Suction Drains

Indications

Suction drains are used in different types of surgery. The primary purpose of a suction drain is:

• To prevent the collection of fluid (blood and infected fluids).
• To prevent the accumulation of air (dead space).
• To characterize collected fluid (like identification of anastomotic leakage).

Standard surgical procedures that require a drain:

• Chest pleural drainage
• Chest surgery
• Lymph node clearance procedure for malignancy
• Breast surgery
• Abdominal surgery
• Thyroid surgery
• Plastic surgery flap procedures

Equipment

Two commonly used suction drains are a low negative pressure bulb vacuum used to drain small amounts of fluid and a high negative pressure bottle drain used for more significant draining amounts of fluid. Its compressed green nozzle ascertains the negative pressure on the bottle.[2]

A radiopaque silicone catheter with multiple perforations on one end and a sharp trocar on another end is accompanied by the device.

Technique or Treatment

How to Insert a Drain Catheter

The drain catheter has a sharp end (trocar) to go through the skin and has multiple perforations on another end for fluid to come through. It is important to know anatomy while inserting the drain to avoid puncturing vital structures such as vessels or nerves. Insert the drain with trocar piercing under the skin with counterpressure applied above the skin surface. Pull it through the skin and insert the safety rubber on the pointed end of the trocar to avoid accidental injury. Pull the catheter till all holes are just inside and trim the perforated catheter to the length needed.

Securing the Drain Catheter with Suture

Skin suture is taken near the drain site, and a loose square knot is applied (i.e., hanging knot). Then come around the drain catheter to tie a double knot, and this can be repeated several times with throw behind and front of the catheter.[3]

Securing Drain in the Microvascular Procedure

The drain catheter should avoid crossing over vascular repair site. Before securing the drain as described above, one or two additional sutures were applied to immobilize the drain catheter placed inside a flap. The additional suture passed through the skin through the nearest catheter hole and then back through the skin, where a loose knot is fashioned on the skin side. This method of securing avoids displacement of the drain. The nursing staff must be shown where the anchoring suture has been placed for extra care.[4][5]

Completing the Circuit

The catheter trocar is cut and attached to a clamped plastic tubing accompanied by a drain. The other end of plastic tubing is connected to the provided reservoir, a bulb in the low-pressure drain, and a negative pressure bottle in the high-pressure drain. Once the skin wound is closed, and the dressing is done, clamp-on plastic tubing is released.

Monitor Drainage

The reservoir collects blood immediately after surgery. The collections gradually become less red over time. The fluid then becomes yellow with occasional blood clots. The surgeon has to be informed if the reservoir fluid suddenly changes to blood with clots or becomes milky white.

Milking the Drain Tube

Milking prevents clogging of the tube. Before milking, perform hand hygiene with soap and water. First, hold the tube at the skin insertion site with the non-dominant hand. Then milk the tube with the dominant hand by gently squeezing between thumb and index finger and moving along the reservoir. Hand sanitizer or alcohol rub can be used for smooth gliding along the tube. The fluid should run along the tube with the finger into the reservoir. It is not necessary to remove all fluid from the tube during milking but remove as much as possible. The tube needs to be milked twice a day for each drain. If milking of the tube does not restore flow, inform the surgeon, it probably means obstruction of the tube inside the body. Do not disconnect, puncture, or kink the drain tubing.

Removing Collection From Low-Pressure Bulb

The bulb is emptied at least three times per day or whenever the bulb is more than 50% full. The drain care needs to be sterile, and the hands must be washed thoroughly with soap and water. Unplug the stopper from the emptying port located at the top of the bulb. Turn the reservoir upside down over the measuring cup. Gently squeeze all fluid from the bulb into a measuring cup. Enter the chart date, time, and volume collected in a measuring cup. Discard the fluid in the measuring cup in a basin or toilet. Caution: Never disconnect drain tubing from the bulb.

Creating Negative Pressure in Low-Pressure Bulb

First, wipe the port opening with an alcohol swab to clean it. Next, gently squeeze the bulb by hand and flatten it as much as possible. With a flattened bulb, plug the stopper into an emptying port as far as possible. Release the bulb and check the bulb is flattened. The bulb expands slowly as the fluid gets filled inside. Constant suction generated by the bulb pulls collected fluid out of the body. Use a plastic tag on the bulb secure to clothing or belt so that bulb lies below the drain insertion site for better drainage.

Changing High-Pressure Reservoir

Change the high-pressure bottle once it is half-full or when the vacuum has weakened as indicated by an expanded nozzle. Before beginning to change the bottle, perform proper hand hygiene by washing with soap water or using hand sanitizer. Ensure that the new high-pressure bottle has been clamped and has a compressed nozzle. Lock both clamps on the bottle planned to be removed. Clean around the connector with an alcohol swab and unscrew the connector to detach the tubing from the bottle. Clean the tube connector with a new alcohol swab. Attach the new bottle without touching the connector. Finally, release both clamps of the new bottle. Measurement is done by keeping the drain on a flat surface, preferably at the same time each day. Observe the fluid reading at eye level and draw a line on a white label, and indicate the date of measurement. Document drainage amount on the given chart.[6]

Care of Drain Insertion Site

It is normal to have little swelling and tenderness at the drain insertion site for a few days. The patient can take a shower 48 hours after surgery in most cases. During the shower, allow the soapy water to flow on the drain site. Pat the skin area with a clean towel and allow it to dry for a few minutes. If unable to shower, clean the drain site with soap and water towel at least once a day. Before cleaning the drain insertion site, perform hand hygiene with soap and water.

The dressing at the insertion site is changed daily. The dressing is usually removed before a shower and after the shower check for signs of infection. Then a new dressing is applied. The conventional method of dressing is to keep a folded gauze below the drain site and secure it with adhesive tape. Another folded gauze is placed above the drain site and secured with adhesive tape.

Look for signs of infection at the drain insertion site like pain, increasing swelling, redness, pus discharge, foul-smelling discharge, or systemic signs like fever. If any of the signs are present, inform the surgeon.

Removal of Drain

Routine practice is to measure the drainage every 24 hours and remove the drain when daily drainage falls below 30 ml/day for two consecutive days.[7] Before cutting suture, do a final milking procedure to check for residual collections. The tube then clamped, and the suture holding the catheter is cut. The catheter is slowly pulled out, and any clots attached to the perforated end of the catheter are gently removed.

Dressing after Drain Removal

After the drain is removed, a folded gauze is applied to the puncture skin hole on the drain site and secured with adhesive tape. The dressing can be removed after 24 hours, and the patient may ask to shower. The further dressing is usually not advised, and an antibiotic ointment may be given twice daily application for a week.

Complications

• Clot formation causes a sudden drop in fluid flow or fluid leak around the insertion site. Try milking the plastic tube. If it does not work, inform the surgeon.
• It can get obstructed by small tissue fragments. The reduced collection may be misleading. When no fluid is collecting, check for occlusion or obstructed by adjacent tissue.
• The catheter can fall out when it slips off the suture. If it happens, keep a pad at the drain insertion site and secure with adhesive tape. Inform the surgeon.

Clinical Significance

The performance of a closed-suction system can be optimized by increasing intracavitary tube length, decreasing extra cavitary tube length, increasing tube diameter, increasing the pressure differential, use a perforated catheter, squeezing a low-pressure bulb side-to-side, and milking drain tubing frequently.[8] Whenever indicated, always use closed drain systems and keep drains as short as possible to minimize the risk of retrograde infections. Place the perforated catheter near but never in direct contact with the anastomotic site to prevent drain-induced erosions or leaks. Routine use of prophylactic drainage in colorectal anastomosis shows no benefit in reducing postoperative complications but reduces mortality.[9][10] Patients with large volumes of fluid from the surgical site usually continue to do so after drain removal. They would benefit by keeping the drain for a prolonged period. Surgical site surface area is also a deciding factor to consider when pulling a drain.[11] Drains used for prophylaxis in surgery, such as pancreatic surgery, are removed early to prevent postoperative complications.[12]

Enhancing Healthcare Team Outcomes

An interprofessional team provides a holistic and integrated approach in the care of suction drain. The role of the nurse and family must be determined. If the patient is to be discharged with drain, educate the caretaker who can monitor and care of the drain. The major complication associated with drain is accidental slippage from the wound, and the patient has to be evaluated immediately. The fluid measurement and maintaining the record are essential to time the removal of the drain. The care of the drain insertion site has to be educated to all team members. Inexpensive and straightforward antiseptic intervention at the drain insertion site reduces bacterial colonization of drains.[13] [Level 2] Effective prevention for seroma formation in the postoperative period is with the use of the closed-suction drain. The suction drain should be kept until their output volume was minimal and maintain a high-pressure gradient.[14] [Level 2]

Nursing, Allied Health, and Interprofessional Team Interventions

Inform surgeon if any of the below is noted:

1. Signs of infection at drain insertion site: pain, increasing swelling, redness, pus discharge, foul-smelling discharge, or systemic signs like fever
2. The sudden drop in fluid collection inside the reservoir
3. A fluid leak or malfunction of the drain system
4. Accidental injury to tubing
5. Clots form in tubing and drainage blocked
6. Less than 30 ml/day of fluid output for two consecutive days
7. The drain is no longer secured to the skin with stitches.

Nursing, Allied Health, and Interprofessional Team Monitoring

The role of the interprofessional team in monitoring drain are:

• A provider needs to check the working of a suction drain periodically.
• Providers have to ensure the drain is secure when transferring patients after anesthesia.
• Periodic milking of plastic tube to prevent clot formation and record the time milking.
• Empty the drain, as suggested by the surgeon.
• Identify smell, character, the color of the fluid.
• Measure and record drainage output.
• Excess loss via a suction drain may need intravenous replacement of fluids, discussion with the surgeon.