How do I correctly place a Jackson‑Pratt (JP) drain?

Jackson-Pratt (JP) Drain Placement: Evidence-Based Technique

Critical Pre-Procedure Requirements

JP drain insertion must be performed by adequately trained personnel with mandatory supervision, as this has been shown to reduce complication rates. 1

Personnel and Environment

• A suitable assistant and trained nurse must be present during the procedure 1
• The procedure should take place in a properly equipped room with suitable lighting, resuscitation equipment, oxygen, and suction available 1
• All required equipment must be assembled before starting 1

Pre-Insertion Checklist

• Routine coagulation studies are only needed in patients with known risk factors (e.g., those on hemodialysis, following cardiac surgery, or on anticoagulation) 1
• Where possible, correct any coagulopathy or platelet defect before drain insertion 1
• Obtain informed consent explaining the procedure's nature, risks, benefits, and alternatives 1, 2

Patient Positioning and Site Selection

Optimal Positioning

• Position the patient with the arm on the affected side behind the head to expose the surgical area 1
• Alternative positions include lateral decubitus or upright leaning over a table with pillow support 1
• Under general anesthesia, the patient may be supine with slight rotation to improve access 1

Site Selection Principles

• Use ultrasound guidance when placing drains in fluid collections to identify the optimal insertion site 1
• Mark the skin at the intended site, ensuring the mark is not placed where it will cause discomfort when the patient lies on it 1
• Document the patient's position clearly so it matches during the actual insertion 1

Anesthesia Considerations

Local Anesthesia Technique

• Infiltrate local anesthetic using a small gauge needle to raise a dermal bleb first 1
• Then perform deeper infiltration into subcutaneous tissue, intercostal muscles, periosteum, and parietal pleura 1
• Use 0.25% bupivacaine at maximum dose of 2 mg/kg (0.8 ml/kg) over 8 hours, or lignocaine up to 3 mg/kg 1

Sedation Safety

• If using sedation instead of general anesthesia, it must only be administered by personnel trained in conscious sedation, airway management, and pediatric resuscitation 1
• Full monitoring equipment identical to that used for general anesthesia is mandatory 1
• Intravenous access is required before any sedation 1

Sterile Technique (Critical Safety Step)

Strict sterile technique is essential to prevent wound infection or secondary complications. 1

• Use sterile gloves, gown, and equipment throughout 1, 3
• Perform extensive skin cleansing with betadine or chlorhexidine over a large area 1, 3
• Apply sterile towels after skin preparation 1, 3

Drain Insertion Technique

Key Technical Points

• Never use substantial force or a trocar to insert a drain 1
• Make an adequate incision to allow proper drain placement without forcing 3
• For surgical drains, use blunt dissection technique rather than sharp penetration 1
• Small bore drains may be inserted using the Seldinger technique 1

Drain Size Selection

• Small bore drains (8-12 French) should be used whenever possible to minimize patient discomfort 1
• Large bore rigid drains are reserved for specific surgical indications and should be placed by surgeons 1
• Studies show small drains are as effective as large bore tubes with better patient tolerance 1

Post-Insertion Management

Securing the Drain

• Secure the drain adequately to prevent dislodgement, which occurs in 40-80% of inadequately secured drains 4
• Use appropriate suturing or securing devices at the skin exit site 4

Monitoring and Maintenance

• Maintain closed-suction system integrity 4
• Monitor drain output volume and character 4
• Drains may be left in place for extended periods (up to 43 days in studies) without significantly increasing infection risk, even with prosthetic material present 4

Common Pitfalls and How to Avoid Them

Avoid These Critical Errors

• Do not proceed without adequate training and supervision – this is the single most important factor in reducing complications 1
• Never place drains posteriorly where intercostal arteries run in the middle of intercostal spaces, increasing bleeding risk 1
• Avoid posterior placement that causes patient discomfort when lying supine and increases kinking risk 1
• Do not rely on auscultation alone for position verification when relevant – always confirm with imaging 1

Complication Prevention

• Be aware that drains can cause bowel obstruction if intestinal loops wrap around them 5
• Recognize that drain breakage during removal can occur, requiring endoscopic retrieval 6
• Monitor for signs of infection, though colonization (occurring in 63% of drains) does not necessarily indicate clinical infection 4

Antibiotic Considerations

• Perioperative antibiotics are appropriate, but prolonged prophylactic antibiotics while drains remain in place are not supported by evidence 4
• Reserve antibiotics for clinical signs of infection rather than drain colonization alone 4