Journal of Surgery Current Trends & Innovations Category: Clinical Type: Research Article

The Use of Surgical Drains amongst the Orthopaedic Surgeons of Kuwait

Bader Al-Hindi1, Aliaa Khaja1*, Sager S Hanna1, Mohammad AlAwadh1 and Ali Jarragh2
1 Department Of Trauma And Orthopedics, Al Razi Orthopedic Hospital, Kuwait City, Kuwait
2 Department Of Medicine, Kuwait University, Jaber Hospital, Khalid Ben Abdul Aziz Street, Kuwait

*Corresponding Author(s):
Aliaa Khaja
Department Of Trauma And Orthopedics, Al Razi Orthopedic Hospital, Kuwait City, Kuwait
Tel:+965 66135777,
Email:aliaa.khaja@gmail.com

Received Date: May 18, 2020
Accepted Date: May 23, 2020
Published Date: May 30, 2020

Abstract

Background: The use of surgical drains has been a controversial topic among all surgical specialties and the outcome of its use has conflicting data especially in orthopaedic surgery. The aim of this study was to see if orthopaedic surgeons in Kuwait know the current guidelines and evidence-based practice. The study also aimed to investigate if demography, background, experience as well as subspecialty among orthopaedic surgeons can influence their usage of surgical drains. In addition, to assess their adherence to the international recommendations for the use of surgical drains. 

Method: An electronic survey was constructed, based on the current evidence from the literature provided by high-level institutions/organizations and Evidence-Based Medicine (EBM) sources. Including evidence from the WHO, CDC and Cochrane reviews. The survey was sent to all orthopedic surgeons in Kuwait (Total of 116), 73 participants responded (63% response rate). In addition the questions also surveyed demographic data regarding subspecialty and technical habits of use. 

Results: The survey included a total of 73 orthopedic surgeons from different hospitals and subspecialties .It contained a total of 21 questions in which 7 questions were further subdivided into 6 categories. The categories represent 6 items of the current EBM policies, aiming to address the participant’s knowledge by point scoring. A total score of 6 (maximum score) is only achieved by 1 surgeon. 4 Surgeons had a score of 0. The majority of surgeons (88%) scored between 1 and 3 points out of 6. All the secondary objectives were statistically insignificant. 

Conclusion: These results show that orthopedic surgeons in Kuwait are not updated with the current evidence-based practice regarding the use of surgical drains in Orthopedic Surgery.

Keywords

Infection; Orthopedic surgery; Surgical drains

INTRODUCTION

The use of surgical drains was historically recorded by Hippocrates in 460-370 BC; he had used hollow tubes to drain an empyema in the abdomen. However, the surgeon who was firstly accredited with the use of modern surgical drains among orthopedic patients was Ambroise Pare 1510-1590 [1,2]. 

The use of orthopedic surgical drains has been subject to controversy [3]. On one hand, it is a tool used for evacualting surgical site hematomas, preventing the formation of a cultural medium for infection [3,4]. Infections are a much dreaded complication most surgeons face, and are the management is usually complex [5]. Another complication orthopedic surgeon’s fear is compartment syndrome [6]. So they believe drains help reduce the risk of this detrimental emergency [5,6]. On the other hand, the literature also reports that retrograde infection might be introduced. In other words, what comes out can get in. This was seen in old draining systems [7,8]. Yet there is still a considerable risk of this happening when utilizing newer drainage systems [8]. 

While some orthopedic subspecialties, for instance in spine surgery, prefer the usage of drains, others [7-9] like reconstruction surgery avoid it, for fear of biofilm formation. The results of infections could at times be catastrophic [8,10]. 

Although there are exceptions, many schools of thought have provided guidelines and protocols for using surgical drains [11]. The most commonly used examples are the National Institute for Health and Care Excellence, and the WHO guidelines for SSI [11,12]. For the purpose of this study we will be using the latter, as it is used as a reference for the surgical drains policy in Kuwaiti Hospitals. The guideline provides details on prophylactic antibiotic use, and time of drain removal timings recommended to reduce the risks of surgical site infections. 

The current literature, however, favors moving away from the use of drains and supports trends that minimizes the complications of using this utility when possible [12]. The usage of surgical drains has often led to increased numbers of days spent in hospital post-operatively and number of wound dressings [13]. This would ultimately decrease the cost-effectiveness of healthcare facilities, and inversely affect patient satisfaction rates [13-15]. Another vital issues reported in the literature is the increased need for blood transfusions in patients who have surgical drains inserted [14,15]. Blood transfusions open the door for unnecessary transfusion related complications and an increase demand for blood that could be utilized elsewhere, especially since it is already a scarce resource. Alternatives to avoid these blood transfusions related issues have been proposed, and the evidence is promising [14,15]. To the author’s current knowledge, no studies have been previously done to assess the knowledge of orthopedic surgeons regarding the use of surgical drains. 

The aim of this study is to identify possible knowledge deficiencies and try to address them. This in turn will improve the current clinical practice. The need for this study is to scan for misconceptions and old practices that our participants still believe to be true, like the risks of infection hematomas, wound dehiscence, and the need for secondary surgery. It is important for our surgeons to know the consequences of malpractice and not keeping their knowledge up-to-date with the current guidelines.

METHODOLOGY

In this study, a descriptive approach was followed to quantitatively measure the level of knowledge of participants about the surgical drains and to establish their technical habits when using the drains. 

For this purpose, seven multiple choice questions were included in the survey construct of 21 questions. A total of 7 questions with only one correct answer per question were designed to assess current EBM facts into 6 categories; Hematoma, Seroma and Wound Dehiscence, Blood transfusion, need for secondary surgery, wound infection, wound dressing and length of hospital stay. A point scoring system was used to calculate the surgeons’ level of knowledge about surgical drain use. The lowest score was zero and the highest score was six. The scores are also converted into a percentage value for easier analytical perception.

The survey itself was distributed via electronic communication; all 116 targeted participants received the survey 2 times, with a two week interval. Only 73 participants responded (Response rate 63%). 

The data analysis was done using SPSS IBM (v. 26) and Graphpad Prism (v. 8). Mann-Whitney U test and Kruskal-Wallis H test are performed to compare the level of knowledge of different demographic groups about the surgical drains, and their routine application among the physicians. The survey being factual based, using yes or no responses, construct validity and reliability of this questionnaire was not necessary.

RESULTS

In table 1, the demographic characteristics of the individuals who participated in this study are shown. The absolute majority of the participants were male (N=71), and only 2 participants were female (2.7%).

Around 60% of all participants were working in Al-Razi Orthopaedic Hospital, while 23% of them were employed in Al-Farwaniya Hospital. The majority of the participants (64.4%) were between 35 to 44 years old, while 22% of them were older than 45 years old, and the rest were between 22 and 34 years old. In addition, it was shown that around 66% of all participants who worked at the hospitals were Registrars, while around 13% were Specialist or Senior Specialists. 

Furthermore, it could be described that the most common subspecialty among the participants were Upper (61.6%) and Lower (59%) Limb Trauma with Arthroplasty (26%) at third place. 

 

Frequency

Percentage

Mean (%)

Median (%)

Gender

   

Female

2

2.7

   

Male

71

97.3

   

Hospital

H (5) = 2.142

p = 0.829

Al-Adan Hospital

2

2.7

28.60%

28.60%

Al-Farwaniya Hospital

17

23.3

28.60%

28.60%

Al-Jahra Hospital

2

2.7

28.60%

28.60%

Al-Razi Orthopedic Hospital

44

60.3

26.30%

28.60%

Military Hospital

1

1.4

14.30%

14.30%

Mubarak Al-Kabeer Hospital

7

9.6

30.60%

28.60%

Age Group

H (3) = 2.207

p = 0.531

22-34

10

13.7

32.90%

28.60%

35-44

47

64.4

27.40%

28.60%

45-54

10

13.7

21.40%

14.30%

55-64

6

8.2

26.20%

21.40%

Job Title

H (5) = 4.608

p = 0.466

Assistant Registrar

5

6.8

37.10%

42.90%

Consultant

3

4.1

23.80%

14.30%

Registrar

48

65.8

26.20%

28.60%

Senior Registrar

7

9.6

30.60%

28.60%

Senior specialist

2

2.7

21.40%

21.40%

Specialist

8

11

26.80%

28.60%

Speciality Field

   

Spine

6

8.2

   

Hand

7

9.6

   

Arthroscopy

7

9.6

   

Arthroplasty

19

26

   

Lower Limb Deformity

4

5.5

   

Upper Limb deformity

3

4.1

   

Foot and Ankle

11

15.1

   

Upper Limb Trauma

43

58.9

   

Lower Limb Trauma

45

61.6

   

Pelvis

12

16.4

   

Paediatric Orthopedics

15

20.5

   

Oncology

1

1.4

   

Table 1: Demographic Characteristics of the participants – Mean and median total score (%) of the seven guideline questions are also calculated for each grouping along with Kruskall-Wallis H test to determine differences between different demographic groups; the results are reported as H (df) and p value. 

When it comes to the level of knowledge about the surgical drains, the mean and median of total score were calculated. The mean was 1.904 (±1.082) while the median was 2. The maximum observed score (6) obtained only by one participant, and the lowest grade (0), was scored by 4 participants. Around 88% of all participants reached a total score between one and three. According to the Kruskall-Wallis H test which was performed to determine total score differences between various demographic groups, no significant difference could be established between different groupings in the level of knowledge about the surgical drains (p>0.05). In table 2, the total score is broken down into the 7 questions, and the frequency of correct and wrong responses for each question is calculated.

General Guidelines about Surgical Drains

Correct

Wrong

Frequency

%

Frequency

%

Do you think drains increase or decrease the risk of haematoma/seromas or wound dehiscence?

10

13.70%

63

86.30%

Does the usage of drains increase or decrease the need for transfusions?

10

13.70%

63

86.30%

Do you think drains increase or decrease the requirements for secondary surgery?

30

41.10%

43

58.90%

Do you think drains increase or decrease the risk of wound infections?

11

15.10%

62

84.90%

Does removing the drain before 5 days post-op decrease the risk of infection?

11

15.10%

62

84.90%

Do you think drains increase or decrease the requirement for wound dressings?

32

43.80%

41

56.20%

Do you think drains increase or decrease the requirement for stay in hospital?

35

47.90%

38

52.10%

TOTAL

 

27.20%

 

72.80%

Table 2: General Guideline questions about using surgical drains – the questions are multiple choices and only one is correct. The percentages of correct and wrong answers for each question are illustrated in this table

The relationship between experience and level of knowledge about surgical drains 

In order to measure the level of association between experience in the orthopaedic field and the level of knowledge about the evidence-based practice of surgical drains, the Spearman correlation coefficient calculated was -0.278 (p < 0.001). Unfortunately, the results showed a negative correlation between the level of theoretical knowledge about the surgical drains and experience of the participants in orthopaedic field. 

Habits &complications using surgical drains 

As shown in Figure 1, it is indicated that 54.8% of all participants use surgical drains frequently, while 5.5% always use drains during surgery. Forty Eight percent of all participants reported that drains rarely cause unnecessarily prolonged hospital stay, while 28.8% reported occasional prolongation. 

Figure 1: Percentages of habits & complications using surgical drains.

 Technical habits of using drains 

According to the results of the survey (Table 3), 51% of all participants use closed drain systems, while only 2.8% of them use open drain systems. Multilayer drains were used by 30.1% of the participants. In addition, the most common drain size which was used in surgeries was Medium size drain (61.6%). Large drains were used by 28.8% of the participants. Seventy four percent used only one drain for the same location. The majority (75.3%) reported that they use different incisions to insert the drain, while 24.7% use the same incision. With regards to the location of the drain, the answers of the participants were quite heterogenous. The drain was inserted below the incision in 43.8% of the time, while 27.4% placed the drain above the incision, and 28.8% parallel to it. However, approximately all of the participants (91.8%) indicated to secure the drain with suture. When it comes to using antibiotics, 67.1% of the participants saw it unnecessary to specifically use prophylaxis for drain usage. Second (52.1%) or the third (38.4%) post-operative day are reported by participants to be the most common time to remove the drain. After removal of the drain, the patients are normally discharged within the same day (28.8%) or most commonly after 24 hours (53.4%). 

 

Frequency

Percentage

How often do you use a drain in your surgeries in general?

Always

4

5.5

Frequently

40

54.8

Occasionally

17

23.3

Rarely

12

16.4

How often do you use a drain in your standard surgeries which you are most comfortable preforming?

Always

7

9.6

Frequently

34

46.6

Never

3

4.1

Occasionally

17

23.3

Rarely

12

16.4

What type of drain system do you use?

Active drain systems

12

16.4

Closed drain systems

37

50.7

Closed drain systems; Active drain systems

9

12.3

Closed drain systems; Passive drain systems

1

1.4

Open drain systems; Closed drain systems; corrugated drains

1

1.4

Open drain systems; Closed drain systems; Passive drain systems; corrugated drains

1

1.4

Passive drain systems

12

16.4

What size drain do you usually use?

Large

21

28.8

Medium

45

61.6

Small

7

9.6

Where do you place the drain?

Above the incision

20

27.4

Below the incision

32

43.8

Parallel to the incision

21

28.8

On average, by which post-operative day do you remove the drain?

Day 1

1

1.4

Day 2

38

52.1

Day 3

28

38.4

Day 4

3

4.1

Day 5

3

4.1

How soon after the removal of the drain do you discharge your patient?

After 24 hours

39

53.4

After 48 hours

10

13.7

More than 48 hours

3

4.1

Same day

21

28.8

Has the usage of drains ever caused an unnecessarily prolonged hospital stay?

Almost always

2

2.7

Frequently

5

6.8

Never

10

13.7

Occasionally

21

28.8

Rarely

35

47.9

Do you think drains increase or decrease the risk of prosthetic infections?

Decrease

17

23.3

Increase

15

20.5

No effect

18

24.7

Not sure

23

31.5

Table 3: Technical habits and opinions about the usage of surgical drains.

DISCUSSION

This survey study looked into the current practice of using surgical drains in orthopaedic surgery in Kuwait, and what the current evidence regarding this topic suggests, compared to whether the surgeons in Kuwait are adherent to it. The main 6 categories that we used to compare benefit vs no benefit differences were:

Hematoma, seroma and wound dehiscence (no difference) 

A retrospective study by the Journal of Neurosurgery: Spine (n=1799) found no statistical significance with regards to Hematomas, Seromas and wound Dehiscence [11,16]. The most current studies were done by breast surgeons post-mastectomy. Their conclusion is reflected in the WHO guidelines and A Cochrane review [17]. It is worth noting that the participants of the previous studies had a higher risk of bruising. This in turn resulted in a large number of surgeons refraining from using surgical drains altogether in their practice [18,19]. 

Blood transfusion (increase)

The orthopaedic literature has a long history of inquisitive research regarding the use of postoperative surgical site drains [16,20]. For instance, in total joint arthroplasty and some spinal surgeries, surgical site drains were associated with increased rates of transfusion [11-13]. These results are supported by a Cochrane review [20-22]. Of our study cohort, an alarming 86% of them did not know this. 

Secondary surgery (no difference)

Both the Journal of Neurosurgery: Spine and Cochrane review analysis both confirmed that not using a surgical drain didn’t increase the odd of a secondary surgery or return to the theatre [17-20]. Yet about 60% of our participants thought the contrary. 

Wound infection(no difference) 

A large percentage of our participants believed that drains reduce the risk of infection. Yet, all hospital policies enforce a minimum of 3 doses of prophylactic antibiotic rule for all surgeries in Kuwait, despite evidence showing that 1 prophylactic dose is enough. There are no clear guidelines for antibiotic use when patients have surgical drains inserted. This is why educating our surgeons on evidence is necessary, since most surgeons practice based on their acquired experience and not EBM. 

The WHO SSI guidelines produced a pooled analysis. This analysis showed that there is insufficient evidence to ascertain if prolonged antimicrobial prophylaxis is either beneficial or harmful SSI [11,22]. However,the current recommendations advocate against the use of prophylactic antibiotics in patients beyond 24hours [11]. As this will cause and increase in the rate of Clostridium Difficile infections and acute kidney injuries. It has also been established that there is insufficient evidence that the date of drain removal does statistically increase of decrease the risk of SSI [11]. 

The Cochrane review and the Journal of Neurosurgery: Spine both published and they both concluded that there was no difference in infection rate among patients who had a surgical drain when compared to patients who didn’t [11,19,20]. The Cochrane review further declared that the correlation between wound healing and drain usage was statistically insignificant [11,23]. 

Wound dressing (increase) 

The majority of the studies reached a consensus that the requirement for regular dressing was increased among patients with surgical drains more than 2-folds, but this didn’t attribute to neither an increase nor decrease in the surgical site infection risk [11,15,24]. Although our study did not aim to measure the frequency of dressing exchange, about 40% of the participants in this study had knowledge of this. 

Length of hospital stay(increase) 

Opposing evidence was available from the WHO SSI guidelines and a Cochrane review. WHO used an non-orthopaedic metanalysis and suggested an increase in hospital stay [11,14-16]. The evidence from Cochrane review was based on 5 orthopaedic studies that were small in number and weak in design [11,15,25]. There is however, no current evidence that states otherwise. The vast bulk (approximately 50%) of our participants were aware of this fact and have witnessed this increased length of hospital stay in their practice. 

In brief, the orthopaedic surgeon should justify its use as per Guideline Development Group (GDG). Their survey acknowledged in their survey that drains are painful and uncomfortable to patients and patients wish them taken our early. Even for patients who developed seromas that required a return to the hospital and aspiration [7,25,26].

CONCLUSION

The approach to the use of surgical drainage systems is not a “one size fit all,” and it should be on a case by case manner. However, there is a deficiency of knowledge amongst the Kuwaiti Orthopaedic surgeons that merit for defensive medicine and probable malpractice. Orthopaedic surgeons in Kuwait should adhere with the current evidence-based approach to the usage of surgical drains.

LIMITATIONS

The small number of participants reflected on the accuracy of the data; however the response rate was relatively higher than expected. Other important topics were not surveyed nor taken into account, such as prolonged antibiotics used, Venous Thromboembolism (VTE), and hospital acquired infection (non-wound related). This was due to different hospital policies which the authors could not standardize for the purpose of this study.

CONFLICT OF INTEREST

None

SOURCE OF SUPPORT

None

REFERENCES

  1. Memon MA, Memon MI, Donohue JH (2001) Abdominal drains: A brief historical review. Ir Med J 94: 164-166. 
  2. Ghaly DN, Khalifa YEM, Bakr HMA, Mahran MAA (2018) To use closed suction drain or not after total hip arthroplasty; A randomized controlled trial? J Curr Med Res Pract 3: 180-186.
  3. Si HB, Yang TM, Zeng Y, Shen B (2016) No clear benefit or drawback to the use of closed drainage after primary total knee arthroplasty: A systematic review and meta-analysis. BMC Musculoskelet Disord 17: 183.
  4. Armaghani SJ, Menge TJ, Lovejoy SA, Mencio GA, Martus JE (2014) Safety of topical vancomycin for pediatric spinal deformity: Nontoxic serum levels with supratherapeutic drain levels. Spine 39: 1683-1687.
  5. Schroeder JE, Girardi FP, Sandhu H, Weinstein J, Cammisa FP, et al. (2015) The use of local vancomycin powder in degenerative spine surgery. Eur SpineJ 25: 1029-1033.
  6. Wang D, Xu J, Zeng WN, Zhou K, Xie TH, et al. (2016) Closed suction drainage is not associated with faster recovery after total knee arthroplasty: A prospective randomized controlled study of 80 patients. Orthop Surg 8: 226-233.
  7. Boutsiadis A, Reynolds RJ, Saffarini M, Panisset JC (2017) Factors that influence blood loss and need for transfusion following total knee arthroplasty. Ann Transl Med 5: 418.
  8. Mujagic E, Zeindler J, Coslovsky M, Hoffmann H, Soysal SD, et al. (2019) The association of surgical drains with surgical site infections – A prospective observational study. The American Journal of Surgery 217: 17-23.
  9. Kumar V, Singh A, Waliullah S, Kumar D (2019) Analysis of efficacy in postoperative use of closed suction drain in cases of traumatic dorsolumbar spine injury. J OrthopTraumatol Rehabil 11: 1-5.
  10. VK Gautam, R Deshmukh, Kamra P, Gulati A, Banjare (2019) A prospective study to compare early postoperative outcomes in patients undergoing total knee replacement with or without drain. International Journal of Orthopaedics Sciences 5: 519-521.
  11. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, et al. (2016) New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. The Lancet Infectious Diseases 16: 288-303.
  12. Ishida K, Tsumura N, Kitagawa A, Hamamura S, Fukuda K, et al. (2011) Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty. Int Orthop 35: 1639-1645.
  13. Coskun D, Aytac J, Aydinli A, Bayer A (2005) Mortality rate, length of stay and extra cost of sternal surgical site infections following coronary artery bypass grafting in a private medical centre in Turkey. J Hosp Infect 60: 176-179.
  14. Scomacao I, Cummins A, Roan E, Duraes EFR, Djohan R (2020) The use of surgical site drains in breast reconstruction: a systematic review. Journal of Plastic, Reconstructive & Aesthetic Surgery 73: 651-662.
  15. Parker MJ, Livingstone V, Clifton R, McKee A (2007) Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev 18.
  16. Herrick DB, Tanenbaum JE, Mankarious M, Vallabh S, Fleischman E, et al. (2018) The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: a multicenter retrospective study. Journal of Neurosurgery 29: 1-7.
  17. Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, et al. (2019) Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events. JAMA Surgery 154: 590-598.
  18. Barton A, Blitz M, Callahan D, Yakimets W, Adams D, et al. (2006) Early removal of postmastectomy drains is not beneficial: results from a halted randomized controlled trial. Am J Surg 191: 652-656.
  19. Cobb JP (1990) Why use drains? J Bone Joint Surg Br 72: 993-995.
  20. Liu Y, Li Y, Miao J (2016) Wound drains in posterior spinal surgery: a meta-analysis. J Orthop Surg Res 11: 16.
  21. Chen ZY, Gao Y, Chen W, Li X, Zhang YZ (2014) Is wound drainage necessary in hip arthroplasty? A meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol 24: 939-946.
  22. Johansson T, Engquist M, Pettersson LG, Lisander B (2005) Blood loss after total hip replacement: a prospective randomized study between wound compression and drainage. Journal of Arthroplasty 20: 967-971.
  23. Nixon J (2000) Wound drainage ? the long term results after primary hip and knee arthroplasty [abstract]. Journal of Bone and Joint Surgery 2: 125.
  24. Poeran J, Ippolito K, Brochin R, Zubizarreta N, Mazumdar M, et al.(2019) Utilization of Drains and Association With Outcomes: A Population-Based Study Using National Data on Knee Arthroplasties. J Am Acad Orthop Surg 27: 913-919.
  25. Crowther CA, Harding JE (2007) Repeat Doses of Prenatal Corticosteroids for Women at Risk of Preterm Birth for Preventing Neonatal Respiratory Disease. Cochrane Database Syst Rev 18.
  26. Mosleh S, Fard FB, Jokar M, Akbari L, Aarabi A (2019) Prevalence of Surgical Site Infection after Orthopedic Surgery and Some Related Factors at the Selected Hospitals of Isfahan University of Medical Sciences . Paramedical Sciences and Military Health 13: 43-53.

Citation: Al-Hindi B, Khaja A, Hanna SS, Alfeeli M, AlAwadh M, et al. (2020) The Use of Surgical Drains amongst the Orthopaedic Surgeons of Kuwait. J Surg Curr Trend Innov 4: 036

Copyright: © 2020  Bader Al-Hindi, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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