Surgical Vacuum Drains: Types, Uses, and Complications

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Surgical Vacuum Drains: Types, Uses, and Complications
Surgical Vacuum Drains:
Types, Uses, and
Complications
RAJARAMAN DURAI, MD, MRCS; PHILIP C.H. NG, MD, FRCS
1.2
ABSTRACT
High- and low-pressure vacuum drains are commonly used after surgical procedures.
High-pressure vacuum drains (ie, sealed, closed-circuit systems) are efficient and
allow for easy monitoring and safe disposal of the drainage. Low-pressure vacuum
drains use gentle pressure to evacuate excess fluid and air, and are easy for patients
to manage at home because it is easy to reinstate the vacuum pressure. Perioperative
nurses should be able to identify the various types of commonly used drains and their
surgical applications. Nurses should know how to care for drains, how to reinstate
the vacuum pressure when necessary, and the potential complications that could
result from surgical drain use. AORN J 91 (February 2010) 266-271. © AORN, Inc,
2010
Key words: surgical drains, four-channel vacuum drains, low-pressure vacuum
drains, high-pressure vacuum drains, negative pressure.
D
rains are commonly used after surgical
procedures and can be classified as either
active or passive.1 Active drains use negative pressure to remove accumulated fluid from a
wound. Passive drains depend on the higher pressure inside the wound in conjunction with capillary action and gravity to draw fluid out of a
indicates that continuing education contact
hours are available for this activity. Earn the contact hours by reading this article, reviewing the
purpose/goal and objectives, and completing the
online examination and learner evaluation at http://
www.aornjournal.org/ce. The contact hours for this
article expire February 28, 2013.
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wound (ie, the difference in pressure between the
inside and the outside of the wound forces the
fluid out of the wound).
Passive drains, such as a Penrose drain, do not
require special attention; the dressing is changed
when it becomes saturated, or, if the drain is attached to a reservoir, then the reservoir is emptied
or changed when it is full. Active drains, however, do require special maintenance. The collection reservoir of an active drain expands as it collects fluid drainage by exchanging negative
pressure for fluid. The drain becomes ineffective
if the vacuum is lost. This article provides information on the various types of commonly used
vacuum drains, nursing care of drains, methods to
reinstate a drain’s vacuum pressure, and potential
complications of drain use.
© AORN, Inc, 2010
SURGICAL VACUUM DRAINS
USE OF DRAINS
Drains are used both prophylactically and therapeutically. The most common use is prophylactic
after surgery to prevent the accumulation of fluid
(eg, blood, pus) or air. In any surgery in which a
dead space (eg, a cavity) is created, the body has
a natural tendency to fill this space with fluid or
air. Use of a prophylactic drain is not routinely
recommended after clean surgical procedures,2,3
although some articles claim that use of drains
results in seroma reduction,4,5 and results of research have shown that use of vacuum drains may
not influence the outcome after tissue expander
use in breast surgery.6 Surgical drains commonly
are used after procedures on the thyroid,2 breast,7
and axillary area as well as after abdominal procedures and joint replacements.8,9 Vacuum drains
may be used to drain perirectal wounds,10 and
certain special vacuum drains (ie, endoluminal)
are available to treat anastomotic leaks that may
occur after intestinal resection and anastomosis.11,12
DRAIN INSERTION
Typically, when a drain is required, it is inserted
at the end of a surgical procedure. Frequently, the
drain is inserted through a separate hole a few
centimeters from the main incision to decrease the
risk of a postoperative wound infection. There are
two methods to insert a vacuum-type drain. The
first method is used with drains that have a sharp
trocar attached to the tube. The surgeon uses the
trocar with some drains attached to pierce the
skin from the inside of the wound at the desired
site and pulls the attached tube out through the
stab wound. The surgeon places the inner end of
the tube at the required site and detaches the trocar. The surgeon may secure the drain to the skin
with a stay-stitch. After the wound is closed, the
scrub person connects the tube to the reservoir.
Suction may be attached to the reservoir to facilitate wound drainage.
The second method for drain insertion is used
when a trocar is not attached to the drainage tube.
In this case, the surgeon uses a forceps to pierce
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the abdominal wall from the inside of the wound
and pushes the forceps through the subcutaneous
tissue. He or she then incises the overlying skin
with a scalpel. The surgeon opens the tip of the
forceps to grasp the end of the drain tube and
pulls the drain into the wound to the desired location. The surgeon may secure the tube to the patient’s skin with a stay-stitch. The scrub person
connects the tube to the reservoir after the wound
is closed.
Vacuum drains are classified according to the
degree of pressure used. Typical bottled vacuum
drains (eg, Redi-vac) use high negative pressure.
Bulb-shaped suction devices (eg, Jackson-Pratt)
and collapsible four-channel vacuum drains (eg,
J Vac, Blake) use low negative pressure.
HIGH-NEGATIVE-PRESSURE DRAINS
High-pressure bottled vacuum drains have the
advantages of being sealed, closed-circuit systems
that allow for easy monitoring and safe disposal
of the drainage. These systems consist of a clear,
plastic reservoir with a rubber cap that has indicator wings to monitor the presence of vacuum
pressure and an opening in which to connect the
drainage tube. When a vacuum is present in the
system, the wings on the rubber cap are close
together; the wings are apart if the vacuum is
lost. The end of the drainage tube that is inserted
into the wound has multiple openings on its inner
side through which fluid can be evacuated from
the wound. The wound should be closed before
the clamps on the drain are opened; otherwise the
vacuum will be lost as the tube sucks in atmospheric air.
Although the patient’s condition and type of
surgical procedure indicate appropriate monitoring
times and documentation of drainage volumes, the
amount of drainage typically is measured two to
four hours after surgery and every six hours
thereafter. Occasionally, the surgeon may decide
to clamp the tube for a couple of hours if it
drains too much (eg, more than 100 mL an
hour).13 This may occur after some procedures,
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DURAI—NG
the connection end of the Yankauer suction catheter tightly against the white plastic attachment of
the vacuum bottle and turns on the suction machine. In both methods, when the rubber cap
shows evidence of enough vacuum pressure in the
bottle, the clinician clamps the plastic attachment
on the drainage tube to retain the vacuum pressure, then the clinician disconnects the suction
machine tubing.
Figure 1. One method to reinstate the pressure in a
high-pressure bottled vacuum drain is to attach the
plastic tube (arrow) to the suction unit and then
release and close the valve when appropriate.
such as joint replacements. Once every 24 hours,
the nurse should mark the drainage reservoir bottle and record the volume of drainage collected in
24 hours.
Reinstating Vacuum Pressure
When the vacuum is lost, the drain will not function, so the tube has to be connected to a new
bottle or the vacuum must be reinstated by one of
the following methods. A clinician removes the
bottle from the drainage tube and loosens the
plastic attachment. In method #1 (ie, the suctiontube method), the clinician connects the plastic
tube of the suction machine to the white plastic
attachment of the vacuum bottle and turns on the
suction machine (Figure 1). In method #2 (ie, the
reverse Yankauer suction method), the clinician
inserts the tip of a Yankauer suction catheter into
the suction machine tube. The clinician then holds
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AORN Journal
LOW-NEGATIVE-PRESSURE DRAINS
Low-pressure vacuum drains have a plastic bulbshaped reservoir and a silicone drainage tube,
with multiple side holes at the end that is inserted
into the wound. When the bulb is compressed, air
is forced out, which creates negative pressure in
the system. Low-negative-pressure drains work
gently to evacuate excess fluid and air.
It is easy to educate the patient so that he or
she can care for a bulb-type, low-pressure vacuum drain at home without help. Removing the
plug from the exit valve allows the bulb to inflate. The amount of drainage is easily quantified
with the measurement marks on the side of the
bulb. The patient empties the contents into a disposable container or cup by squeezing the bulb
reservoir, then the patient squeezes the bulb again
and replaces the cap, thus recreating the negative
pressure. The patient can also be instructed on
Figure 2. A four-channel vacuum drain ready for
insertion.
SURGICAL VACUUM DRAINS
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scrub person connects the drain tube to the outlet
adaptor. The scrub person folds or bends the reservoir into a U shape by pressing both thumbs on
the marked areas in the middle part of the reservoir, which releases the locking system (Figure
3). The scrub person removes the plug from the
exit valve and repeats the procedure by bending
the reservoir to create vacuum pressure. The
scrub person then reseals the reservoir with the
plug. The scrub person may have to repeat this
process several times until all the air is removed
from the reservoir. On the postoperative nursing
unit, the nurse monitors drain output and empties
the reservoir when required. A vacuum is easily
visible by the undistended or unfolded appearance
of the reservoir. The bag will appear larger when
the vacuum is lost.
Figure 3. To use a four-channel vacuum drain, the
clinician bends the reservoir into a “U” by pressing
both thumbs on the marked spots to release the
lock.
how to remove the drain at home without assistance, if necessary.
A four-channel vacuum drain is a type of lowpressure drain; the primary difference is the size
and shape of the reservoir.14 The drain tube is
soft and flexible,15 and the reservoir is foldable
with two outlets (Figure 2). One outlet is used for
connecting to two drains and another outlet is
used for emptying the contents. The drainage tube
has four tiny lumina that join to form a single
lumen. The advantage of a four-channel vacuum
drain is that it is unlikely to become occluded by
the omentum because of the tiny size of the
holes. The disadvantage is that the holes may not
be large enough to evacuate larger particles of
tissue or blood clots.
After the surgeon inserts the drain by using
one of the two methods previously described, the
DRAIN REMOVAL
The negative pressure in the reservoir should be
released by removing the plug from the exit
valve, and the bulb or reservoir should be disconnected before the drain is removed. After cutting
the stay-stitch, if there is one, the nurse or patient
smoothly pulls out the drain. Drain removal can
be painful for some patients, so the patient may
wish to take an oral analgesic before removing
the drain. After removing the drain, the nurse or
patient should clean the drain-tube site with antiseptic and a small dry cotton swab. If the site is
oozing, then the nurse can apply a gauze dressing.
If there is a large quantity of drainage, then the
nurse can apply a stoma bag.
COMPLICATIONS OF VACUUM DRAINS
Although drains serve an important function, there
are potential complications with their use. Some of
these complications include the following:

Breakage—Drains are made of strong silicone
or polyvinyl chloride plastic and, therefore,
are not likely to break, but breakage can occur.16 Laparoscopy may be required if part of
a drain breaks off inside the patient’s abdomen during removal.17
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Difficulty in removal—If a drain remains inserted for a long period of time, it may become difficult to remove. On occasion, the
drain has been stitched to the wound during
closure of deeper layers. The nurse should
report any difficulty encountered during drain
removal to the surgeon. The wound may need
to be temporarily opened to remove the drain.
Inadvertent removal—Drains may get tangled
in the patient’s other lines (eg, IV tubing,
electrocardiogram leads) or become tangled in
clothing or linen and accidentally be pulled
out. This might cause bleeding or pain.
Infection—Although one purpose of surgical
drains is to evacuate excessive fluid accumulation to prevent bacterial proliferation, drains
can increase the risk of infection via retrograde bacterial migration. Typically, drains are
removed when they are draining a negligible
amount (eg, less than 25 mL per day; less
than 1 mL per hour) to minimize this risk.
Occlusion—Drain tubes can become occluded
by blood clot, tissue, or the omentum. This can
lead to the formation of a hematoma and subsequent discomfort and increased risk for infection.
Pain—Drain sites can be painful and may prevent the patient from lying on the side where the
drain is inserted. Furthermore, some patients are
apprehensive about moving with a drain in place
after surgery; lack of movement can potentially
increase the risk of postoperative immobility
complications (eg, venous thrombosis).
Unsightly scar—A drain site is left to heal by
secondary intention so the site may form a
puckering scar. When possible, the surgeon
may place the drain in a skin crease to help
improve cosmesis.18
Visceral perforation—Drains left in place for a
long period of time can erode into the bowel
and lead to visceral perforation.19
gical drain use. Understanding how to create the
negative pressure vacuum will help nurses provide better drain care and better patient education.
Knowing how to recreate the negative pressure in
a high-pressure reservoir is particularly useful
when an underfilled high-pressure vacuum drain
bottle loses its vacuum pressure. Low-pressure
vacuum drains have the advantages of easy emptying and easy recreation of the gentle, negative
low-pressure vacuum, and they are easy for patients to manage at home.
Editor’s note: Redi-vac™ is a trademark of
Atrium Medical, Hudson, NH. Jackson-Pratt® is
a registered trademark of Cardinal Health, Dublin, OH. J Vac® and Blake® are registered
trademarks of Ethicon, St Louis, MO.
References
1.
2.
3.
4.
5.
6.
7.
8.
SUMMARY
Perioperative nurses need to know the surgical
uses of high- and low-pressure vacuum drainage
systems as well as potential complications of sur270
AORN Journal
9.
Durai R, Mownah A, Ng PC. Use of drains in surgery:
a review. J Perioper Pract. 2009;19(6):180-186.
Suslu N, Vural S, Oncel M, et al. Is the insertion of
drains after uncomplicated thyroid surgery always necessary? Surg Today. 2006;36(3):215-218.
Kumar M, Yang SB, Jaiswal VK, Shah JN, Shreshtha
M, Gongal R. Is prophylactic placement of drains necessary after subtotal gastrectomy? World J Gastroenterol. 2007;13(27):3738-3741.
Ismail M, Garg M, Rajagopal M, Garg P. Impact of
closed-suction drain in preperitoneal space on the incidence of seroma formation after laparoscopic total extraperitoneal inguinal hernia repair. Surg Laparosc Endosc Percutan Tech. 2009;19(3):263-266.
Chowdri NA, Qadri SA, Parray FQ, Gagloo MA. Role
of subcutaneous drains in obese patients undergoing
elective cholecystectomy: a cohort study. Int J Surg.
2007;(6):404-407. Epub June 8, 2007.
McCarthy CM, Disa JJ, Pusic AL, Mehrara BJ, Cordeiro PG. The effect of closed-suction drains on the incidence of local wound complications following tissue
expander/implant reconstruction: a cohort study. Plast
Reconstr Surg. 2007;119(7):2018-2022.
Barton A, Blitz M, Callahan D, Yakimets W, Adams
D, Dabbs K. Early removal of postmastectomy drains is
not beneficial: results from a halted randomized controlled trial. Am J Surg. 2006;191(5):652-656.
Sundaram RO, Parkinson RW. Closed suction drains do
not increase the blood transfusion rates in patients undergoing total knee arthroplasty. Int Orthop. 2007;31
(5):613-616. Epub September 1, 2006.
Kumar S, Penematsa S, Parekh S. Are drains required
following a routine primary total joint arthroplasty? Int
Orthop. 2007;31(5):593-596. Epub October 11, 2006.
SURGICAL VACUUM DRAINS
10.
11.
12.
13.
14.
15.
16.
Durai R, Ng PC. Perirectal abscess following procedure
for prolapsed haemorrhoids successfully managed with
a combination of VAC sponge and Redivac systems.
Tech Coloproctol. 2009;13(4):307-309. Epub July 14,
2009.
Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg
F, Jauch KW. Endoluminal vacuum therapy for the
treatment of anastomotic leakage after anterior rectal
resection. Rozhl Chir. 2008;87(8):397-402.
Richterich JP, Heigl A, Muff B, Luchsinger S,
Gutzwiller JP. Endo-SPONGE: a new endoscopic treatment option in colonoscopy. Gastrointest Endosc. 2008;
68(5):1019-1022. Epub June 4, 2008.
Brueggemann PM, Tucker JK, Wilson P. Intermittent
clamping of suction drains in total hip replacement reduces postoperative blood loss: a randomized, controlled trial. J Arthroplasty. 1999;14(4):470-472.
Tsuda Y, Takemura T, Shimamura Y, Iwasa S. Usefulness of silicone Blake drains after cardiac surgery [in
Japanese]. Kyobu Geka. 2003;56(12):1017-1019.
Rayatt SS, Dancey AL, Jaffe W. Soft fluted silicone
drains: a prospective, randomized, patient-controlled
study. Plast Reconstr Surg. 2005;115(6):1605-1608.
Campbell W, Wallace W, Gibson E, McCallion K.
Intra-abdominal drain fracture following pancreatic necrosectomy. Ir J Med Sci. Epub ahead of print April 9,
2009.
www.aornjournal.org
17.
18.
19.
Bharathan R, Dexter S, Hanson M. Laparoscopic retrieval of retained Redivac drain fragment. J Obstet
Gynaecol. 2009;29(3):263-264.
Dhar V, Townsley R, Black M, Laccourreye O. Thyroid surgery: the sub-mental drain. J Laryngol Otol.
2009;123(7):786. Epub October 17, 2008.
Carter P. Perforation of the bowel by suction drains.
Br J Surg. 1993;80(1):129.
Rajaraman Durai, MD, MRCS, is a specialist
registrar at University Hospital Lewisham,
London, UK. Dr Durai has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Philip C.H. Ng, MD, FRCS, is a consultant
surgeon for the Department of Surgery at University Hospital Lewisham, London, UK.
Dr Ng has no declared affiliation that could be
perceived as a potential conflict of interest in
publishing this article.
AORN Journal
271
EXAMINATION
CONTINUING EDUCATION PROGRAM
1.2
Surgical Vacuum Drains: Types,
Uses, and Complications
PURPOSE
To educate perioperative nurses about the use of surgical vacuum drains.
OBJECTIVES
1.
2.
3.
4.
5.
6.
Differentiate between passive and active drains.
Identify uses of surgical drains.
Discuss how drains are inserted.
Explain how to reinstate vacuum pressure.
Describe low-pressure vacuum drains.
Identify complications associated with drain use.
The Examination and Learner Evaluation are printed here for your convenience. To
receive continuing education credit, you must complete the Examination and
Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. Passive drains
a. use negative pressure to remove accumulated
fluid from a wound.
b. depend on the higher pressure inside the
wound in conjunction with capillary action and
gravity to draw fluid out of a wound.
c. use the sodium-potassium pump to exchange
sodium ions across the cell membrane with
potassium, which draws fluid out of the
wound.
2. The collection reservoir of an active drain exchanges negative pressure for fluid, so if the vacuum is lost, the drain becomes ineffective.
a. true
b. false
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3. The most common use of drains is to
a. introduce medication such as antibiotics into
the surgical wound after surgery.
b. decrease postoperative pain.
c. prevent the accumulation of fluid or air
postoperatively.
d. monitor pressure inside the wound.
4. Use of a prophylactic drain is routinely recommended after clean surgical procedures.
a. true
b. false
5. When a surgeon inserts a drain with an attached
trocar, he or she pierces the skin from the outside
of the wound at the desired site and pulls the attached tube in through the stab wound.
a. true
b. false
© AORN, Inc, 2010
CE EXAMINATION
6. When a surgeon inserts a drain without an attached trocar, the surgeon
1. uses a forceps to pierce the abdominal wall
from the inside of the wound.
2. pushes the forceps through the subcutaneous
tissue.
3. incises the overlying skin with a scalpel.
4. grasps the end of drain tube with the forceps
and pulls it into the wound.
5. secures the tube to the patient’s skin with a
stay-stitch.
a. 2 and 3
b. 1, 4, and 5
c. 2, 3, 4, and 5
d. 1, 2, 3, 4, and 5
7. If vacuum pressure is lost in a high-pressure bottled vacuum drain, the vacuum can be reinstated
by using the ___________________ method.
1. reverse Yankauer suction
2. suction camshaft
3. suction tube
4. inversion suction
a. 1 and 3
b. 2 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4
8. The advantages of bulb-type, low-pressure vacuum drains include that
1. they can easily be cared for by the patient at
home without help.
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2. the amount of drainage is easy to quantify.
3. the patient can be instructed on how to remove
the drain without assistance at home.
4. they work gently to evacuate excess fluid and
air.
a. 1 and 2
b. 3 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4
9. The advantage of a four-channel vacuum drain is
that it
a. can evacuate larger particles of tissue or blood
clots.
b. can be used in multiloculated cavities.
c. is unlikely to become occluded by the
omentum.
d. has a higher negative-pressure vacuum.
10. Potential complications of drain use include
1. breakage or occlusion.
2. difficult or inadvertent removal.
3. electrolyte imbalance.
4. infection.
5. pain or unsightly scar.
6. visceral perforation.
a. 1, 3, and 5
b. 2, 3, 4, and 6
c. 1, 2, 4, 5, and 6
d. 1, 2, 3, 4, 5, and 6
The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor,
with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell
have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
AORN Journal
273
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
1.2
Surgical Vacuum Drains: Types,
Uses, and Complications
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. Rate the items as described
below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Differentiate between passive and active
drains. Low 1. 2. 3. 4. 5. High
2. Identify uses of surgical drains.
Low 1. 2. 3. 4. 5. High
3. Discuss how drains are inserted.
Low 1. 2. 3. 4. 5. High
4. Explain how to reinstate vacuum pressure.
Low 1. 2. 3. 4. 5. High
5. Describe low-pressure vacuum drains.
Low 1. 2. 3. 4. 5. High
6. Identify complications associated with drain
use. Low 1. 2. 3. 4. 5. High
CONTENT
7. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
8. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
9. Will you be able to use the information from
this article in your work setting? 1. Yes 2. No
10. Will you change your practice as a result of
reading this article? (If yes, answer question
#10A. If no, answer question #10B.)
10A. How will you change your practice (Select all
that apply)
1. I will provide education to my team regarding why the change is needed.
2. I will work with management to change
and/or implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for the change.
4. I will implement the change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other:
10B. If you will not change your practice as a result
of reading this article, why? (Select all that
apply)
1. The content of the article is not relevant to
my practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make a
change.
4. Other:
11. Our accrediting body requires that we verify the
time you needed to complete the 1.2 continuing
education contact hour (72-minute) program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center
approves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this
activity for relicensure.
Event: #10007; Session: #4000 Fee: Members $6, Nonmembers $12
The deadline for this program is February 28, 2013.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each
applicant who successfully completes this program will be able to print a certificate of completion.
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Vol 91
No 2
© AORN, Inc, 2010

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