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Nurse's guide to surgical drain removal

Knowlton, Mary C. DNP, RN, CNE

doi: 10.1097/01.NURSE.0000470418.02063.ca
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Follow the step-by-step guide presented here to properly remove closed active drainage systems and avoid complications.

Mary C. Knowlton is accelerated BSN program director at Western Carolina University in Cullowhee, N.C.

The author has disclosed that she has no financial relationships related to this article.

DRAINAGE DEVICES are used primarily after surgery to remove excess fluid from the surgical site; this minimizes the accumulation of blood and exudate, helping to prevent infection and facilitate healing.1,2 Although many types of surgical drains are available, this article focuses on the removal of closed active drainage systems, specifically the closed suction drain with a bulb/grenade reservoir (see Types of surgical drains). It won't address drains such as pigtail catheters, chest tubes, or T-tubes, as these are typically removed by the healthcare provider.

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Preventing fluid accumulation

When a surgical procedure creates a dead space, the body naturally tends to fill the space with fluid.3 Drains are typically placed during the surgical procedure to prevent this fluid accumulation. A small incision separate from but close by the primary surgical incision is made for drain placement. Placing the drain outside the surgical wound decreases the risk of wound infection.4,5,6

The timing of drain removal after surgery depends on the type of procedure, the average daily amount of drainage, and the surgeon's preference. The risk of infection increases the longer the drain remains in place, so most drains are removed within 24 to 48 hours after surgery.3,7 Open drains carry a greater risk for infection because they provide a direct communication from the external environment to the surgical cavity, which can allow bacteria to enter.4,7

As with other nursing skills, facility policy and procedure may vary regarding specific procedural steps and dictate whether an RN can perform this procedure. The following serves as a generic procedural description for a bulb reservoir device.

  • Prepare for the procedure by verifying the provider's order and the patient's identity, and gather supplies: a suture removal kit, sterile and nonsterile gloves, sterile drape, biohazard disposal container, supplies for surgical site care as indicated, sterile gauze dressing or other appropriate dressing, and tape or a transparent occlusive dressing.
  • Perform hand hygiene, explain the procedure to the patient, including possible discomfort, and administer analgesia as prescribed. Don appropriate personal protective equipment and raise the bed to a comfortable working level.
  • Use a sterile drape or a nonsterile absorbent drape to create a workspace near where the drain is located on the patient's body.
  • Remove any dressings over the drain site and dispose of them in the appropriate biohazard container. Assess the site for any signs and symptoms of infection and report findings to the surgeon as needed.
  • Empty the bulb reservoir in the usual fashion but don't reinsert the plug. Keep the bulb fully inflated so it doesn't exert negative pressure suction during drain removal.3,8
  • If the drain has been sutured in place, remove the sutures per facility policy.
  • Using sterile technique, grasp the bulb's tubing and pull the drain onto the drape, using steady pressure until the entire drain has been removed.

Never apply excessive force when attempting to remove the drain. Stop the procedure and notify the surgeon immediately if you feel resistance during removal. Drains that have been in place for longer periods may be more difficult to remove due to the growth of tissue around the drain.8

Ensure that the entire drainage tube has been removed; a jagged or torn appearance may indicate drain fracture. If this is the case, stop the procedure and notify the surgeon.8,9

  • Provide surgical site care as indicated. Apply a folded sterile gauze dressing to the drain site using sterile technique, and secure the gauze with tape or with a transparent occlusive dressing.
  • Return the patient to a comfortable resting position and clean the workspace, making sure to dispose of sharps appropriately. A dressing may be necessary for 3 to 5 days to manage residual drainage.8

Document the procedure, including the patient's response, and record the amount and characteristics of the drainage.

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Watch for problems

Although uncommon, possible complications associated with removal of a surgical drain include infection and drain fracture or retention of a drain fragment. Monitor the surgical drain site for signs of infection, including pain, erythema, warmth, edema, and purulent drainage, and notify the surgeon of these findings. Assess for and manage drain fracture/retention of drain fragment as described above.6,7

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Ensure safe, quality care

Nurses caring for surgical patients should be well versed in the various types of drainage systems. Knowing the proper technique for drain removal and being aware of potential complications are essential to ensure high quality and safe patient care.

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Types of surgical drains

Temporary surgical drainage systems are classified as either active or passive. Active drains provide negative pressure suction; passive drains rely on gravity drainage.1,8

Both types of drain can be either open or closed systems. An open drainage system is one that opens to the atmosphere; a closed drainage system empties into some type of collection device and isn't open to the external environment.3

An example of an open passive drainage system is the flat ribbon-like drain, commonly known as a Penrose drain. This type of drain provides gravity drainage by creating a conduit from the surgical site to an area outside the body. The exterior portion of the drain is typically covered by surgical gauze/sponge that must be changed as needed when it becomes saturated with drainage.

An example of a closed active drainage system (the focus of this article) is a drain connected to a bulb reservoir that resembles a grenade (commonly called a Jackson Pratt or JP drain, as shown at right below) or a spring-based evacuator (such as a Hemovac drain, as shown at left below). Both types of device are activated by removing the drainage plug from the emptying port, compressing the drainage collection reservoir, and then reinserting the drainage plug so that the collection reservoir remains closed; this creates a low negative pressure vacuum. As fluid collects in the bulb or spring-based collection reservoir, the unit expands and the negative pressure is lost, requiring emptying and reactivation before it reaches maximum collection volume.5 Drainage collection reservoirs should be emptied before they become half full, which may require emptying as frequently as every 4 hours.7 The drain is ineffective when the collection reservoir is expanded and the vacuum is lost.3

Figure

Figure

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REFERENCES

1. Gaines RJ, Dunbar RP. The use of surgical drains in orthopedics. Orthopedics. 2008;31(7):702–705.

2. Swartz AL, Azuh O, Obeid LV, et al. Developing an experimental model for surgical drainage investigations: an initial report. Am J Surg. 2012;203(3):388–391.

3. Durai R, Ng PC. Surgical vacuum drains: types, uses, and complications. AORN J. 2010;91(2):266–274.

4. Durai R, Mownah A, Ng PC. Use of drains in surgery: a review. J Perioper Pract. 2009;19(6):180–186.

5. Whitson BA, Richardson E, Iaizzo PA, Hess DJ. Not every bulb is a rose: a functional comparison of bulb suction devices. J Surg Res. 2009;156(2):270–273.

6. Diana M, Hübner M, Eisenring MC, Zanetti G, Troillet N, Demartines N.Measures to prevent surgical site infections: what surgeons (should) do. World J Surg. 2011;35(2):280–288.

7. Williams J, Toews D, Prince M. Survey of the use of suction drains in head and neck surgery and analysis of their biomechanical properties. J Otolaryngol. 2003;32(1):16–22.

8. Walker J. Patient preparation for safe removal of surgical drains. Nurs Stand. 2007;21(49):39–41.

9. Jaafar S, Vigdorchik J, Markel DC. Drain technique in elective total joint arthroplasty. Orthopedics. 2014;37(1):37–39.

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RESOURCES

Czarnecki ML, Turner HN, Collins PM, Doellman D, Wrona S, Reynolds J. Procedural pain management: a position statement with clinical practice recommendations. Pain Manag Nurs. 2011;12(2):95–111.

Makins A, Jess C, Johnson N. Randomised trial showing that lidocaine should be “squirted” through a peritoneal drain before it is removed. J Obstet Gynaecol. 2007;27(2):168–170.

Yiannakopoulos CK, Kanellopoulos AD. Innoxious removal of suction drains. Orthopedics. 2004;27(4):412–414.

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