How to declot a surgical drain?

How to Declot a Surgical Drain

When a surgical drain suddenly stops draining, immediately check for obstruction by flushing the drain to restore patency. 1

Immediate Assessment and Action

• Check for mechanical obstruction first by examining the drain for kinking or displacement before assuming clot formation 1
• Assess whether the drain is still producing output or has completely ceased draining 1
• Never apply vigorous suction or excessive pressure, as this can damage the vascular wall, collapse soft-walled catheters, or cause catheter rupture 2

Flushing Technique for Blocked Drains

• Flush the drain when sudden cessation of drainage occurs to check for and clear blockage 1
• Use gentle irrigation with sterile saline (0.9% Sodium Chloride) to attempt to restore patency 2
• Avoid excessive force during flushing, which could rupture the catheter or expel clot material into circulation 2

Thrombolytic Therapy for Persistent Clots

If simple flushing fails and the drain remains occluded by clot:

• Consider instillation of alteplase (Cathflo Activase) at 1 mg/mL concentration for catheter occlusion 2
  • For patients ≥30 kg: instill 2 mg in 2 mL 2
  • For patients <30 kg: use 110% of internal lumen volume, not exceeding 2 mg in 2 mL 2
• Allow 30-minute dwell time, then assess function by attempting to aspirate 2
• If unsuccessful after 30 minutes, allow up to 120 minutes total dwell time 2
• A second dose may be instilled if catheter function is not restored after 120 minutes 2

Important Precautions with Thrombolytics

• Use caution in patients with active bleeding, recent surgery (<48 hours), thrombocytopenia, or known infection in the catheter 2
• Using thrombolytics in infected catheters may release localized infection into systemic circulation 2
• Monitor for bleeding complications, which are the most frequent adverse reaction with thrombolytics 2

Alternative Mechanical Techniques

• "Stripping" or "milking" the drain involves squeezing and rolling the tubing to mechanically dislodge clots 3
• This manual technique can achieve approximately 94% stripping efficiency when performed correctly 3
• Apply gentle, progressive pressure along the length of the drain tubing toward the collection reservoir 3

When Conservative Measures Fail

• If the drain cannot be unblocked and significant fluid remains, remove and replace the drain 1
• Consider upsizing the catheter if recurrent clotting occurs 1
• For complex situations with persistent drainage issues despite manipulation, surgical consultation may be necessary 1

Special Considerations for Specific Drain Types

For Chest Drains (Pleural Space)

• Never clamp a bubbling chest drain, as this can cause life-threatening tension pneumothorax 1
• Low-pressure suction (5-10 cm H₂O) may help prevent blockage with debris in pleural infections 1
• Regular flushing of small-bore drains has been suggested but lacks controlled evidence in pediatrics 1

For Abdominal/Surgical Drains with Internal Drainage

• If a percutaneous drain exists alongside internal drainage, clamp it except during lavage to maintain pressure gradient favoring internal drainage 1
• Perform aggressive lavage every 4-6 hours through the percutaneous drain if clinical response is inadequate 1
• Continuous free drainage reduces pressure in collections and prevents effective internal drainage 1

Common Pitfalls to Avoid

• Do not assume all drainage cessation is due to clotting—catheter malposition, mechanical failure, or suture constriction are alternative causes 2
• Avoid leaving drains in place too long, as prolonged catheterization increases infection risk through retrograde contamination 4, 5
• Do not use excessive force during any manipulation, which risks catheter damage or clot embolization 2
• Maintain strict aseptic technique during all drain manipulations to prevent introducing infection 2, 5