Suction Drains

Indications

Suction drains are commonly indicated in surgical procedures where the risk of fluid accumulation is significant, and there is a need to remove excess fluid to prevent complications such as infection, seroma, hematoma, or abscess formation. Some of the key indications for the use of suction drains include:

• Postoperative fluid accumulation
  • Following surgeries involving large tissue dissections, such as abdominal, thoracic, or pelvic procedures, there is often a risk of fluid accumulation at the surgical site. Suction drains are placed to remove this excess fluid and prevent the formation of seromas or hematomas, which could complicate recovery.
• Prevention of dead space
  • Dead space occurs when tissue planes or cavities are left without adequate drainage, potentially leading to fluid collection. Suction drains eliminate this potential by draining fluids and helping promote proper tissue re-approximation, especially in complex reconstruction and graft surgeries.
• Pancreatic and biliary surgery
  • Suction drains are commonly used in pancreatic and biliary resections or reconstructions to reduce the risk of postoperative fistulas. They help monitor signs of leakage or bile collection and allow for early intervention if necessary.
• Trauma and abscess drainage
  • Suction drains are indicated in managing traumatic injuries or abscesses, where purulent or serous fluids must be removed to reduce the risk of infection. This is especially critical in retroperitoneal and intraabdominal trauma, where fluids can accumulate and cause complications if not drained effectively. Drains are also used for source control in abscess management.[10][11][12]
• Infection or inflammation
  • In certain cases, such as after surgical resection of infected tissue or in the presence of abscesses, suction drains can help evacuate infectious fluids or pus, reducing the chance of wound contamination and promoting healing.
• Cardiothoracic procedures
  • Following thoracic surgeries such as coronary artery bypass grafting or lung resections, suction drains are commonly placed to drain any pleural effusions, blood, or fluid collections that can develop in the pleural space. This prevents complications like infection or impaired respiratory function.
• Cosmetic and reconstructive surgery
  • Suction drains are often used after aesthetic procedures, such as tummy tucks or breast reduction surgeries, to prevent seroma formation in the areas of extensive skin and fat dissection.
• Anastomotic monitoring
  • An indwelling drain placed near a new anastomosis can provide a window into the local environment, allowing for early detection of fluid leaks or complications at the anastomotic site.
• Lymphadenectomy
  • Following large dissections such as lymphadenectomy, drains are placed to drain serum and lymph, preventing the accumulation of fluids that may cause complications.

In each case, suction drains are essential in eliminating blood, serum, air, or any fluid that may have leaked during the procedure. Their use enhances the surgical outcome by preventing fluid-related complications, improving healing, and reducing the risk of infection and other postoperative issues.

Contraindications

Suction drains are valuable tools in many surgical procedures, but there are several contraindications to their use. In patients with a high risk of infection at the insertion site, such as those with active infections or uncontrolled sepsis, suction drains may exacerbate the problem by introducing pathogens, potentially worsening the condition. Additionally, patients with poor tissue integrity—such as those with extensive wounds, burns, or compromised blood supply—may not be suitable candidates, as the placement of a drain could impair healing, leading to necrosis or further tissue breakdown. Severe coagulopathy is another contraindication, as patients with bleeding disorders or those on anticoagulation therapy are at increased risk for excessive bleeding or hematoma formation during drain insertion. Active negative pressure dressings are relatively contraindicated over vessels in the presence of coagulopathy, malignancy, or in areas where occlusion is not feasible.

In obese individuals with excessive subcutaneous fat, suction drains may become displaced, infected, or less effective due to difficulty positioning or maintaining adequate drainage. Similarly, specific anatomical sites may not allow for proper drain placement, especially in confined spaces such as the pelvis or retroperitoneum, where the risk of ineffective drainage increases. Patients with severe, uncontrolled ascites may not benefit from suction drains, as they could exacerbate fluid imbalances or electrolyte disturbances. A preexisting fistula at the drain insertion site could also worsen leakage, so a drain should be avoided until the fistula is addressed.

Finally, individuals with conditions known to impair wound healing, such as poorly controlled diabetes, vascular insufficiency, or those on immunosuppressive therapy, may face complications like infection, dehiscence, or poor tissue approximation, making drain placement inappropriate. Patient preferences or psychological factors may sometimes discourage drain use, requiring alternative fluid management strategies. Careful evaluation of these contraindications is essential for ensuring the safe and effective use of suction drains.

Equipment

The equipment for closed and open suction drains consists of various components designed to facilitate effective fluid drainage, with differences in design and functionality based on the type of system used.

Closed Suction Drain Equipment

Closed suction drains are designed to maintain a sterile, sealed environment while draining fluids. Key components include:

• Drain tube
  • Closed suction drains often use tubing that can be round or flat, perforated or channeled, and is typically made from silicone. Round tubing is sized in French units, while flat tubing is measured in millimeters. Channel drains have multiple channels for drainage, while perforated tubing has multiple holes along its length for better fluid drainage. The tubing is often connected to a trocar for easier insertion into tissues.
• Collection chamber
  • This is a sealed, often transparent container where the drained fluid collects. This device may have graduated measurements for fluid monitoring.
• Negative pressure source
  • Active negative pressure is achieved through devices like the Jackson-Pratt drain, where the tubing is connected to a bulb reservoir that drains via negative pressure. Vacuum-assisted drains use suction devices to create negative pressure, typically set at 125 mm Hg. These systems may include sterile or antibiotic-impregnated foam, occlusive dressing, and tubing for continual or intermittent negative pressure.
• Suction tubing and valve
  • Suction tubing is typically flexible and connected to the collection chamber and the vacuum device. The valves regulate suction and prevent backflow. A closed system can be created with materials like tubing and syringes.[10][13] 

Open Suction Drain Equipment

Open suction drains are more straightforward in design and less controlled than closed suction drains. They include:

• Drain tube (Penrose or other)
  • Open drains, like the Penrose drain, are usually made from polypropylene, latex, or silastic, allowing fluid to drain freely from the wound. The Penrose drain has various widths and can be easily cut to the desired length.
• Absorbent dressings
  • An external dressing, such as gauze or pads, absorbs the fluid that drains from the tube. Open drains rely on gravity and capillary action for drainage, and the fluid is typically absorbed by dressings that need to be changed regularly.
• Wicking material
  • Open drains work on the principle of capillary action, and materials like latex or polypropylene serve as the wick that draws the fluid from the wound to the outside. This passive drainage mechanism is simpler but less controlled than closed suction drains.[10][13]

While closed suction drains are ideal for more controlled, continuous drainage, especially in large or complicated surgeries, open drains are often used for less critical drainage needs or where continuous suction is unnecessary. Each system is selected based on the procedure, expected drainage volume, and clinical requirements.

Personnel

A multidisciplinary team of healthcare professionals manages suction drains, each contributing expertise at different process stages. Their roles are critical for ensuring the successful placement, maintenance, and monitoring of suction drains and managing potential complications.

• Surgeon
  • The surgeon determines the need for a suction drain based on the surgical procedure and the anticipated fluid accumulation. They also handle the drain placement during surgery, selecting the appropriate drain type (closed or open) and the optimal location. Surgeons must be skilled in drain insertion techniques, recognizing when a drain is necessary and how to avoid complications such as tissue damage or improper positioning.
• Nurses (surgical, postoperative, or wound care nurses)
  • Nurses play a key role in the immediate postoperative care of patients with suction drains. They are responsible for monitoring the drains for patency, assessing the output, and ensuring the correct functioning of the drain system (eg, checking for leaks or blockages). Nurses also educate patients about drain care, such as how to empty collection chambers, maintain cleanliness, and recognize signs of infection.
  • Postoperative Nurses ensure that drains are properly secured and maintained during the recovery phase. They also monitor for signs of complications such as infection, leakage, or dislodgement of the drain.
  • Wound care nurses may assist in managing wounds around the drain site, ensuring proper dressing changes, and maintaining sterile technique to prevent infection.
• Anesthesiologist
  • During surgery, the anesthesiologist ensures the patient is safe while under anesthesia as the surgeon places the suction drain. The anesthesiologist must be attentive to changes in vital signs, which can signal complications such as blood loss or fluid leakage around the drain, requiring immediate attention.
• Surgical technologist
  • Surgical technologists assist the surgeon in placing the suction drain by providing the necessary tools and materials. They also help set up the sterile field, ensure the drain is prepared and ready for use, and assist in placing it, including securing it appropriately.
• Radiologist (if necessary)
  • In some cases, especially with closed suction drains or when there is suspicion of complications like fluid accumulation or air embolism, radiological imaging (such as ultrasound or computed tomography scans) may be required to assess the drain's placement and function. The radiologist may guide percutaneous drain placement or provide follow-up imaging to ensure no complications, such as retained fluid or drain displacement.

Technique or Treatment

A drain is typically inserted through a separate puncture site a few centimeters away from the surgical wound. The tubing often features a sharp end (trocar) for skin penetration, with multiple perforations on the opposite end for drainage. To use the trocar, make a small stab incision in a sterile area a few centimeters from the surgical site and pull the tubing through, ensuring the perforated section remains within the body cavity. Alternatively, surgical forceps can position the tubing in the desired location. The tubing should be trimmed to the required length.

Once positioned, the tubing is secured to the skin with a nonabsorbable suture and a sterile dressing. The insertion site must be sealed tightly to prevent leakage and ensure proper fluid and air drainage. Multiple loops around the tubing may be used for secure positioning.[14] The tubing should be placed carefully to avoid injury to vascular, biliary, or other anastomotic structures. In flaps, the drain should be immobilized to maintain tissue contact, and an anchoring suture is often placed at the most proximal drainage hole for added security. The interprofessional team must remain aware of this anchoring suture.[15][16]

Once the skin wound is closed and a dressing is applied, the tubing is connected to a collection system, such as a bulb, bottle, or other drainage device. Depending on the surgeon's instructions, the drainage output is measured, discarded, or sent for analysis. Initially, drainage may be sanguineous, followed by serosanguineous or serous fluid. The surgeon should be notified of any significant changes in the amount or quality of drainage.

The tubing should be regularly stripped to prevent clogging. After hand washing, pinch the tubing at the skin insertion site with the non-dominant hand, then gently squeeze it with the dominant hand to move the contents toward the reservoir. Use hand sanitizer or alcohol rub to smooth the movement of the tubing. Removing all fluid from the tube is unnecessary, but as much as possible should be cleared. If the flow becomes impeded, the surgeon should be informed.

The collection reservoir is emptied regularly, or when full, and drainage volume is recorded. All handling of the drain must be sterile. Unplug the stopper from the emptying port to empty the bulb, turn the bulb upside down, and squeeze to remove the fluid. Unless otherwise instructed, the fluid should be discarded in a designated basin or toilet. Not disconnecting the tubing from the bulb is crucial. If negative pressure needs to be restored, open the port and gently squeeze the bulb to collapse it. Once compressed, seal the stopper in place and release the bulb to allow it to reexpand. The bulb can be secured to the patient's clothing with a safety pin to minimize tension and support optimal drainage. If the bulb weakens, it may need to be replaced. To do so, clamp the tubing, clean the connection with an alcohol swab, detach the old bulb, and attach the new one without contaminating the connector. Release the clamps to restore negative pressure once the new bulb is in place.

The dressing around the insertion site should be changed daily, ideally timed with the patient’s shower. The standard dressing is a drain gauze secured with sterile tape. The drain site should be inspected at least twice daily for signs of erythema, edema, or increased drainage. The surgeon should be notified of any pain or excessive drainage at the site.[17]

Drains are typically removed when drainage decreases to a minimal level. Before removal, strip the tubing to check for residual fluid. Cut the sutures securing the drain, and gently twist to release any adhesions. The drain should be removed with steady pressure and uncoiled by releasing the securing strings if the drain is a pigtail catheter. Always follow the manufacturer’s instructions to minimize patient discomfort. Debris or clots may be present at the tip, and the surgeon may request laboratory analysis of the tip or for the drain to be disposed of properly. The drain site should be covered with a sterile pressure dressing and changed as needed.[18][19]

Complications

Suction drains, while beneficial in preventing fluid accumulation, are not without complications. One common issue is clogging, which may necessitate mechanical or pharmacologic interventions to clear the blockage. If the drainage is impeded, fluid may leak around the insertion site, leading to excoriation and irritation of the surrounding tissue. Drains can also introduce pathogens into a sterile space, potentially resulting in localized or systemic infections. In some cases, drains may become dislodged or fractured, requiring repositioning, replacement, or retrieval of fragments. Extended use of drains can provoke a foreign body reaction, and if left in place for too long, they may integrate into the surrounding tissue. Additionally, negative pressure systems, though effective in drainage, may delay wound closure and increase the risk of fistula formation.[20][21] Despite these risks, studies have shown no significant increase in surgical site infections among patients who shower with indwelling surgical drains, suggesting that proper hygiene and care may mitigate some of these complications.[22]

An interprofessional team provides an integrated approach to the care of a suction drain. The role of the nurse and caregivers, including family, is crucial to drain monitoring and care. Drain-based education is key in preventing infection and timely reporting of clinical drain information. Bedside measures reduce bacterial colonization of drains and ensure ongoing efficacy following hospital discharge.[23][24] 

Clinical Significance

Several measures can increase drain efficiency and reduce the complication risk. The efficacy of a closed-suction system can be optimized by increasing intracavitary tube length, decreasing extra cavitary tube length, increasing tube diameter and the pressure differential, using a perforated catheter, squeezing a low-pressure bulb side-to-side, and milking drain tubing frequently.[1] Closed drain systems with short extra cavitary lengths minimize the risk of retrograde infections. The drain should not be placed directly on an anastomosis to prevent drain-induced erosions or leaks.[25][26][27]

Controversy remains about whether prophylactic drain placement following clean-contaminated intrabdominal surgery prevents surgical site infections. Results from a study including 2833 persons, 187 of whom were diagnosed with a surgical site infection, demonstrated no difference in the incidence of infection between those with and without drains.[28] A study on drains in abscess prevention in complicated appendicitis was inconclusive. Drain placement may increase hospital stay without added benefit in some cases.[29][30][31] Drains should be removed early to prevent drain-related complications and prolonged hospital stays.[4]

A study including 320 persons compared postoperative infection rates for open and closed suction drains following pancreatic surgery. Fluid contamination and other postoperative outcomes were comparable between the groups.[32] Results from a study comparing closed suction drains connected to negative pressure to those using gravity drainage demonstrated no difference between the 2 in postoperative fistula formation, surgical site infections, or time to drain removal.[33][34]

Enhancing Healthcare Team Outcomes

Effective management of suction drains requires a collaborative approach, where each healthcare team member plays a crucial role in ensuring patient safety, improving outcomes, and enhancing overall care. Clinicians are responsible for determining the appropriate type of drain based on clinical indications and ensuring proper insertion. They also monitor for complications such as infection or clogging and make decisions regarding drain removal. Nurses play a key role in the day-to-day management, including tracking the drain site for signs of infection, assisting with drain care, and educating patients on drain maintenance at home. Regular communication between nurses and other clinicians is critical to assess drain output, recognize early signs of complications, and provide prompt interventions. Pharmacists contribute by prescribing appropriate antimicrobial therapy when needed and managing any pharmacologic treatments for drain-related complications.

Interprofessional collaboration is vital to minimize the risks associated with suction drains. Effective communication between healthcare team members ensures that concerns related to drain performance, such as clogging or infection, are promptly addressed. A coordinated approach helps in the timely replacement or adjustment of drains and ensures proper follow-up care. For example, a clinician might discuss any changes in drain output with the nursing team, while a pharmacist may provide recommendations for preventing infection or managing pain. This teamwork and continuous dialogue enhance patient-centered care by improving patient satisfaction, promoting timely interventions, and ensuring safe, efficient handling of drains from insertion to removal. Regular team meetings and documentation also support continuity of care, ensuring that all healthcare professionals are aligned on patient needs and treatment goals.

Nursing, Allied Health, and Interprofessional Team Interventions

Timely communication regarding drain status is important to patient well-being. Nursing and all interprofessional team members must inform the treating provider of erythema, purulent discharge at the drain site, or systemic concerns such as fever and malaise. Additionally, any perceived drain malfunction or change in character or quantity of drain output must be reported immediately.

Nursing, Allied Health, and Interprofessional Team Monitoring

The interprofessional team's role in monitoring drains includes assessing drain function and positioning, regularly stripping drain tubing, emptying and recording output quantity, and replacing significant fluid losses.