Penrose Drain Placement, Management, and Removal
Direct Recommendation
Penrose drains should NOT be used routinely for superficial wound drainage, as they are ineffective at preventing wound complications and may increase infection risk by serving as a conduit for bacterial entry. 1, 2
When Penrose Drains Should NOT Be Used
Avoid Penrose drains in the following scenarios:
Routine surgical wound drainage – A randomized controlled trial of 105 breast biopsy patients demonstrated that Penrose drains had no effect on postoperative wound complications (28% with drain vs 17% without drain), proving them ineffective compared to no drainage. 2
Prevention of hematomas or seromas – The same study showed Penrose drains failed to prevent these collections, whereas closed suction drains (like Jackson-Pratt) significantly reduced complications from 21% to 10%. 2
Clean and clean-contaminated surgical cases – The World Society of Emergency Surgery guidelines explicitly recommend against routine drain use in these settings due to lack of benefit and potential for increased morbidity. 1
Any situation where closed suction drainage is available – Closed suction systems are superior to passive Penrose drains for preventing fluid accumulation and reducing surgical site infections. 2
Limited Acceptable Uses for Penrose Drains
Penrose drains may be considered only in these specific circumstances:
1. Complex Superficial Abscesses
- Use looped Penrose drains through multiple small incisions for large, complex subcutaneous abscesses that extend over a wide surface area. 3
- This minimally invasive technique avoids large incisions and extensive packing/dressing changes. 3
- The drain provides continuous passive drainage while tissues heal. 3
2. Remote/Rural Settings Without Medical Follow-up
- Fix Penrose drains to wound dressings (not skin) so they automatically remove during dressing changes, eliminating the need for a physician to remove them. 4
- A retrospective study of 54 drains in rural Japan showed 100% automatic removal with zero drain-related complications (no hematomas, infections, seromas, or drain breakage). 4
- This technique is specifically valuable for minor soft tissue trauma or small subcutaneous tumor excisions in areas lacking resident physicians. 4
3. Hybrid Drainage Systems
- Combine a Penrose drain inside a silicone drain to prevent tip occlusion by fibrin while maintaining drainage capability. 5
- This allows conversion to sump tube drainage if complications like leakage or abscess occur. 5
Critical Management Principles If Penrose Drains Are Placed
Placement Technique
- Use sterile technique with betadine or chlorhexidine skin preparation over a large area to prevent wound site infection or secondary contamination. 1
- Infiltrate local anesthetic (0.25% bupivacaine 2 mg/kg max, or lidocaine 3 mg/kg max) into skin, subcutaneous tissue, and deeper structures before placement. 1
- Never use substantial force or a trocar during insertion to avoid tissue trauma. 1
Drain Fixation
- Traditional method: Suture drain to skin, requiring physician removal 1-7 days postoperatively. 4
- Alternative method for remote settings: Sew drain onto wound dressing for automatic removal during dressing changes. 4
Removal Timing
- Remove drains as soon as possible (ideally within 24 hours to 7-14 days maximum) to minimize infection risk, as prolonged drainage increases surgical site infection rates. 1, 6, 7
- Remove immediately if infection is suspected or if drainage becomes purulent. 6, 7
- Remove when output is minimal (<30 mL daily) or serous in character. 1
Key Pitfalls to Avoid
Infection Risk
- Penrose drains serve as microbial conduits allowing pathogens to migrate from skin to deeper tissues, with an overall infection risk ratio of 2.47 (95% CI 1.71-3.57). 1
- Never extend drain use beyond necessary – each additional day increases bacterial colonization risk. 1, 6
Ineffectiveness Compared to Alternatives
- Passive drainage is inferior to active suction – closed suction drains reduce complications by 50% compared to Penrose drains in breast surgery. 2
- Penrose drains do not prevent fluid collections that they are intended to manage. 6, 2
Proper Drain Positioning
- Keep surgical bulb at gravity level at all times to prevent drained fluid from re-entering the surgical pocket. 1
- Place drains through subcutaneous tunnels rather than directly through incisions to reduce infection risk. 1
Contraindications
- Never use in place of closed suction drainage when the goal is to prevent hematoma or seroma formation. 2
- Avoid in patients requiring extended drainage beyond 7-14 days, as Penrose drains lack the safety profile for prolonged use. 1
Evidence-Based Alternatives
When drainage is truly indicated, prefer: