Chapter 16: Perioperative care
Skip chapter table of contents and go to main content
Source: Reproduced from Brooks et al. ([38]) with permission of John Wiley & Sons.
Source: Adapted from Ngo et al. ([130]) and Nottingham University Hospital and Rushcliffe PCT ([153]).
Surgical drains
Definition
A surgical drain is a device, such as a tube, inserted intraoperatively into a body cavity (e.g. bladder or chest wall) or opening of a surgical wound to facilitate discharge of fluid or air.
Related theory
Surgical drains are used in many different types of surgery with the aim of decompressing, draining or diverting either fluid (blood, pus, gastric fluids, lymph or urine) or air from the site of the surgery (Mayerson [120], Vecchio et al. [209], Wong et al. [233]) to help prevent infection and facilitate healing (Knowlton [91]).
Drains can be open or closed and are made from latex, silicone or PVC (polyvinyl chloride) (Table 16.12, Figure 16.39). All drains induce some degree of tissue reaction (e.g. inflammation or fibrosis) as they are foreign bodies; however, the softer the drain, the less likely it is to cause tissue erosion. The type of drain used will be determined by the substance being drained (e.g. viscous versus thin fluid), the reason for the drain, the drain location and the volume of drainage (Mayerson [120]).
Table 16.12 Open and closed drains
| Type of drain | Description | Examples |
|---|---|---|
| Open drains | Open drains are ‘open’ to the air with the exudate ‘passively’ collecting onto a sterile dressing, such as gauze (if only minimal) or a drainage bag (if copious), from the surgical wound bed. These drains are cheap, simple and versatile, and can be used in any part of the body in both clean and infected wounds. They can be brought out through the end of a wound or more commonly through a separate stab incision. It is important to suture open drains to the skin to prevent them from falling out. As these drains are ‘open’, there is an associated risk of infection; however, the development of deep infection from retrograde tracking of micro‐organisms is rare owing to the continuous outward flow of exudate. |
Penrose drains: thin‐walled soft rubber latex tubes that collapse to resemble a flat ribbon. Being very soft, they are considered safe to lay adjacent to bowel or other internal organs.
Yates drains: quite flat but composed of multiple small tubules stuck side by side; much stiffer than Penrose drains. The tubules can be peeled off longitudinally to create any width of drain required.
Corrugated drain: wavy strips of PVC (polyvinyl chloride), still relatively stiff. They usually have a radiopaque strip down the middle (see Figure 16.39a). |
| Closed drains | Closed drains are ‘closed’ to the air with the fluid collecting into a sealed collection system (bags or bottles); thus, the drain contents remain clean. Closed drains can be divided broadly into those that employ suction (active drains, e.g. Redivac, chest) and those that do not (passive drains). | Redivac, exudrain. |
| Closed non‐suction drains (passive) | Closed non‐suction drains (passive) are dependent on gravity and the pressure differential between the body cavity and the exterior in order for fluid to be drained ( Brooks et al. [38]). They are commonly used after abdominal and pelvic surgery. They are characterized by a collapsible plastic bag on the end of the drainage tubing. | Examples include urinary catheter (Foley), nasogastric tube (Ryle), Robinson's drain and Bonanno catheter (see Figure 16.39b). |
| Closed suction drains (active) | Closed suction drains (active) combine gravity drainage with active suction created by the drainage system, which also acts as a reservoir for the drained fluid. They are commonly used in the subcutaneous tissues after abdominal, breast, plastic or orthopaedic surgery to obliterate dead spaces and prevent blood or serous fluid collections. They typically comprise a fine‐bore tube with an end hole and multiple side perforations/drainage holes. For suction to be effective, all drainage holes must be located inside the drainage cavity (i.e. inside the skin). | Examples include drains connected to either a pre‐vacuumed hard plastic bottle (e.g. Redivac; see Figure 16.39c) or to a soft concertina‐style bottle (designed to be squeezed before connection to generate negative pressure; see Figure 16.39d). |
Figure 16.39 (a) Top to bottom: corrugated, Yates and Penrose drains. (b) Robinson's drain attached to a sterile closed drainage bag. (c) Redivac drain. (d) Concertina drain.
An open drain allows the drainage of fluids outside the body. For example, in a Penrose drain (a closed drain), an artificial conduit is left in the wound and connected to a container that is placed outside the body. A closed drain may be classified as passive, meaning it relies on gravity (e.g. a Robinson drain), or active, meaning it relies on negative pressure (e.g. a Redivac drain) (Khan et al. [89]) (Table 16.12).
Evidence‐based approaches
Principles of care
Drains serve an important function as they allow the movement of fluid (e.g. blood, pus and serum) and air that has collected within a cavity in the body to pass outside the body. They reduce the risk of infection, promoting wound healing and making the cavity smaller (Wiker and Dalby [227]). However, they are also associated with complications such as haemorrhage, tissue inflammation, retrograde bacterial migration and drain entrapment (Walker [217]). It is essential that nurses are familiar with the monitoring and management of surgical drains and also the processes involved in their removal.
The management of a surgical drain is determined by its type, purpose and location; individual trusts’ local procedural guidelines should be referred to. If a patient has more than one drain, each one should be numbered to prevent confusion. Drains should be firmly secured at the exit site (e.g. with a suture), and, if attached to a drainage bag or bottle, they should also be secured at one other point (e.g. with adhesive tape).
To minimize the risk of cross‐infection, the drainage bag or bottle should not be placed directly on the floor but should be placed below the level of the wound to facilitate drainage. Drainage output should be measured and recorded on the fluid balance chart or wound drainage chart, as accurate 24‐hour totals are necessary for making decisions about drain management. Drains should be monitored regularly throughout a shift; this should be undertaken as clinically indicated (e.g. each time clinical observations are recorded). Nurses must monitor changes in the character (colour, viscosity and odour) and volume of drainage fluid. Unexpected drainage volume (too high or too low) or type (unexpected fluids, e.g. blood in urinary catheter) should always prompt further investigation by the clinical team and could indicate that something is wrong (see Problem‐solving table 16.13). The length of the drainage tubing (from drain exit point) should also be recorded on surgery documentation and regularly observed for signs of dislodgement (withdrawal or retraction). Furthermore, drain tubing and connections should regularly be inspected for signs of disconnection (e.g. suction pressure source), damage, blockages (viscous fluid, e.g. blood clots, pus or gastric contents) or kinks. For wound drains, it is also important that nurses observe the skin surrounding the drain site for signs of swelling, infection or haematoma. Swabs of wound and drain sites should only be taken if infection is suspected (e.g. due to inflammation of wound margins, pain, oedema, pyrexia and/or purulent exudates). Procedure guideline 16.7: Drainage systems: changing the dressing around the drain site for both open and closed drains offers guidance on dressing the drain site of both open and closed drains.
The Daily Drain Drill was created by Brooks et al. ([38]) and outlines regularly and daily drain checks (Box 16.13).
Box 16.13
The DDD (Daily Drain Drill)
- Volume of fluid (24‐hour total)?
- Type of fluid?
- Blocked, kinked, leaking or displaced?
- Adequately secured?
- Adequate suction?
- Ready for removal?
Drains should be emptied frequently using clean technique or standard precautions to reduce the strain on the suture line and ensure maximum drainage (Lippincott Williams & Wilkins 2018). However, the dangers of introducing infection should be weighed against the need to empty the drain. Vacuum bottles (e.g. Redivac bottles) and underwater sealed drains (e.g. chest drains) are not emptied but renewed when full (see Procedure guideline 16.8: Closed drainage systems: changing a vacuum bottle).
With the exception of urinary catheters and Ryle's tubes, surgical drains are usually removed once the drainage has stopped or become less than approximately 25–50 mL/day. In some instances drains are ‘shortened’ by withdrawing them gradually (typically 2 cm/day) before they are completely removed or fall out, to promote gradual closure of the tract. The drain may also be ‘cut and bagged’ to facilitate easier mobilization. In each of these circumstances, the decision is taken by the surgical team. See Procedure guideline 16.10: Wound drain shortening for open drainage systems and Procedure guideline 16.11: Wound drain shortening for closed drainage systems for instructions concerning surgical wound drain shortening and removal.
Procedure guideline 16.7
Drainage systems: changing the dressing around the drain site for both open and closed drains
Procedure guideline 16.8
Closed drainage systems: changing a vacuum bottle
Procedure guideline 16.9
Wound drain removal: closed drainage system
Procedure guideline 16.10
Wound drain shortening for open drainage systems
Procedure guideline 16.11
Wound drain shortening for closed drainage systems
| This refers to open and closed drainage systems only (not chest drains). The surgical team must be contacted in the event of any of the following problems occurring. | |||
|---|---|---|---|
| Problem | Cause | Prevention | Action |
|
Blocked drain
Blockage should be suspected when there is a sudden drop in drainage output, lower output than expected, or no output at all. |
Overly tight sutures, kinking.
Ingrowth or collapse of surrounding tissues.
Debris accumulation and blood clots in the lumen. Commonly a drain is blocked due to lumenal debris, which may not be visible from external inspection. | Drain tubing and connections should be regularly inspected for blockages or kinks. |
The surgical team should be informed prior to any action being taken.
‘Milk’
Manual ‘milking’ of debris out through the drain can help to dislodge the obstruction or break it up into smaller debris. This can be done by gently squeezing the tube between your thumb and index finger while moving your fingers along the tubing towards the suction bottle. |
| Unexpected fall in drain output may result from drain dislodgement rather than blockage. Advice should be obtained from the surgical team prior to any intervention. |
Aspirate
After ruling out external compression, a drain can usually be unblocked by aspirating the drain according to local trust guidelines.
This should not be undertaken without instruction from the surgical team.
Flush
Failing aspiration and milking, an attempt can be made to flush the drain with sterile saline using aseptic technique according to local trust guidelines. This can push back in any debris too large to be aspirated through the drain. Flushing also helps to re‐establish drainage where tissue collapse or adhesion around the drain interferes with its function.
No attempt should be made to flush a drain without instruction and guidance from the surgical team that inserted the drain. | ||
| Leaking drain |
Determined by site of leakage.
Leakage occurring around the exit site of a suction drain is usually due to a blocked drain rather than a perforation in the drain. The drainage fluid may find its way out along the external surface of the drain when the lumen is blocked.
Leakage around the tubing or connections is due to damaged tubing or connections.
Skin incision too big for the drain. |
Drain tubing and connections should be regularly inspected for blockages, kinks or damaged tubing/connectors.
Ensure the drainage bag is lower than the drain site. |
The surgical team should be informed prior to any action being taken.
Blocked drain
Unblock the drain using the methods outlined above for blocked drains.
Connections
Using aseptic technique, replace the tubing according to the manufacturer's instructions and tighten the connections as appropriate.
Reduce the size of the skin incision
If the skin incision is too big, report this to the surgical team for guidance. They may consider an additional suture or may cut and bag the drain to collect the leaking exudate. See Procedure guideline 16.11: Wound drain shortening for closed drainage systems for information on the ‘cut and bag’ procedure. |
| Loose drain | Causes may include the drain‐securing suture cutting through the skin, loose knot tying or traction on the drain. |
The majority of drains need to be well secured, preferably at two points. Ensure regular observation of the drain to check it is firmly secured at its exit site (e.g. with a suture) and one other point (e.g. with adhesive tape).
Be aware of the length of the drain from exit site at the skin to the drainage bag (if applicable); this should be documented in nursing/medical notes. |
The surgical team should be informed prior to any action being taken.
Loose drains must be re‐secured appropriately and promptly. If the suture around the drain appears loose, the surgical team should be contacted immediately, and they may consider placing a stitch through the skin next to the drain exit site under local anaesthetic, then tying the suture securely around the drain.
Extra security can be provided by taping the drain/tubing to the skin. Open drains should be prevented from falling into the drainage cavity, e.g. by passing a large sterile safety pin through the drain. See step 15 in Procedure guideline 16.10: Wound drain shortening for open drainage systems for guidance on how to perform this procedure. |
| Drain retraction | Drain retraction is caused by a loose drain being pushed inwards, e.g. during dressing change or from patient movement. |
The majority of drains need to be well secured, preferably at two points. Ensure regular observation of the drain to check it is firmly secured at its exit site (e.g. with a suture) and one other point (e.g. with adhesive tape).
Be aware of the length of the drain from exit site at the skin to the drainage bag (if applicable); this should be documented in nursing/medical notes. |
The surgical team should be informed prior to any action being taken.
Re‐secure
This should be dealt with as a loose drain (see ‘Loose drain’ above).
Alert: Drains suspected to have partially retracted inside a wound should be left in place and properly re‐secured by a member of the surgical team and a safety pin placed through the tubing to prevent further retraction (see Procedure guidelines 16.10 and 16.11).
Alert: Attempts to pull the drain back out should be avoided unless the distance of retraction is known (e.g. drain retraction witnessed or length at skin surface marked). Otherwise any attempt to pull the drain back out may lead to it being dislodged altogether.
Reposition
Drains that have clearly retracted inwards should be pulled out by a member of the surgical team to a length that allows removal at a later date before being re‐secured.
Alert: A drain that is ‘cut and bagged’ must always be secured with a large, sterile safety pin placed through the external tubing close to the skin to prevent retraction (see Procedure guideline 16.10). |
| Drain appears to be falling out or has fallen out | This may be due to:
|
The majority of drains need to be well secured, preferably at two points. Ensure regular observation of the drain to check it is firmly secured at its exit site (e.g. with a suture) and one other point (e.g. with adhesive tape).
Be aware of the length of drain the from exit site at the skin to the drainage bag (if applicable); this should be documented in nursing/medical notes. |
In this event a member of the surgical team should be contacted immediately for guidance.
Re‐secure
A drain that has only partially migrated out should be re‐secured and the surgical team informed. It should not be pushed back in as the externalized part is now contaminated.
Examine
If a drain has fallen out completely, the tube must be inspected to ensure that the drain is intact and saved for inspection by the surgeon. Also ensure that no part of the drain is left inside. If there is any doubt, an X‐ray should be performed to ensure no part of the drain remains inside the body. The surgeon will decide if the drain requires replacement and make the necessary arrangements. A wound management bag may be placed over the exit site to catch any ongoing drainage from a mature tract. |
| Broken drain or tubing, or retained drain |
This is usually caused by repetitive physical trauma with potential contributing factors including:
A high‐risk factor is a drain that is ‘cut and bagged’ without use of a safety pin. | The majority of drains need to be well secured, preferably at two points. Ensure regular observation of the drain to check it is firmly secured at its exit site (e.g. with a suture) and one other point (e.g. with adhesive tape). |
In this event a member of the surgical team should be contacted immediately for guidance.
Replacement
If breakage occurs to the external part of the drain or tubing, then the drain might still be able to function. It may be reconnected to a new reservoir or have tubing replaced as appropriate. A safety pin should be placed through the tubing to prevent retraction.
Removal
If the break is flush with the skin exit site, the surgeon should be contacted immediately and then it should be removed by the surgeon so as not to push it further inside the wound. The surgeon will do this using aseptic technique, taking care to avoid pushing the broken part further inside or creating tissue bleeding, which may further obscure vision. If the surgeon is unable to remove the drain, intraoperative removal under X‐ray guidance or an open procedure may be necessary. |
| Inflamed drain exit site |
Minimal redness can often be seen around drain exit sites due to local irritation.
Cellulitis at the drain exit site may appear as a more pronounced zone of redness, warmth and tenderness. Fever and/or tachycardia may also be present as part of the systemic inflammatory response.
Purulent discharge at the drain exit site may persist around drains that have been in place beyond the acute post‐operative phase. However, the discharge must be examined by the surgical team to distinguish between purulent drainage fluid coming up around the outside of the drain and local abscess collection (unusual). |
The majority of drains need to be well secured, preferably at two points. Ensure regular observation of the drain to check it is firmly secured at its exit site (e.g. with a suture) and one other point (e.g. with adhesive tape).
Cleanliness of site. |
Irritation
If local irritation is suspected, no treatment is required other than good wound care according to local trust guidelines to keep the drain exit site clean and dry, and regular monitoring of the drain to ensure it is firmly secured at the exit site (e.g. with a suture) and one other point (e.g. with adhesive tape).
Cellulitis
The surgical team should be informed if cellulitis is suspected as this can indicate inadequate drainage. Antibiotics are not indicated unless there is significant associated cellulitis or systemic immunosuppression.
Purulent discharge
If an abscess has been excluded, then local care for a small wound should be given according to local trust guidelines. Where there is an abscess collection, the treatment in some cases is drainage by a member of the surgical team using appropriate aseptic technique. This can usually be done via a simple incision after infiltration with local anaesthetic. Antibiotics are not indicated unless there is significant associated cellulitis or systemic immunosuppression. |
| Atypical drainage fluids |
Unexpected fluids coming up from around a drain or in the drain lumen may be due to:
Blood
Bleeding can be deep or superficial, early or delayed.
Early bleeding
This usually results from a vessel being accidentally pierced by the trocar during insertion or by the drain stitch. | Ensure the drain is well secured to minimize the risk of tissue erosion into adjacent structures. |
In this event a member of the surgical team should be contacted immediately for guidance.
Bleeding or early bleeding
The team registrar or consultant must be notified of any significant bleeding. Superficial bleeding will usually settle with local pressure but on occasion may require additional suturing by a member of the surgical team. Deep bleeding may need angiography or surgery. |
|
Delayed bleeding
May indicate erosion of a vessel by the drain anywhere along the drain tract. Erosion into blood vessels may appear as an initial ‘herald bleed’ consisting of a brief and brisk fresh bleed, which may be followed by a more catastrophic haemorrhage at a later stage. | Ensure the drain is well secured to minimize the risk of tissue erosion into adjacent structures. |
Anastomotic leak or tissue erosion
There are several possible approaches, including observation only, reducing or stopping suction (if applicable), partial withdrawal of the drain, removal of the drain or intraoperative repair. The approach taken will be determined by the surgical team. Anastomotic leaks may be verified by testing for appropriate biochemical markers (e.g. amylase for suspect pancreatic anastomotic leak or creatinine for urinary tract anastomotic leak). If the concentration of the particular biochemical marker in the drainage fluid is significantly higher than the serum concentration, then leakage should be suspected. | |
| High drainage output | Unless it is suspected that the drain is blocked, a sudden increase in drain output usually signifies a complication, such as an anastomotic leak or erosion into adjacent organs (see ‘Atypical drainage fluids’ above). | n/a |
In this event a member of the surgical team should be contacted immediately for guidance.
Management steps appropriate to the cause should be undertaken. |
|
Vacuum failure for suction drains
When the vacuum suction reservoir fills with air, loss of vacuum has occurred. | This may be the result of:
| The drain's tubing and connections should be regularly inspected to ensure the maintenance of the vacuum within the bottle (according to the manufacturer's instructions). | If the vacuum of the drainage system is continually being lost, check all connections for evidence of an air leak and for any wound drain perforations exposed above skin level. Any drain hole outside the skin should be covered with an occlusive dressing or bandaging using aseptic technique to stop the air leak. Air leaks elsewhere in the system should be stopped, preferably by tightening of connections and/or replacement of any defective component. Otherwise occlusive tape may also be used to seal such defects. If no air leak or suction reservoir defect is found, an opened wound edge or some abnormal communication from the drainage cavity ought to be suspected. The surgical team must be notified. |
| Drain appears stuck and will not come out on attempted removal. | Potential causes include:
| Check operation notes to determine number and types of sutures in situ prior to attempting drain removal. | Recheck operation notes to ensure all non‐absorbable stitches have been removed. Loosening up of the drain should be done if possible, especially for a drain that has been in for some time. For round drains, this can be done by gently rotating the drain to release it. For flat drains, gentle movement from side to side can achieve this. Note: removal using excess force should not be attempted. Assistance from the surgical team should be sought if the drain does not loosen easily. |
