Fatigue During Long Operations

The Victorian Surgical Consultative Council

Penrose Drain Tube Use and Hazards – a VSCC Clinical Practice Guide

PENROSE DRAIN TUBE USE AND HAZARDS

There are several clinical indications for the placement of a surgical drain, that can be largely divided into therapeutic or prophylactic reasons, including but not restricted to: 1) to remove blood/ exudates/ transudates and gas, thereby minimising the potential for wound infection; 2) to obliterate dead space thereby promoting more prompt wound healing; and

3) to monitor/ manage post-operative anastomotic leakage.

Drains are either open or closed and the latter may drain passively or with the aid of suction. Broadly speaking it is preferable to use a closed system as it more accurate and has a reduced risk of contamination. Drains should remain safely secured to skin, until removed.

Where an open drain is used (e.g. corrugated, Penrose, Yeates drain) it is imperative that the drain is secured in a manner that prevents both premature dislodgement and retraction. Penrose drains contain latex.

Retained Penrose drains. There have been several further sentinel events recently reviewed by the Victorian Surgical Consultative Council (VSCC) involving retained Penrose drains. Retained Penrose drains were found to have occurred when either a suture was not used to secure the drain at the exit site, or the retaining suture was cut to facilitate ‘shortening’ or staged withdrawal of the drain. In the latter cases the drain was neither re-secured nor modified (e.g. with a safety pin) to prevent migration. In all cases the drain was ‘assumed’ to have been removed. The retained drains were discovered between 8 days and 15 months later because of persisting symptoms and in one case despite repeated plain xraying. Penrose drains do not have radio-opaque markers - additional CT imaging was needed to identify the retained drain.

Following a review of these cases the VSCC makes the following recommendations:

1) The use of closed drains is preferable to open drains. Care during closure of incisions must be used to avoid tethering or damaging drains while suturing each layer.

2) Ideally, drains should be radio-opaque or have markers to facilitate easier radiological detection.

3) All drains should be secured in accordance with locally developed and approved procedures, preferably involving suturing to the patient’s skin at the exit site.

4) The Victorian Hospitals Post-operative Orders form helps to document the placement of and post-operative management of the drain. The type of drain and length should be clearly documented in the operative notes.

5) Penrose drains should not be “shortened” or withdrawn in stages. Penrose drains are soft and small, often used in the perineum or other locations which are awkward for inspection, dressing or shortening. The “shortening” is hazardous.

6) If a drain is to be withdrawn in stages, it should preferably not be shortened by cutting, and should be re-secured appropriately after each withdrawal. When finally removed, its length must be checked against that documented in the operative notes.

7) Clearly document the removal of drains, intact. In the absence of clear documentation of an intact drain removal, appropriate medical imaging must be undertaken to ascertain if it (or a fragment of it) is retained, or to confirm that it is no longer present.

VSCC Approved: August 2013