A nurse is caring for a client who has a surgical wound with a penrose drain in place

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Introduction 

Aim

Definition of Terms

Assessment

Troubleshooting

Removal

Evidence Table

Links

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, amount of drainage expected and surgeon preference. 

Aim

Definition of Terms

• Jackson-Pratt™ – a soft pliable tube with multiple perforations and 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 used for larger draining amounts.
• Pigtail™– Small lumen with a coil in the shape of a pigtail, used for draining a single cavity, passive drains, easily blocked (discuss with surgical registrar if safe to flush). 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 colonised by bacteria if left in situ for an extended period of time.
  

Assessment

Initial

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

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, increased pain and risk of infection.

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

Regularly discuss removal plan with treating team. D rains 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 regularly whilst the drain is in situ. Appropriate analgesia should be provided when necessary, particularly prior to removal. Please refer to the pain assessment and management guideline for more information.

Investigations

If suspecting infection, notify treating medical team and ask if a swab of the insertion site or sample of any ooze should be collected 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 therefore 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. 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. When the Redivac™ drain is changed (to ensure suction reapplied) ensure “standard aseptic technique” is utilised, please refer the Aseptic Technique Policy for more information. This procedure must be approved by AUM or treating doctor.

Moving a patient with a drain tube

Assess the patient including 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 moved position, 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 immediately.
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 ordered by the treating team in the patient’s progress notes on EMR.
Inform patient/parent about removal process and possible associated pain.

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 RCHprocedure for more information. If using analgesia ensure it is given 30-45 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 in the flowsheets.

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 immediately.

The surgical fellow should order an immediate X-ray 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 Policy & Procedure: 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. 

Links

• Chest Drain Management Nursing Guideline
  
• Pleural and mediastinal drain management after cardiothoracic surgery Nursing Guideline. 
•  Pain assessment and management nursing guideline
• Aseptic Technique Policy
• Wound care nursing guideline
• Procedure for Missing/Non Intact Drains (RCH only)
• Procedural sedation ward and ambulatory areas at RCH
• Procedural pain managementnursing guideline
  

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Emily Gard, RN, Platypus, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2020.