Surgical Drains: Indications, Types, & Principals of Use

Indications The four indications for applying a surgical drain are: 1-To collapse surgical dead space in areas of redundant tissue (e.g., neck and axilla) 2- To provide focused drainage of an abscess or grossly infected surgical site 3- To provide early warning notice of a surgical leak (either bowel contents, secretions, urine, air, or blood)—the so called sentinel drain 4- To control an established fistula leak

Drain Types Open, Flat, Penrose Dependent on gravity and capillary action Drainage related to surface area Penrose - latex Advantages Allow drainage Help obliterate dead space Soft / malleable – less painful Disadvantages Very irritating Allow bacterial ingress Cannot be connected to suction Gravity dependent

Drain Types Tube Single lumen +/- side holes Silicone, polyvinyl chloride, red rubber Advantages Drain from both within and outside of lumen Can be connected to suction Can be used with closed collection system Disadvantage Discomfort due to stiffness

Drain Types Double lumen Sump drains – open/open suction Drainage of fluid via large lumen Sump lumen – smaller and allows ingress of air AIR Advantages More efficient than single lumen Maintain patency longer than single lumen Disadvantages Risk of contamination of wound as environmental air drawn in – reduced with filter FLUID AIR

Drain Types Passive Active Continuous suction Intermittent suction

Passive Drains Passive Drain by means of pressure differentials, overflow, and gravity Provides a stent that keeps a draining tract / cloaca open Allow egress via a path of least resistance Flat or with a lumen Open or Closed – Closed preferred

Passive Drains Passive closed Advantages Disadvantages Allow evaluation of volume and nature of fluid Prevent bacterial ascension Eliminate dead space Help appose skin to wound bed – quicker wound healing Disadvantages Gravity dependent – affects location of drain Drain easily clogged

Active Drains Vacuum pulls fluid / gas from the wound Closed to atmosphere = Closed suction Vacuum applied to a single lumen tube Not gravity dependent

Active Drains

Active Drains Advantages Disadvantages Keep wound dry – efficient fluid removal Can be placed anywhere Prevent bacterial ascension Help appose skin to wound bed – quicker wound healing Allows evaluation of volume and nature of fluid Disadvantages High negative pressure may injure tissue Drain clogged by tissue

Principals of Ideal Use Aseptic site preparation (clip, scrub, debride, lavage) Place to avoid anastomosis sites and major vessels Exit through separate stab incision, away from surgical incision Aseptic postoperative management (cover with sterile bandage, change before strike through, clean & dry cage)

Complications and Failure of Drains Poor Drain Selection Poor Drain Placement Poor Post-operative Management

Complications and Failure of Drains Infection Ascending bacterial invasion Foreign body reaction Decreased local tissue resistance Bacterial hiding places Poor placement – fluid accumulation, drain kinked Poor postoperative management

Complications and Failure of Drains Discomfort / Pain Thoracic Tubes – diameter too large Stiff tubing Inefficient Drainage Exiting in non-dependent locale (passive drains) Kinked tube Obstructed Poor drain selection – diameter too small to remove viscous fluid

Complications and Failure of Drains Breakdown of anastomotic sites Erosion into hollow organs (firm drains) Incisional dehiscence / hernia Poor placement Premature Removal Accumulation of fluid Decreased Mobility DVT/PE Increased hospital stay