any odor
A sudden decrease in output may indicate blockage or drain dislodgement
A sudden increase or change in character (e.g., becoming serosanguinous or purulent) can signal a complication.
Signs Of Complications:
Signs of drain-related complications include: increased local pain and tenderness, erythema or purulence at the exit site (infection), fever, increased wound drainage, or systemic signs of sepsis
Leakage around the drain can indicate improper sealing.
Removal Criteria:
Drains are typically removed when the daily output falls below a predetermined threshold (e.g., <20-30 mL/24 hours) or when the fluid character becomes consistently serous and minimal
The absence of significant dead space and the presence of healthy granulation tissue are also important factors
Drains are generally removed as early as feasible to reduce infection risk.
Post Removal Care:
After drain removal, the exit site is usually covered with a sterile dressing
Patients are instructed on wound care and to report any signs of infection or fluid accumulation
Some surgeons may advise patients to perform light physical activity to prevent fluid re-accumulation.
Complications And Prevention
Infection:
Ascending infection from the skin through the drain tract is a common complication
Prevention includes sterile insertion technique, using closed suction drains, securing the drain appropriately, and prompt removal once no longer indicated
Local wound care and sterile dressings are crucial.
Bleeding And Hemorrhage:
The drain itself can cause minor bleeding
Major hemorrhage is rare but can occur if the drain erodes into a vessel
Careful placement away from major vessels and monitoring output for bloody drainage are important
Active suction should not be initiated if significant bleeding is suspected.
Pain And Discomfort:
Drains can cause discomfort and pain, especially when the patient moves
Secure suturing, appropriate drain size, and adequate analgesia are key to managing pain
Patients should be educated on how to move to minimize pulling on the drain.
Fistula Formation:
Prolonged drain presence can lead to the formation of a persistent sinus tract or fistula
This is more common with drains left in place for extended periods or those placed in contaminated fields
Early removal and good wound healing are preventative measures.
Drain Blockage And Kinking:
Fibrin, blood clots, or kinking of the tubing can lead to drain blockage
Regular assessment of output and ensuring the drain is not kinked or compressed are important
Some closed suction systems have a mechanism to express any clots
Regular repositioning of the patient can prevent kinking.
Key Points
Exam Focus:
Understand the indications for drain use
Differentiate between active and passive drains, and their respective advantages/disadvantages
Know common drain types (Penrose, JP, Hemovac, chest tubes) and their typical applications
Recognize signs of drain-related complications.
Clinical Pearls:
Always place drains through a separate stab incision if possible
Secure drains firmly with sutures
Monitor output diligently and document it
Remove drains as soon as they are no longer indicated to minimize infection risk
Educate patients about drain care and warning signs.
Common Mistakes:
Leaving drains in for too long without reassessment
Failing to secure drains properly, leading to dislodgement
Misinterpreting drain output, especially a sudden decrease
Placing drains in a position that kinks or causes discomfort
Inadequate sterile technique during insertion or dressing changes.