Why wound drain is not recommended routinely
of not using a wound drain with regard to a reduced risk of wound infection, but no significant differences were achieved.”1
A statement of the 19th century British surgeon Lawson Tait, “When in doubt, drain”, has led to a widespread routine prophylactic postoperative placement of drains.1
But since then, a number of studies have been published questioning the benefits of routine wound drainage.1,2
The prophylactic use of drainage of enteric anastomoses is said to be associated with an increased risk of anastomotic breakdown and fistula formation.3
Guidelines
Guidelines
| Guideline | Recommendation | Category (if mentioned) | |
| CDC4 | “If drainage is necessary, use a closed suction drain.Place a drain through a separate incision distantfrom the operative incision. Remove the drain assoon as possible.” | Category IB | |
| WHO1 | “The panel suggests that perioperative antibiotic prophylaxis should not be continued to the presence of a wound drain for the purpose of preventing SSI.” | Conditional recommendation, low quality of evidence | |
“The panel suggests removing the wound drain when clinically indicated. No evidence was found to recommend an optimal timing of wound drain removal for the purpose of preventing SSI.” | Conditional recommendation, very low quality ofevidence | ||
| NICE5 | - | - | |
| KRINKO6 | Wound drains should not be used routinely, butonly when specifically indicated and for the shortesttime possible. Open drains should not be usedbecause of the risk of infection. If drains areindicated, they should be drained via a separateincision. | - | |
HARTMANN:
Denise Leistenschneider, Senior Clinical Consultant
"The use of drains should be critically considered in light of the study evidence."
What is recommended?
Drainage type:4
use closed suction drain
Drainage placement:4,6
through a separate incision away from the surgical incision
Drainage removal:4,6
remove drain as soon as possible
Indications for surgical drainage in abdominal surgery
Some possible indications for surgical drainage are:3
- “Decompression of viscus (e.g. duodenostomy, T-tube in common bile duct)
- Large potential dead space (e.g. abdominoperineal resection, abscess cavity)
- Insecure closure of hollow viscera (e.g. duodenum) – may provide an early warning of fistula
- Established or potential fistula (e.g. gastrointestinal, biliary and pancreatic)
- Presence of necrotic or infected tissue
- Doubtful haemostasis – may provide an early warning of haemorrhage”
Comparison of active and passive drain3
| Active drain | Passive drain | |
| Function | Works by negative pressure created by compressible drums or mechanical education system | Depends on pressure differentials and gravidity |
| Pressure gradient | Low to moderate negative – 100 to 150 mmHg High negative – 300 to 500 mmHg (sump only) | Positive |
| Drain site dressing | Minimal or not required | Increased incidence because of limited effect on the dead space |
| Fluid collections | Decrease incidence because negative pressure improves tissue apposition and obliterates dead space | Increase incidence because of limited effect on the dead space |
| Retrograde infection | Lower incidence especially with closed suction system | Higher incidence with open system |
| Radiographic studies via drain | Easy to perform | Difficult except in special circumstances, e.g. T-tube and NGT |
| Pressure necrosis | Greater incidence | Less common |
NGT = nasogastric tube. Table modified from Memon et al. 2002
Possible complications of drains3
- Haemorrhage, fistula and perforation because of erosion
- Inflammation
- Impaired healing
- Leackage
- Pain
- Postoperative pyrexia
- Fluid, electrolyte and protein loss
- Pneumoperitoneum, pneumothorax
- Surgical emphysema
- Excessive fluid secretion
References
- WHO (2016) Global guidelines for the prevention of surgical site infection. World Health Organization 2016.
- Sagar PM, et al. (1993) Randomized trial of drainage of colorectal anastomosis. Br J Surg 80(6): 769–771.
- Memon MA, et al. (2002) The uses and abuses of drains in abdominal surgery. Hospital Medicine 63(5): 282–288.
- CDC (1999) Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 20(4): 247–278.
- NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated:19 August 2020. www.nice.org.uk/guidance/ng125.
- KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
In focus
Publications
Scientists around the world work daily to identify and assess infection risks. This scientific debate is an indispensable prerequisite for increasing the safety of patients and medical staff.
Here you will find a selection of recent studies and publications...
Here you will find a selection of recent studies and publications...
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