Drain Management Procedure

CHHS15/052
Canberra Hospital and Health Services

Clinical Procedure
Drain Management
Contents
Contents....................................................................................................................................1
Purpose..................................................................................................................................... 3
Alerts......................................................................................................................................... 3
Scope........................................................................................................................................ 3
Section 1 – Wound drains......................................................................................................... 3
1.1 Capillary action drains.........................................................................................................4
Management.....................................................................................................................4
Shortening and removing a capillary action drain.............................................................4
1.2 Closed Drainage Systems/ Low suction drains....................................................................5
Management.....................................................................................................................6
1.2.1 Redressing insertion site..........................................................................................7
1.2.2 Emptying Bellovac/Exudrain/Handyvac bulb or bellow and recharge vacuum........7
1.2.3 Changing of drainage bag.........................................................................................8
1.2.4 Removing closed drainage system/low suction drain..............................................8
Section 2 – Radiologically inserted drains...............................................................................10
2.1 Drainage catheter securement and dressing....................................................................10
2.2 Flushing of a radiologically inserted drainage catheter.....................................................13
2.3 Aspirating then flushing of a biliary catheter....................................................................15
2.4 Needleless injection cap, 3-way tap and connecting tube management..........................16
2.4.1 Needleless injection cap change............................................................................16
2.4.2 Adding a 3-way tap, needleless injection cap and connecting tube.......................17
2.5 Drainage bag change.........................................................................................................18
2.6 Removal of a radiologically inserted drainage catheter....................................................19
Section 3 – Indwelling Pleural / Peritoneal Drainage Catheter System management (currently
using PleurX®)......................................................................................................................... 21
Patient / Caregiver Education.................................................................................................22
3.1 Draining fluid.....................................................................................................................22
3.2 Weekly dressing for the patient not undergoing drainage of fluid...................................25
Doc Number Version Issued Review Date Area Responsible Page

CHHS15/052 1.1 December 2014 December Surgery, Oral Health 1 of 43
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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS15/052
Potential complications of pleural drainage....................................................................27

Potential complications of peritoneal drainage..............................................................27
Troubleshooting..............................................................................................................27
Section 4 – External ventricular Drain (EVD) management in ICU and 9B...............................28
Educational content................................................................................................................28
Nursing Management of an EVD.............................................................................................29
4.1 Measurement of cerebrospinal fluid (CSF)........................................................................30
Procedure............................................................................................................................... 30
4.2 Redressing insertion site...................................................................................................30
4.3 Change of drainage bag.....................................................................................................31
4.4 Sampling of cerebrospinal fluid from EVD - Adults...........................................................31
4.5 Removal of EVD.................................................................................................................33
Section 5 – Therapeutic Ascitic Tap/Paracentesis...................................................................34
5.1 Principles of therapeutic ascitic tap..................................................................................34
5.2 Removal of an Ascitic tap..................................................................................................35
Implementation...................................................................................................................... 36
Related Policies, Procedures, Guidelines and Legislation.......................................................36
References.............................................................................................................................. 36
Definition of Terms................................................................................................................. 38
Search Terms.......................................................................................................................... 38
Attachments............................................................................................................................40
Attachment 1 - Management of a Radiologically Inserted Drainage Catheter........................41
Attachment 2 - Resources for radiologically inserted drainage catheter................................42
Attachment 3 - Discharge planning for patients with indwelling pleural/peritoneal drainage
catheter systems.....................................................................................................................43
Attachment 4 - Resources for indwelling pleural/peritoneal drainage catheter system.........44

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Purpose
The purpose of this procedure is to outline the safe and effective management of patients
with drains being cared for under the direction of ACT Health.
This clinical procedure provides information for nurses and midwives who care for patients
with drains in the community and hospital settings.
Alerts
5 Moments for Hand Hygiene must be used by all staff when attending to patient care. The 5
Moments for Hand Hygiene can be performed with either soap and water, alcohol based
hand rub or alcohol impregnated wipes (ACT Health Hand Hygiene Procedure). In patients’
homes soft pre moistened cloths are used instead of soap and water.
Aseptic non touch technique is used for all clinical procedures in this document (CHHS
Aseptic Non Touch Technique Procedure), unless stated otherwise.
Scope
The Drain Management Procedure describes practices which will be performed by nurses
and midwives. New staff or students (within their defined scope of practice) will be required
to perform these skills under the direct supervision of a competent practitioner.
Nurses and midwives providing assessment, education and clinical procedures must have
current theoretical and clinical knowledge in drain management.
This procedure pertains to: wound drains, radiologically inserted drains, indwelling
pleural/peritoneal drains and external ventricular drains.
Out of scope are: chest drains and drains in neonates.
Section 1 – Wound drains
This section provides procedural information in the management of capillary action drains
and closed drainage systems in the community and hospital settings.
Wound drains are inserted by a Medical Officer (MO) in the Operating Theatre.

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Canberra Hospital: When a drain, which has been inserted by a MO in the Operating Theatre, is removed, a
second nurse who may be a registered nurse or an enrolled nurse must witness the removal of the drain.
Both nurses must sign the Registered Nurse Operating Theatre Report.
1.1 Capillary action drains

These drains facilitate free drainage of fluids by capillary action, gravity or overflow caused
by slight pressure differences. Capillary action drains are also called open/passive drains.
Examples include:
 Penrose drains: soft latex rubber
 Corrugated drains: rubber or polyurethane and formed into a corrugated strip that can
be cut to width as well as length
 Portex drains: hollow single lumen tube of polyurethane material available in different
bore widths
Management
 Clean and redress drain site every 1-3 days to minimise bacterial load – redress with a
sterile wound drain bag if exudate levels are high, or a sterile dry dressing if the exudate
levels are low.
 Shorten or remove drain as per MO instructions.
Shortening and removing a capillary action drain

Equipment
 Soft pre-moistened cloth (community only) and Alcohol Based Hand Rub (ABHR)
 Dressing trolley or identify suitable clean surface in the home setting.
 Detergent impregnated wipes (to clean trolley or surface)
 Personal protective equipment (PPE) including safety glasses, goggles or shield and clean
gloves and gown
 Basic dressing pack
 Sterile scissors
 Sterile metal forceps
 Sterile safety pin (if shortening the drain)
 Sterile Dressing towel
 Combine dressing and gauze swabs
 Sterile gloves
 Stitch cutter (if drain is sutured in)
 30mL Normal Saline solution at body temperature
 Adhesive tape
 Waste receptacle
 Appropriate dressing to manage exudate, or redress the drain site

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Procedure
1. Check MO orders regarding removal of drain or amount of drain to be shortened
2. Explain procedure to the patient, obtain consent, ensure patient comfort
3. Ask the patient if they have any allergies to dressings or adhesive tapes – if so, record in
the clinical record/medication chart
4. Ensure the patient has adequate analgesic cover prior to dressing change if required or
requested
5. Attend hand hygiene
6. Clean dressing trolley or suitable surface in the patient’s home with detergent
impregnated wipes and wipe surface dry with disposable paper towel
7. Gather equipment
9. Position patient with wound drain area exposed, place under-pad in position in
proximity to the drain site
11. Don gown prior to opening sterile equipment, don clean gloves and safety glasses
12. Set up equipment at the patient's bedside or suitable area in the patient’s home
13. Open the basic dressing pack and add additional sterile equipment
14. Remove and discard dressing, remove and discard gloves
15. Attend hand hygiene and don sterile gloves
16. Clean the drain site and wound, swab gently and in one direction only (clean to dirty)
17. Remove suture (if present) with stitch cutter
18. Shorten drain:
a. withdraw drain gently, using a rotating movement to the prescribed length
b. Secure drain with a sterile safety pin by inserting the pin in the drain flush to the skin
and at right angles to the wound (the pin will prevent the drain tube from slipping
back into the wound)
c. Cut the drain 4cm above the level of the safety pin.
d. Place drain dressing around the drainage tube under the safety pin
e. Apply secondary dressing and secure with adhesive tape - a wound drainage bag
may be applied if drainage is excessive
19. Remove drain:
a. Withdraw drain gently, using a rotating movement for circular drains
b. Swab wound, if required
c. Apply exudate absorbing dressing, secure with adhesive tape if necessary - a wound
drainage bag may be applied if drainage is excessive
20. Discard equipment and gloves, attend hand hygiene
21. Document in clinical record and nursing care plan
1.2 Closed Drainage Systems/ Low suction drains

These drains are connected under sterile conditions to the inlet tubing thereby achieving a
totally closed drainage system. The bellow/bulb is emptied with the system remaining
closed. An inner non return valve system prevents air or liquid reflux returning to the patient
from the bellows or the bulb. The bellows or bulb must not be more than half full to function
effectively.
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Surgeons may prefer to leave these drains on free drainage (no suction). Check MO orders
on return from the Operating Theatre.
Examples include:
 Exudrain (100 mL capacity in bulb)
 Bellovac (220 mL capacity in bellow)
 Handyvac (125 mL capacity in bulb)
Note: The drainage bags are not interchangeable
Management
 Change dressing 3rd daily or more frequently if required
 Record amount of drainage onto fluid balance chart or drain output chart.
 If drainage slows down or the tubing appears blocked:
o gently milk the tube, be careful not to dislodge the drain
o ‘strip’ the tubing from the wound outwards, toward the drainage device: using one
hand to anchor the tubing, apply gentle, intermittent exterior pressure to the tubing
with the fingers of the other hand to assist the drainage through the tubing
 Report to the medical team if:
o drainage is suddenly stopping (drainage should decrease gradually, not abruptly)
o drainage is increasing
o there is sudden change in the colour of the drainage – the drainage becomes bloody
again or changes to a milky white fluid. Drainage should gradually change from blood
to straw coloured fluid
o increase in redness or swelling around insertion site
o drain dislodges
 Educate patients about drain management prior to discharge to the community and
refer to community nursing:
o Educate patient how to empty the bulb/bellow - the bulb/bellow must not be more
than half full to function effectively. The bulb/bellow is to be emptied daily or more
frequently if necessary
 Community nurses:
o Reinforce education and ask the patient to keep a daily record of the drainage
o Ensure that the patient or the carer have demonstrated the ability to empty the bulb
and are aware to seek medical advice if complications or signs of infection occur
 Remove drain as per MO instructions. For breast drains this will generally be when the
daily measurements are less than 20 – 30 mL on two consecutive days (refer to MO
orders). Breast drains are usually removed within 2 weeks of the time of surgery, contact
MO for guidance if a breast drain is insitu for more than 2 weeks
 Monitor the drain site post removal of the drain. Report any fluid build up to the MO as
the surgical site may need aspiration
1.2.1 Redressing insertion site

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Equipment
 Soft pre-moistened cloth (community only) and ABHR
 Safety glasses, clean gloves
 Sterile gloves
 Dressings
 30 mL Normal Saline solution at body temperature
 Disposable plastic blue sheet
 Combine or gauze swab
 Adhesive tape
Procedure
3. Open dressing pack and add additional sterile equipment, pour saline solution
4. Don clean gloves and safety glasses
5. Remove and discard the soiled dressing
6. Discard gloves, attend hand hygiene, don sterile gloves
7. Clean the skin around the insertion site with gauze and saline, using a circular motion
from the centre outwards, allow the skin to dry
8. Place a “loop” in the drain tube close to the insertion site and tape in place. This will
minimise trauma at the insertion site if the tube is accidently caught or tugged
9. Apply an appropriate dressing over the insertion site. Many surgeons permit the
application of a waterproof dressing, such as Opsite or Tagaderm to enable the patient
to shower with ease. If the patient is allergic to these dressings, or the insertion site is
infected, apply a non adherent dressing and tape it into place
10. If infection is present or suspected take a wound swab and notify the patient’s surgeon
11. Discard gloves, attend hand hygiene
12. Document the appearance of the insertion site in clinical record and record actions
taken e.g. wound swab taken
1.2.2 Emptying Bellovac/Exudrain/Handyvac bulb or bellow and recharge vacuum

Equipment

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Procedure
1. Explain the procedure to the patient, obtain consent, ensure patient comfort
4. Close the inlet clamp (closest to the patient)
5. Check that the outlet clamp is open (closest to the drainage bag)
6. Squeeze the bulb/compress the bellows, transferring the contents into the drainage bag
7. Open the inlet clamp
8. Closing the outlet clamp is optional
9. Suction is now re-established NB: Always check that the inlet (patient) clamp is left open
11. Document drainage amount in the patient’s clinical record. Use a permanent marker to
place a date/time mark on the back of the drainage bag to indicate the level of the fluid
loss each day
1.2.3 Changing of drainage bag

In the initial post operative period the drainage bag is changed daily and the amount is
recorded on the fluid balance chart.
Equipment
 Clinical waste receptacle
 Compatible drainage bag
Procedure
1. Explain the procedure to the patient, obtain consent, ensure patient comfort
4. Close the outlet clamp (closest to the drainage bag)
5. Disconnect the bag and connect the new bag to the outlet tube. Ensure connection is
dry
7. Document in clinical record
Some patients prefer to connect the drainage bag only when the bellows/bulb requires
emptying. This allows the patient more freedom to disguise the drain under clothing. In this
case, the drainage bag simply needs connecting only when emptying the bellows/bulb and
can therefore be used until the drainage bag is full. Keep the caps closed on the
bellows/bulb and the drain bag whilst they are separate.
1.2.4 Removing closed drainage system/low suction drain

Suction should be released prior to removal to prevent damage to underlying tissues.
Release suction half an hour prior to removal by clamping drain near wound entry site.

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Patients in the community: ensure the patient is aware of time of drain removal in case the
patient wishes to take analgesia prior to the procedure. The patient/carer may clamp the
drain near the wound entry site in order to release the suction prior to the nurse visiting.
Equipment
 Safety glasses, clean gloves, gown
 Sterile gloves
 Sterile stitch cutter
 30 mL Normal Saline solution at body temperature
 Dry dressing
 Adhesive tape
 Sharps container
Procedure
3. Don safety glasses and gown prior to opening sterile equipment
5. Open dressing pack and add additional sterile equipment, pour saline solution
6. Don clean gloves
7. Empty bellows/bulb to allow final measurement of content. Ensure vacuum has been
released by closing inlet clamp near wound entry site
8. Remove the dressing and adhesive tape from the drainage tube
9. Place the disposable blue plastic sheet under the patient
10. Attend hand hygiene and apply sterile gloves
11. Remove the suture near the exit site of the drain (if suture present)
12. Anchor the drain site by placing pressure with fingers on the skin on either side of the
drain
13. Pull the drain gently rotating it slowly as you remove it, check if tip is intact
14. Apply dry dressing
15. Dispose of equipment in clinical waste and sharps container, attend hand hygiene
16. Document in clinical record, including whether tip is intact
Back to Table of Contents

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Section 2 – Radiologically inserted drains

This section provides procedural information in the management of patients with a
radiologically inserted drainage catheter in the community and hospital settings.
A flow chart outlining steps in the management of a radiologically inserted drainage catheter
is attached (Attachment 1). A list of recourses including a contact list and consumables
product information is also attached (Attachment 2).
General Information
The purpose of a drainage catheter is to remove unwanted fluid or air (bile, urine, pus,
blood, ascitic or pleural) from a cavity, organ or duct through a catheter inserted under the
guidance of CT, ultrasound or fluoroscopy. A percutaneous radiologically inserted drainage
catheter (Abscess, Ascites, Biliary, Chest or Nephrostomy) can be inserted by a Radiologist in
the Medical Imaging Department. In some cases a MO may insert an abdominal or chest
catheter in the ward.
Drainage catheters come in different shapes: straight, curved and pigtail with the pigtail
being the most commonly used.
Notify the MO/Specialist/Registrar if:

 The patient reports pain or there is difficulty with flushing the catheter
 There is leakage around the catheter insertion site (light drainage may occur for the first
1 to 3 days after catheter insertion)
 There is inflammation, swelling or purulent discharge around the catheter insertion site
 The catheter has moved more than 2 cm or has dislodged
 The patient reports nausea, vomiting, fever, chills or weakness
2.1 Drainage catheter securement and dressing

The dressing is changed once per week and more often if the integrity of the dressing or seal
is breached. More frequent sterile dressing changes may be indicated if infection is present.
The StatLock® is replaced at least every 7 days.
Equipment
 Soft pre-moistened cloths (community only) and Alcohol Based Hand Rub (ABHR)
 Clean gloves
 Sterile gloves
 Safety eyewear
 Gown (non sterile)
 Dressing pack
 30 mL Normal Saline solution
 Chlorhexidine 2% alcohol 70% swab sticks x 4 (3 for skin + 1 for catheter)
 Alcohol 70% swabs
 Securement device (StatLock® Universal Plus in the appropriate size)
 Sterile scissors (to trim the StatLock® to enhance patient comfort if required)
 Occlusive dressing(s) 10 cm x 12 cm
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 Securing tape
 Tape measure
 Disposable blue plastic sheet
StatLock® Universal Plus
Procedure
3. Set up equipment following aseptic technique
5. Don safety eyewear, gown and clean gloves
6. Place blue sheet under the catheter
7. While ensuring the catheter is secured to the patient’s skin with tape, carefully remove
the old occlusive dressing. Never use scissors to remove the dressing as accidental
cutting of the catheter can occur
8. Inspect the surrounding skin for redness, tenderness, swelling or irritation. If infection is
suspected, swab site for culture and inform MO
9. At the first dressing / securement device change and subsequent changes measure and
record the length of exposed catheter from the insertion site to the ‘hub’. Compare with
measurement recorded in clinical record.

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E.g. 10.5cm
Insertion Hub
site
Picture 1 – Measurement of the external length of the catheter – insertion site to ‘hub’
10. StatLock® Removal Technique:

a. Disengage: open the StatLock® device retainer by pressing the tab and lifting the lid
b. Carefully lift the catheter from the retainer
c. Dissolve: first lift the edge of the anchor pad using 3-4 alcohol swabs. Then
continue to stroke the under surface of the pad with alcohol swabs to dissolve
adhesive anchor pad away from skin. Do not force pad to remove
11. Ensure the catheter is secured to the patient’s skin with tape
12. Measure, compare and record the external length of the catheter (see Picture 1 above)
13. Remove gloves, attend hand hygiene
14. Don sterile gloves
15. If required, trim the ‘butterfly wings’ of the StatLock® using sterile scissors
16. If crusting or dressing residue is visible, cleanse with normal saline-soaked gauze, clean
insertion site, removing crusting as able. If necessary, soak crusting to allow for non-
traumatic removal. Allow skin to dry
17. Cleanse the area around the catheter insertion site with Chlorhexidine 2% alcohol 70%
swab sticks x 3, starting at the catheter insertion site and extending outwards using
friction and a continuous circular motion, to incorporate the area that will be covered by
the dressing. Use the 4th swab stick to cleanse the catheter line. Allow the area to dry for
at least 30 seconds, or until visibly dry
18. StatLock® Application Technique:
a. Apply skin prep wipe for enhanced adherence and skin protection. Allow to dry for
10-15 seconds
b. Wipe the catheter with an alcohol swab (so that it is wet for insertion into the
StatLock® retainer)
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c. Always secure catheter to the StatLock® retainer before placing pad on the skin
Bring the StatLock® anchor pad into position. Stabilise the catheter between fingers
and then double tug the catheter to stretch-fit into the retainer
d. Close the lid
e. Peel away the StatLock® paper backing one side at a time. Place on skin
19. Apply gauze over the catheter insertion site and StatLock® to prevent the occlusive
dressing adhering to catheter
20. Place occlusive dressing(s) over the catheter insertion site and StatLock®. Ensure the
catheter is secured by the occlusive dressing and the dressing is waterproof
21. Ensure the catheter is secured to the patient’s side with tape
22. Remove gloves, safety eyewear and gown
24. Dispose of rubbish into clinical waste receptacle
25. Document in clinical record and in the ‘Drain Management Observation Chart’ including
amount, colour, consistency and odour of drainage
2.2 Flushing of a radiologically inserted drainage catheter

The MO may order that the drainage catheter is to be flushed (in the progress notes, MO’s
Order for Percutaneous Radiological Drain Management’ or ‘Treatment Order’ form).
The order will explain:
 amount of Sodium Chloride 0.9% to be used with each flush
 frequency of flushes
General Information
 The closed drainage system is accessed for flushing via the 3-way tap and needleless
injection cap using a clean technique. If a 3-way tap is not insitu see section 2.4.2 for
the procedure for adding a 3-way tap to the drainage system
 Needleless injection caps are changed weekly using a sterile technique, coordinated
with the dressing change, if the catheter is being flushed.
 Do not use a syringe smaller than 10 mL as a small syringe may increase the pressure of
the flush
Nephrostomy drainage catheter

 Do not instil more than 10 mL of Sodium Chloride 0.9% at one time (NSW Agency for
Clinical Innovation. ACI Urology Network 2012, p. 8).
 Flush the tube very slowly. Do not apply force as over distension of the renal pelvis
could cause renal tissue damage.
Biliary drainage catheter
 The MO may order that the biliary catheter be flushed firmly (but not to cause
discomfort) or using a pulsating movement to dislodge debris.
Equipment
 Soft pre-moistened cloths (community only) and ABHR
 Clean gloves
 Safety eyewear
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 Dressing pack
 Sodium Chloride 0.9% injection 10 mL ampoules - number dependent on orders or
Sodium Chloride 0.9% 30 mL ampoules irrigation solution - number dependent on MO
orders
 Syringe(s) luer lock 10 mL - a new syringe is used for each flush, number dependent on
MO orders
 Drawing up needle(s) - number dependent on MO orders
 Chlorhexidine 2% alcohol 70% swabs - number dependent on MO orders
 Container of warm water (to warm up Sodium Chloride 0.9% ampoules)
 Sharps bin
Procedure
1. Explain the procedure to the patient and obtain consent
2. Check the MO order
4. Don safety eyewear and gown
5. Set up equipment. Draw up warmed sodium chloride 0.9% using 10 mL syringe(s) and
drawing up needle(s)
6. Attend to hand hygiene, don gloves
7. Place blue sheet under the three-way tap
8. Turn the 3-way tap off to the drainage bag
9. Swab the needleless injection cap on the 3-way tap with needleless injection cap with a
chlorhexidine 2% alcohol 70% swab, allow to dry for 30 seconds
10. Remove the drawing up needle from the 10 mL syringe and insert the syringe into the
prepared needleless injection cap and flush the catheter
11. Remove the 10 mL syringe from the needleless injection cap and discard the syringe
12. Repeat steps 10 to 12 depending on the MO order
13. Ensure that 3-way tap is turned to the correct drainage position when the procedure is
completed
14. Discard equipment
2.3 Aspirating then flushing of a biliary catheter

The MO may order that the biliary catheter be aspirated then flushed (in the progress notes,
‘MO’s Orders for Percutaneous Radiological Drain Management’ or ‘Treatment Order’ form).
General Information
 The closed drainage system is accessed for aspirating and flushing via the 3-way tap and
needleless injection cap using a clean technique. If a 3-way tap is not insitu see section
2.4.2: procedure for adding a 3-way tap to the drainage system.
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with the dressing change, if the catheter is being aspirated and flushed.
 Do not use a syringe smaller than 10 mL as a small syringe may increase the pressure of
the flush.
Equipment
 Clean gloves
 Safety eyewear
 Dressing pack
 Sodium Chloride 0.9% injection 10 mL ampoules - number dependent on MO orders or
Sodium Chloride 0.9% 30 mL ampoules irrigation solution - number dependent on MO
orders
 Syringe(s) luer lock 10 mL - number dependent on medical order, a new syringe is used
for each flush / aspiration
 Drawing up needle(s) - number dependent on the medical order
 Chlorhexidine 2% Alcohol 70% swabs - number dependent on medical order
 Container of warm water (to warm up sodium chloride 0.9% ampoules)
 Sharps bin
Procedure
2. Check the MO order
5. Set up equipment. Draw up warmed sodium chloride 0.9% using 10 ml syringe(s) and
drawing up needle(s)
6. Attend hand hygiene, don gloves
7. Place plastic blue sheet under the 3-way tap
8. Turn 3-way tap off to the drainage bag
9. Swab the needleless injection cap on the 3-way tap with a chlorhexidine 2% alcohol 70%
swab, allow drying for 30 seconds
10. Insert the 10 mL syringe into the needleless injection cap, gently pull back on the syringe
and aspirate as much fluid as possible. Remove and the syringe from the needleless
injection cap and discard the syringe
11. Swab the needleless injection cap on the 3-way tap with a chlorhexidine 2% alcohol 70%
swab, allow drying for 30 seconds
12. Remove the drawing up needle from the 10 mL sodium chloride 0.9% syringe and insert
the syringe into the prepared needleless injection cap and flush the catheter. Gently pull
back on the syringe and aspirate as much fluid as possible. Remove the syringe from the
needleless injection cap and discard the syringe
13. Repeat steps 10 to 13 depending on the medical order
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14. Ensure that 3-way tap is turned to the correct drainage position when the procedure is
completed
16. Remove gloves, safety eyewear and gown, attend hand hygiene
2.4 Needleless injection cap, 3-way tap and connecting tube management
General Information
A patient may have a 2-way tap/stopcock (2-way tap is not available as a single item, it is
packaged as part of the connecting tube) or a 3-way tap/stopcock attached to the catheter.
Occasionally no tap is attached to the catheter.
 Apply a 3-way tap to the catheter using a sterile technique if the MO has ordered
flushes. The closed drainage system can then be accessed for flushing via the 3-way tap
and needleless injection cap using a clean technique
with the dressing change, if the catheter is being flushed
2.4.1 Needleless injection cap change

Equipment
 Sterile gloves
 Safety eyewear
 Dressing pack
 Chlorhexidine 2% alcohol 70% swabs x 2
 Needleless injection cap x 1
 Syringe 10 mL
 Drawing up needle
 Sodium chloride 0.9% 10 mL ampoule x 1

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Procedure
4. Set up equipment following aseptic technique. Open dressing pack. Open needleless
injection cap, drawing up needle and chlorhexidine 2% alcohol70% swabs onto sterile
field
6. Ensure the 3-way tap is turned off to the catheter
7. Attend hand hygiene, don sterile gloves
8. Using sterile gauze to hold the ampoule draw up sodium chloride 0.9% using 10mL
syringe and drawing up needle
9. Prime needleless injection cap with sodium chloride 0.9% and leave on sterile field
10. Place sterile dressing towel under the catheter
11. Using gauze x 2 (1 to hold the catheter, 1 to remove needleless injection cap to maintain
sterility), remove old needleless injection cap, discard, and clean vigorously around the
end of the lumen with 1 chlorhexidine 2% alcohol 70% swab for 10 seconds, then repeat
with 2nd swab. Allow to dry for 30 seconds
12. Replace with new needleless injection cap
13. Ensure the 3-way tap is turned to the correct position to allow fluid to drain into the leg
bag
2.4.2 Adding a 3-way tap, needleless injection cap and connecting tube
The drainage bag is changed weekly using a clean non-touch technique see section below -
‘Drainage bag change’ - however it may be convenient to change the bag as part of the
following procedure.
Equipment
 Sterile gloves
 Safety eyewear
 Dressing pack
 Chlorhexidine 2% alcohol 70% swabs x 2
 3-way tap/stopcock x 1
 Needleless injection cap x 1
 Syringe 10 mL
 Drawing up needle
 Sodium chloride 0.9% 10 mL ampoule x 1
 Connecting tube (Cook CTU14.0-30-ST) x 1
 Drainage leg bag 500 mL or similar drainage bag
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 Sharps bin
Procedure
5. Set up equipment following aseptic technique. Open dressing pack. Open needleless
injection cap, drawing up needle, 3-way tap, connecting tubing, leg bag and
chlorhexidine 2% alcohol 70% swabs onto sterile field
8. Using sterile gauze to hold the ampoule draw up sodium chloride 0.9% using 10mL
syringe and drawing up needle
9. Prepare the 3-way tap for connection by removing and discarding the caps
10. Place the needleless injection cap into the top port of the 3-way tap
11. Prime needleless injection cap and 3-way tap with sodium chloride 0.9% and leave on
sterile field
12. Remove the single tap from the connecting tube and replace with the 3-way tap. Discard
the single tap
13. Attach the new leg bag to the connecting tube
14. Place sterile dressing towel under the catheter
15. Using gauze x 2 (1 to hold the catheter, 1 to disconnect the old 3-way tap, connecting
tubing and leg bag to maintain sterility), clean vigorously around the end of the lumen
with 1 chlorhexidine 2% alcohol 70% swab for 10 seconds, then repeat with 2 nd swab.
Allow to dry for 30 seconds
16. Grasp the new 3-way tap, connecting tubing and leg bag and connect to the catheter.
Ensure the connection is secure. Do not over-tighten as this can lead to cracking in the
connection
17. Ensure the 3-way tap is turned to the correct position
2.5 Drainage bag change

The MO may order that the catheter is to be connected to a bag for drainage (in the
progress notes, ‘MO’s Orders for ‘Percutaneous Radiological Drain Management’ or
‘Treatment Order’ form).
 The drainage bag is changed weekly using a clean non-touch technique
 Drainage bag and tubing should be kept free from kinks and lower than the catheter
insertion point to minimise back flow into the catheter
 The bag is emptied when it is ½ to ⅔ full

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Equipment
 Clean gloves
 Safety eyewear
 Drainage leg bag 500 mL or similar drainage bag
Procedure
3. Don safety eyewear, gown and gloves
4. Place the plastic blue sheet under the catheter
5. Ensure the 3-way tap on the catheter is turned off to the drainage bag
6. Carefully disconnect the drainage bag from the connector tubing (do not twist the
connector tubing or the catheter) remove the old drainage bag and immediately
connect the new drainage bag. Ensure the connector tubing or drainage bag does not
come in contact with a source of contamination during the procedure
7. Ensure that 3-way tap is set to the correct drainage position and fluid is draining freely
when the process is completed
8. Secure the new bag with tape to patient’s side, below the level of the catheter insertion
site, ensuring there is no tension on the catheter. If a leg bag is used secure bag to
patient’s leg using leg straps
9. Note colour, odour and consistency of drainage bag contents then measure volume
before disposing of the drainage bag
2.6 Removal of a radiologically inserted drainage catheter
The MO may order that an abscess, ascites or biliary catheter is to be removed in the
community on the ‘MO’s Orders for Percutaneous Radiological Drain Management’ or
‘Treatment Order’ form.
Nephrostomy and Chest Catheters are not removed in the community. Refer the patient to
the treating MO for catheter removal.

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Equipment
 Clean gloves
 Sterile gloves
 Safety eyewear
 Dressing pack
 30 ml Normal Saline solution
 Fine suture removal set
 Self adhesive small island dressings
 Sharps bin
Procedure
1. Inform the patient of the procedure and obtain consent
2. Check MO order
5. Set up equipment
6. Attend hand hygiene, don clean gloves
8. Locate the retaining thread. The end of the thread is secured on the external section of
the catheter:
a. Under a rubber sheath - carefully split the distal end of the rubber sheath with
scissors from the suture removal sent and cut or loosen the thread to release the
curled internal catheter tip ‘pig tail’ or
b. Within a locking loop – lift the clamp and loosen the thread to release the curled
internal catheter tip ‘pig tail’ or
c. Via a cap with a ring attached - loosen the cap to release the curled internal
catheter tip ‘pig tail’
9. Remove the dressing, StatLock® and securing tapes
10. Inspect surrounding skin for redness, tenderness, swelling or irritation
11. Discard gloves
13. Clean the insertion site if required. Use gauze soaked in normal saline in a spiral pattern
beginning at the insertion site and moving outward. Dry thoroughly with gauze
14. Apply counter pressure with the non-dominant hand. Remove the catheter by
withdrawing the catheter until the tip of the catheter emerges through the insertion site
15. Inspect the catheter to ensure it is intact
16. Use gauze soaked in normal saline in a spiral pattern beginning at the insertion site and
moving outward. Dry thoroughly with gauze
17. Apply a dry dressing
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20. Educate patient/carer to:

a. Remove the dressing before showering, wash area with warm soapy water, rinse
and dry well with a clean towel. Leave area open if the catheter exit site has closed
and is clean and dry. If the site is open and/or moist, continue daily dry dressings
until the exit site has closed and the area is clean and dry
b. Monitor site and report any signs or symptoms of infection
21. Document in clinical record, including condition of tip of catheter

Section 3 – Indwelling Pleural / Peritoneal Drainage Catheter System
management (currently using PleurX®)
This section provides procedural information in the management of recurrent pleural

effusions and abdominal ascites in the community and hospital settings.
The indwelling drainage catheter system is inserted by a Radiologist in the Medical Imaging
Department or by a Thoracic Surgeon in the Operating Theatre. The indwelling drainage
catheter is removed by a MO.
General information
The pleural catheter system is indicated for intermittent, long term drainage of
symptomatic, recurrent pleural effusion, including malignant pleural effusion. The device is
indicated for the palliation of dyspnoea and sometimes may provide a pleurodesis.
The peritoneal catheter system is indicated for recurrent effusions that do not respond to
medical management of the underlying disease to provide symptomatic relief of abdominal
pressure and discomfort caused by the accumulation of abdominal ascites. Abdominal
drainage is not likely to resolve peritoneal ascites.
Patients/caregiver may be assessed for capacity and suitability for management of the
drainage procedure in the home, after consultation with the MO.
A registered nurse (RN) who is assessed as competent in this procedure may then educate,
and support the patient in the home management of the indwelling pleural/peritoneal
drainage catheter system. If patients/caregivers are not able or willing to drain the effusion
at home, a RN assessed as competent should perform the procedure.
Discharge planning: equipment for discharge and information required for discharge can be
found in attachment 3.
Patient / Caregiver Education

 If patients/caregivers have been assessed as suitable for managing the drainage
procedure, offer initial support and observation of technique to ensure
patient/caregiver is competent in the procedure.
 Patients are supplied with a “PleurX® Drainage Line Set” in hospital and are advised to
have the set at hand if there is a need to present to hospital for intervention. Only the
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“PleurX® Drainage Line Set or the drainage line on the vacuum bottle can be used to
access the valve of the PleurX® catheter. List of resources can be found in attachment 4.
 Educate the patient / caregiver to seek medical advice if:
o Any breathing difficulties or shortness of breath, cough, discomfort, fever, redness
at the site, discharge, change in colour of pleural fluid, swelling, burning, pruritis or
presence of a rash around the entry site
o Pain on drainage is not relieved by closing the drainage clamp, or pain is severe, as
this could be a sign of infection
3.1 Draining fluid

The volume of fluid to be drained should be based on the patient’s fluid collection/comfort.
Drain amount of fluid as per the Community Care ‘Treatment Order’ or ‘Percutaneous
Radiological Drain Catheter Management’ form or hospital MO orders.
ALERT
Draining of fluid from the pleura or peritoneum using the indwelling drainage catheter
system is to provide symptomatic relief. If the patient’s condition is deteriorating or unstable
seek the advice of the treating MO before proceeding with drainage of fluid.
Re-expansion pulmonary oedema may occur if too much fluid is removed too rapidly. Unless
instructed by the treating MO, it is recommended that no more than 1000 mL be drained
from the pleura at one time and no more than 2000 mL be drained from the peritoneal
cavity at one time.
Do not use scissors or other sharp objects near the indwelling drainage catheter.
The blue slide clamp should be used to prevent air entering the pleural space if the catheter
or the valve is damaged.
ALERT
Fluid may leak around the drain insertion site for the first few drainages after drain insertion
and the patient’s skin may become irritated from frequent dressing changes. Consider the
application of a no sting barrier film wipe and a sterile post-op drainage bag with window
(product information can be found in attachment 4). The sterile drainage bag with window is
generally changed weekly. If leakage continues organise for the patient to have a medical
review.
Equipment
The PleurX® Drainage Kit contents
A. Plastic vacuum bottle with attached line x 1
B. Procedure Pack
 Occlusive dressing x 1
 Blue sterile wrapping (wrapped around the following items):
o Pair of gloves x 1

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o Valve cap x 1
o Blue emergency slide clamp x 1
o Gauze swabs x 4
o Fenestrated foam catheter dressing x 1
o Alcohol swabs (for cleaning the outside of the valve) x 3
Additional Equipment
 Soft pre-moistened cloths (community only)
 Alcohol Based Hand Rub (ABHR)
 Clean gloves
 Sterile gloves x 2 pairs
 Safety eyewear
 Dressing pack
 Chlorhexidine 2% alcohol 70% swab sticks x 5 (3 for skin + 2 for catheter or alternatively
Chlorhexidine 2% alcohol 70% swabs x 2 can be used)
 Chlorhexidine 2% alcohol 70% swabs x 2 (for catheter as required)
 Sterile gauze (if required)
 Occlusive dressing (if required)
Procedure
1. Assess patient, inform the patient of the procedure and obtain verbal consent. Discuss
the option of patient having analgesia prior to the procedure
3. Position patient lying in bed or in a semi fowlers reclining position or as best tolerated,
protect patient’s clothes with the blue plastic sheet
4. Clear and/or clean a suitable space for sterile setup
8. Open basic dressing pack, sterile gloves and drainage kit
9. Place sterile chlorhexidine/alcohol swab sticks on sterile field
11. Remove the catheter site dressing and place in clinical waste receptacle
12. Observe site for any redness, swelling or fluid around the catheter and remove gloves
13. Check the sutures, if present, sutures generally are to be removed from the tunnelled
incision site day 7 and from the catheter site day 21 post insertion as per the medical
order
14. Attend hand hygiene and don sterile gloves
15. Remove procedure pack from drainage kit, open protective cover, move occlusive
dressing to basic dressing pack, place blue packaging on a clean surface, open blue
packaging while ensuring contents remain sterile, move gauze, fenestrated foam

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dressing, blue emergency slide clamp onto basic dressing pack, set aside 1 gauze for
dressing and unfold the sterile dressing towel. Open valve cap package and alcohol
swabs and place in sterile dressing tray. Discard blue wrapping and gloves from
packaging
16. Remove vacuum bottle with attached drainage line from the drainage kit and plastic bag,
place onto basic dressing pack, loosen but keep the cover on the access tip. Remove
paper tape and squeeze the clamp on the drainage line until completely closed
17. Connecting the drainage bottle. Hold the catheter with the non dominant hand using
gauze near the valve:
a. Place the sterile dressing towel underneath the uncoiled catheter
b. Using a 2nd gauze to maintain sterility, remove the cap by twisting it counter
clockwise and pulling gently. Discard the cap and gauze
c. Clean around the valve opening vigorously with alcohol swab x 1 for 10 seconds and
allow to air dry for 30 seconds
d. Pick up the drainage line with your dominant hand, remove the cover from the
access tip while maintaining sterility and insert the access tip securely into the valve.
You will feel and hear a click when the access tip and valve are locked together.
ALERT
Do not put anything except the access tip of the drainage line into the PleurX® Catheter
valve, since this could damage the valve. A damaged valve might let air be pulled into the
chest cavity (if the PleurX® Catheter is in the chest) or let fluid leak out through the valve.
18. Drain fluid:

a) The support clip on the vacuum bottle ensures that the vacuum seal on the bottle is
not broken before you are ready. Remove the support clip by grasping the upper part
of the flange and pulling outward
b) Hold the bottle steady with one hand and push the white “T’’ plunger down with the
other hand to puncture the foil seal. The vacuum in the bottle will pull the flexible
bottle cap down
c) Slowly release the clamp on the drainage line to begin drainage. Fluid will flow into
the vacuum bottle. The flow can be slowed down by squeezing the clamp partially
closed to reduce pain of drainage of fluid
It is normal for the patient to feel some pain when draining fluid. The pain may be
lessened when draining by clamping the drainage line to slow or stop the flow of fluid for
a few minutes.
19. The drainage will usually take 5-15 minutes. The flow into the bottle may slow down
when the fluid is almost completely drained. When the flow stops or the bottle is filled,
close the clamp on the drainage line completely. Ensure aseptic technique is maintained
if a 2nd bottle is required
20. Maintain sterility during the procedure, when drainage is complete hold the drainage
line in one gloved hand using gauze, pull the access tip out of the valve in a firm, smooth
motion. Using gauze, clean vigorously around the valve with alcohol swab x 1 for 10
seconds, allow to dry for 30 seconds

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21. Place the new cap over the valve and twist it clockwise until it snaps into the locked
position
22. Place a new dressing post drainage of fluid:
a) Cleanse the area around the catheter insertion site with chlorhexidine 2% alcohol
70% swab sticks x 3, starting at the catheter insertion site and extending outwards
using friction and a continuous circular motion, to incorporate the area that will be
covered by the dressing. Use the 4th & 5th swab sticks or alternatively use 2% alcohol
70% swabs x 2 to cleanse the catheter line. Allow the area to dry for at least 30
seconds, or until visibly dry.
b) Place the foam catheter pad around the catheter
c) Wind the catheter into a loop and place it over the foam pad
d) Cover the catheter with gauze
e) Take the self adhesive dressing and peel away the larger of the two pieces of paper
backing from the dressing
f) Centre the dressing over the gauze swab and press it down
g) Starting at one of the corners where the paper backing remains, bend the shiny
plastic covering back slightly and pinch the corner of the paper and dressing to
separate the plastic covering from the dressing. Peel the plastic covering from the
dressing. Ensure the dressing seals over the catheter. A 2nd occlusive dressing may
be required to ensure a seal.
h) Remove the remaining paper backing from the dressing and press it down.
3.2 Weekly dressing for the patient not undergoing drainage of fluid
On occasions a patient may achieve a spontaneous pleurodesis (control of effusion), and the
treating MO may decide to leave the drainage catheter insitu and continue to monitor the
patient. In this instance the catheter dressing should be attended to weekly and more often
if the dressing or seal is breached. An enrolled nurse who is assessed as competent can
attend to the weekly dressing. There is no need to change the catheter valve cap. The
patient is to be assessed for signs or symptoms of the recurrence of a pleural effusion. The
EN is to report any concerns promptly to the RN who will arrange for the patient to be
drained by a competent RN.
Equipment
 Soft pre-moistened cloths (community only)
 Alcohol Based Hand Rub (ABHR)
 Clean gloves
 Sterile gloves
 Safety eyewear
 Dressing pack

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 Chlorhexidine 2% alcohol 70% swab sticks x 5 (3 for skin + 2 for catheter or alternatively
Chlorhexidine 2% alcohol 70% swabs x 2 can be used)
 Chlorhexidine 2% alcohol 70% swabs x 2 (for catheter as required)
 Fenestrated foam dressing (e.g. PICS : 15385 8.75cm X 7.5cm)
 Occlusive dressing(s) 10 cm x 12 cm
Procedure
1. Assess patient, inform the patient of the procedure and obtain verbal consent
3. Ensure patient has performed hand hygiene if you anticipate that they may be able to
assist by holding the gauze dressing in place while covering with the occlusive dressing
4. Position patient lying in bed or in a semi fowlers reclining position or as best tolerated,
protect patient’s clothes with the blue plastic sheet
5. Clear and/or clean a suitable space for sterile setup
8. Set up equipment
10. Remove the catheter site dressing and place in clinical waste receptacle
11. Observe site for any redness, swelling or fluid around the catheter and remove gloves
12. Attend to hand hygiene using ABHR and don sterile gloves
13. Place the sterile dressing towel underneath the uncoiled catheter
14. Cleanse the area around the catheter insertion site with Chlorhexidine 2% alcohol 70%
swab sticks x 3, starting at the catheter insertion site and extending outwards using
friction and a continuous circular motion, to incorporate the area that will be covered by
the dressing. Use the 4th and 5th swab sticks or alternatively use 2% alcohol 70% swabs x
2 to cleanse the catheter line. Allow the area to dry for at least 30 seconds, or until
visibly dry.
15. Place the foam catheter pad around the catheter
16. Wind the catheter into a loop and place it over the foam pad
17. Cover the catheter with gauze
18. Cover the gauze with the occlusive dressing and press it down. A 2nd occlusive dressing
may be required to ensure a seal
Potential complications of pleural drainage

 Circulatory collapse
 Hypotension
 Pneumothorax
 Re-expansion pulmonary oedema
 Loculation of pleural space
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 Wound Infection
Potential complications of peritoneal drainage

 Circulatory collapse
 Electrolyte imbalance
 Hypotension
 Leakage of ascitic fluid
 Loculation of peritoneal space
 Peritonitis
 Protein depletion
 Wound infection
Troubleshooting
 Amount of drainage gradually declines and the patient does not feel relieved of
symptoms, it is possible that the catheter may be clogged. Consult the treating MO
 Catheter is accidently cut – place the blue slide clamp on the catheter to prevent air
entering the pleural space and seek urgent medical attention (call MO/ambulance)
 Catheter is accidentally dislodged - this is unlikely as it is a tunnelled catheter and has a
polyester cuff that prevents it from being dislodged. In the unlikely event that the
pleural catheter is pulled out, cover the exit site immediately with a sterile, occlusive
dressing taped on 3 sides only (to ensure air can escape) and seek urgent medical
attention (call MO/ambulance). If an abdominal catheter is inadvertently dislodged
cover with a sterile dressing and seek prompt medical attention
 Catheter valve is accidently damaged - place the blue slide clamp on the catheter to
prevent air entering the pleural space and seek urgent medical attention (call
MO/ambulance)
 Change in drainage fluid colour this may be indication of infection or disease
progression. Consult the treating MO
 Drainage is smaller or no fluid is drained ask the patient to cough or turn from side to
side. If fluid is drained normally last time and drainage suddenly stops or you are unable
to drain at all this time, some debris in the fluid may have clogged the line to the bottle.
Squeeze the catheter and the drainage line gently. If the drainage does not begin, follow
the instructions for changing a bottle. If the drainage does not start when you use a
second bottle, consult the treating MO for advice
 Drainage is a little less each time that you drain and the current amount of drainage is
much smaller than previously, a pleurodesis may be forming. Consult with the treating
MO

Section 4 – External ventricular Drain (EVD) management in ICU and 9B
This section outlines the safe nursing practices for the management of an external
ventricular drain (EVD) system in ICU and 9B. It outlines care of the EVD, sampling of

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cerebrospinal fluid (CSF), changing the drainage bag and the nursing management around
the removal of an EVD.
Only experienced RN’s that have been deemed competent to manage and care for a patient
with an External Ventricular Drain (EVD) are permitted to do so. Nurses new to ICU and 9B
will perform these skills under the direct supervision of a competent registered nurse.
Educational content
MODIFIED MONROE-KELLY HYPOTHESIS
The skull is a rigid structure surrounding blood, CSF and brain matter. Any change in volume
of one of these components will change one or more other components, in order to
maintain a constant volume. If the status quo is not maintained, the intracranial pressure
(ICP) will increase.
The EVD is a catheter, which is inserted into the anterior horn of the lateral ventricle on the
non-dominant side to drain CSF when the pressure is too high.
EVD’s function on principles of gravity. CSF drainage (and consequently ICP) is controlled by
the height of the drip chamber relative to the patient. Drainage occurs when the ICP rises
above the pressure of the reference point, commonly the tragus, middle of the ear.
The purpose of EVD is to:

 provide a means of monitoring ICP
 allow drainage and measurement (mL) of CSF
 obtain CSF specimens for pathology/biochemistry purposes

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Nursing Management of an EVD

 When the patient returns from the Operating Theatre, determine the reference point
and the height of the drip chamber as per the Neurosurgeon’s post operative
instructions
 The target ICP range will be determined by the Neurosurgeon/Intensive Care Specialist
 Normal ICP range is 0 – 15 mmHg
Alert
Patients are positioned 30 degrees head up to facilitate venous drainage - whole of bed is tilted to ensure 30
degree head up position while supine. Back of bed only to be raised after spinal clearance from medical team
 Maintain head to body alignment

 For patients with endotrachael tubes (ETT) ensure that ties are not tight and restrictive
to ensure venous drainage
 Neurological and haemodynamic observations are recorded hourly on MetaVision
 Observe nature of CSF drainage, record volume (mL) hourly or as instructed
 Maintain strict asepsis when attending to catheter site and EVD connections
 Observe catheter site for signs of infection
CSF sampling is done at the discretion of the Neurosurgeon or Intensive Care Specialist and
should be done when requested by the medical team. The procedure for CSF sampling is
outlined in section 4.4 in this document.

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Alert
Always clamp the EVD system when repositioning/moving/transferring the patient.
Check patency and re-zero the system after repositioning.
Height of EVD chamber should be adjusted according to the medical team’s recommendations/instructions,
e.g. 20cm above tragus.
4.1 Measurement of cerebrospinal fluid (CSF)

Procedure
1. Wash hands
2. Turn three-way tap off to drainage, and on to ICP monitor
3. Measure the amount of CSF in the measurement container
4. Open clips to allow the CSF in the hourly measurement container to drain into the
drainage bag
5. Reapply clips between the measurement container and the drainage bag
6. Turn the three-way tap off to the ICP monitor, and on to CSF drainage
7. Document hourly amount of CSF on MetaVision (ICU) or EVD/Lumbar Drain observation
chart (9B) record nature of CSF in clinical record e.g. CSF bloodstained, straw coloured,
etc.
Alert
Ensure the three-way tap between the patient and the CSF measurement container is turned to the open
position, to allow drainage of CSF. If the tap is inadvertently left in the closed position, CSF will collect and
consequently cause ICP to rise.
4.2 Redressing insertion site

The EVD insertion site dressing is attended weekly or if the dressing is breached. An
occlusive dressing must be used.
Equipment
 Clean gown
 Sterile gloves
 Dressing pack
 Sterile scissors
 Duoderm – extra thin
 Normal Saline 10mL ampoule x 1
 Chlorhexidine 0.5% in alcohol 70%

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Procedure
1. Explain procedure to patient
2. Prepare equipment
3. Remove old dressing
4. Attend hand hygiene, don gown and sterile gloves
5. Clean insertion site with Normal Saline, allow to dry for 30 seconds
6. Clean with chlorhexidine solution, allow to dry for 2 mins
7. Apply duoderm (cut a keyhole in the duoderm to allow ease of access around the drain
insertion site)
8. Document procedure and status of EVD catheter insertion site in patient’s clinical record
4.3 Change of drainage bag

The EVD drainage bag is changed when full, using a strict aseptic technique. The aim of this
procedure is to prevent return (overflow) of previously drained CSF back into the EVD
drainage system and to maintain EVD patency allowing drainage of CSF as required.
Equipment
 Clean gown
 Sterile gloves
 Sterile towel
 Dressing pack
 Gauze squares
 Artery forceps – sterile
 CSF drainage bag - sterile
Procedure
1. Attend hand hygiene and prepare equipment
2. Clamp clips between CSF measurement container and CSF drainage bag
3. Wash hands, don gown and sterile gloves
4. Assistant unpegs drainage bag from EVD holder, and places end on sterile towel
5. Clean connection site and tubing with chlorhexidine solution, allow to dry for 2 mins
6. Using sterile artery forceps, disconnect old bag from EVD set and connect new bag
7. Reattach bag to EVD holder, and unclamp clips
8. Document date, time and total amount of CSF in drainage bag
4.4 Sampling of cerebrospinal fluid from EVD - Adults

This section describes the procedure for sample collection of CSF from EVD. This section
applies to adult patients in ICU and 9B.
The collection of CSF from an EVD should only be done by Registered Nurses or MOs who
have been assessed as competent by a CDN from ICU or 9B.
Alert
 Never aspirate CSF directly from the ventricular system. Notify the Neurosurgical Registrar immediately if

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CSF does not flow freely into specimen jar

 Never disconnect any part of the EVD, especially the bung at the sampling port of the three way tap. If in
doubt call the Neurosurgical Registrar.
The On-call registrar should be notified immediately if:

 EVD stops draining
 EVD becomes blocked
 There is evidence of leakage from any point of the EVD
The purpose of CSF collection is to monitor:

 The level of micro-organisms within the CSF
 The biochemical and cellular profile of CSF as an indicator of infection and/or bleeding
1. Ensure that a surgical aseptic non touch technique (surgical ANTT) is applied when
sampling CSF from an EVD
2. 1-2mL of CSF is sampled for gram stain, glucose, cell count, culture and sensitivity
3. CSF sampling is at the discretion of the Neurosurgeon or Intensive Care Specialist and
should be done when requested by the medical team.
Equipment
 Goggles
 Mask
 Sterile gown
 Sterile gloves
 Sterile drapes x 2
 General dressing pack
 23 gauge needle
 Sterile black top CSF specimen tube.
 Sterile artery forceps
 2% chlorhexidine/70% Isopropyl Alcohol Solution.
 Dressing trolley
 Access to sharps container
 Alert sticker (ICU only)
Procedure
2. Clean procedure trolley and collect equipment
4. Explain procedure to patient and gain consent, if appropriate
5. Position patient with head up at 30 degrees
7. At sampling bung, turn the 3 – way tap OFF to drain (Ensuring it is off to the transducer
and drainage bag) and open to the patient for CSF collection
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9. Apply goggles and mask

10. Set up trolley in accordance with equipment
11. Perform hand hygiene procedural wash
12. Apply sterile gown and sterile gloves
13. Open sterile drapes
14. Swab/clean the sampling bung 3 times using a separate swab each time allowing to dry
for 30 sec in between each swab, & 1 min for final swab
15. Using forceps, place EVD drainage tubing onto one of the sterile drapes
16. Insert a 23 gauge needle into the cleaned sampling surface of the bung (see Figure 1)
17. Hold the specimen container under the needle and allow the CSF to drip into the
container (approximately 0.5-1.0ml)
18. Remove the needle when collection is complete and dispose of needle into sharps
container
19. Turn the 3-way tap off to the bung to ensure the flow of CSF is restored (ie open to the
patient and/or drain, as per MO’s instructions for the patient’s EVD management
20. Place alert sticker ‘Do not inject’ on sampling bung to ensure nothing is injected into
bung (ICU only)
21. Label specimen and send to pathology with request form
4.5 Removal of EVD

The EVD is removed as directed by the Neurosurgeon in consultation with the Intensive Care
Specialist. Removal of EVD is done by a MO. A suture is required when the EVD is removed
to minimise risk of CSF leak.
Equipment
 Clean gown
 Sterile gloves
 Sterile towel
 Gauze swabs
 Stitch cutter
 Transwab/specimen container (sterile scissors)
 Suture material
 Tape for dressing
 Protective sheet
Procedure
1. Explain procedure, ensure patient privacy
2. Use aseptic technique
3. Prepare equipment
4. Position patient supine with head of bed at 30 degrees
5. Ensure drain is turned off to patient, remove dressing, wash hands
6. Don clean gown, mask and sterile gloves
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7. Clean insertion site with chlorhexidine solution and allow to dry for 2 mins
8. Remove suture and withdraw drain with a firm and even pressure
9. Apply pressure to the insertion site with sterile gauze and maintain pressure for
approximately 5 minutes
10. Apply suture
11. Apply gauze dressing, secure with tape
12. Inspect EVD tip to ensure tip is intact
13. Cut drain 5cms from tip and place in specimen jar and send to microbiology (routinely)
14. Reposition patient, ensure the patient is comfortable

Section 5 – Therapeutic Ascitic Tap/Paracentesis
5.1 Principles of therapeutic ascitic tap

Therapeutic ascitic taps (also known as large volume paracentesis) are often carried out on
inpatient wards or in outpatient clinics. The purpose of the ascitic tap is to remove an
accumulation of fluid from the abdomen to make the patient more comfortable. This should
be carried out by the Medical Officer (MO) or a Registered Nurse working within their scope
of practice (for example, Nurse Practitioner in the Rapid Assessment Unit). The following
key principles in the nursing management of ascitic taps should be followed:
 The patient should empty his/her bladder before the procedure (to reduce risk of
perforation) and baseline vital sign observations should be completed.
 The patient should remain supine in bed while the ascitic tap is in situ. Vital signs and
observations should be performed half hourly for the first hour and then hourly for the
duration of the ascitic tap. The ascitic tap drainage device must be visualised as part of
the observations to ensure the device is still in place.
 Albumin 20% should be administered for patients undergoing large volume
paracentesis. This must be ordered on the fluid order chart by a MO. Routine practice
is to administer one bottle of 100ml Albumin 20% for every two litres of ascitic fluid
drained.
 The ascitic tap drainage device should not be left in situ for more than six hours. For
most patients drainage will stop or significantly slow before this. The nurse should
advise the MO when drainage has stopped and seek advice on removal of the tap. If
fluid stops draining prematurely, contact the MO.
5.2 Removal of an Ascitic tap

Removal of an ascitic tap can be carried out by a MO, RN or EN.
Equipment
 Safety glasses
 Clean gloves
 Clean gown
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 Film dressing (if patient not allergic)
 Clinical waste bin
 Sharps container
Procedure
1. Explain procedure to the patient, obtain consent and ensure the patient is lying
comfortably.
2. Attend hand hygiene.
3. Don safety glasses and gown prior to opening sterile equipment.
4. Attend hand hygiene.
5. Open dressing pack and film dressing.
6. Don clean gloves.
7. Place the disposable blue plastic sheet under the patient.
8. Close two/three way tap located on drain allowing for final output measurement.
9. Remove gloves.
10. Attend hand hygiene and apply new clean gloves.
11. Loosen dressing around ascitic tap drainage device.
12. Anchor the drain site by placing fingers on the skin on either side of the drain.
13. Remove drain in one quick motion, at same angle that tap is sitting in the patient’s skin.
14. Apply folded gauze square and film dressing to site.
15. Discard ascitic tap drainage devicein sharps bin.
16. Discard rubbish in clinical waste bin.
17. Remove gloves and attend hand hygiene.
18. Educate patient to observe site for any bleeding or ascitic fluid leak and report same to
nursing staff. If fluid leakage occurs, lay patient on opposite side to insertion site for 2
hours. If the dressing is consistently being soaked despite this measure, a colostomy bag
may be applied after consultation with the medical team.
19. Advise patient to leave dry dressing in-situ for 24-48 hours.
20. Document removal of drain, appearance of removal site, and any specific measures
taken in patient’s clinical record.

Implementation
This procedure will be communicated to relevant staff via team meetings, and will be
incorporated into existing education and training programs.

Related Policies, Procedures, Guidelines and Legislation
Policies
 Work Health and Safety Policy 2012, Document Number DGD12-036
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Procedures
 Canberra Hospital & Health Services Aseptic Non Touch Technique Procedure 2014,
Document Number CHHS14/011
 Hand Hygiene Procedure 2011, Document Number CED11-50
 Nursing and Midwifery Continuing Competence Policy and Procedure, Document Number
DGD12-050
 Consent and Treatment Policy and Procedure 2012, Document Number DGD12-044

References
1. Adamo R, Saad WEA and Brown DB. Management of nephrostomy drains and ureteral
stents. Techniques in Vascular and Interventional Radiology, 2009;12(3):193-204.
2. Australian Wound Management Association Inc. Standards for Wound Management. 2 nd
edition. 2010.
3. Bard StatLock® Universal Plus Stabilization Device.
4. https://www.bardaccess.com/statlock-other-universal-plus.php
5. Accessed 13 November 2013.
6. Carville K. Wound Care Manual 6th Edition, Silver Chain Nursing Association WA. 2012.
7. Cook Medical. Drainage Workshop Handout. 2010.
8. Hayes D. Pigtail drain tubes: a guide for nurses. Australian Nursing Journal, 2005;
12(10):19-20.
9. Farrell M (Ed.) Smeltzer & Bare’s Text Book of Medical Surgical Nursing. 2nd ed.
Lippincott. Williams & Wilkins. Broadway. 2011.
10. Nicolaou S, Talsky A, Khashoggi K, and Venu V. Ultrasound-guided interventional
radiology in critical care. Critical Care Medicine. 2007;35(5)S186-S197.
11. NSW Agency for Clinical Innovation. ACI Urology Network – Nursing. Nursing
Management of Patients with Nephrostomy Tubes. Guidelines and Patient Information
Templates. 2012.
12. Siddiq M and Darouiche R. Infectious complications associated with percutaneous
13. nephrostomy catheters: Do we know enough? International Journal of Artificial Organs.
2012;35(10):898-907.
14. The Joanna Briggs Institute. ACT Health. Canberra Hospital - Acute Care Practice Manual.
2013. Wound Dressing. 857-858. Closed Wound Suction Drainage Removal.870-874.
15. CareFusion [Homepage of CareFusion] – last updated 2011. [Online]
16. Available: http://www.carefusion.com/ [11 July 2011]
17. PleurX® Pleural Catheter System [Online]
18. Available: http://www.carefusion.com/products-and-services/products-services-
categories/interventional-specialties/pleurx.aspx [11 July 2011]
19. PleurX® Peritoneal Catheter System [Online]
20. Available: http://www.carefusion.com/products-and-services/products-services-
categories/interventional-specialties/pleurx-per-cath.aspx [11 July 2011]

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21. Putnam JB, Walsh GL, et al. Outpatient Management of Malignant Pleural Effusion by a
Chronic Indwelling Pleural Catheter. Journal of Thoracic Surgery. 2000; 69:369-375.
22. The Australian Council on Healthcare Standards (ACHS). [Homepage of ACHS] [Online] –
last updated 19 April 2011. Available: www.achs.org.au/ [6 July 2011].
23. Warren, W., Kim, A., Liptay, M. Identification of clinical factors predicting PleurX®
catheter removal in patients treated for malignant pleural effusion. European Journal of
Cardio-Thoracic Surgery. 2008;33(1):89-94.
24. Australian Wound Management Association Inc. Standards for Wound Management. 2 nd
edition. 2010.
25. Behrendt R. Management of Malignant Ascities: Current Treatment Option. Oncology
Nursing News. 2008:2(1):1-16.
26. CareFusion PleurX® Pleural Catheter System. 2014 Retrieved from September 1 2014
from http://www.carefusion.com/medical-products/carefusion-brands/pleurx/
27. Carville K (2007) Wound Care Manual, Silver Chain Foundation, 5th Edition.
28. Joanna Briggs Institute: Evidence Summaries:
29. Wound drain site – 2011
30. Wound drain: dressing - 2011
31. Vacuum drain (surgical): removal – 2011
32. Closed wound suction drainage: emptying – 2011
33. Closed wound suction drainage: maintenance – 2011
34. Closed wound suction drainage: removal – 2011
35. Closed wound suction drainage: shortening – 2011
36. Smeltzer,S and Bare,B (2004) Clinical Nursing skills: Basic to advanced.
37. Smith S Duell D, Martin B. (2004) Clinical Nursing Skills: Basic to advanced. Pearson
Prentice Hall. New Jersey. 6th Edition.
38. Clochesy, J., Breu, C., Cardin, S., Whittaker, A. and Rudy, E. (1996). Critical Care Nursing.
2nd ed. W.B.Saunders, Philadelphia.
39. Hudak, C.M. et al (1998). Critical Care Nursing: An Holistic Approach. 7th ed.
Lippincott, Philadelphia.
40. Oh, T.E. (Ed). (1996). Intensive Care Manual. 4th ed. Butterworth Heinman, Oxford
41. Liverpool Health Service ICU “Collection of CSF from an EVD” Guideline March 2006,
Central Sydney Health Service.
42. RPAH ICU Nursing Policy and Procedure “CSF collection”, March 2004.
43. The St George Hospital ICU Nursing Procedure Manual “Collection of Specimens from
Ventricular Drains”.
44. South Eastern Sydney Illawarra Wollongong Hospital “Cerebral Spinal Fluid Sample
Collection” Policy.
45. Pericleous, M., Sarnowski, A., Moore, A., Fijten, R. & Zaman, M. 2016, The clinical
management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal
syndrome: A review of current guidelines and recommendations, European Journal of
Gastroenterology and Hepatology, 28:e10-e18.
46. Sir Charles Gardiner Hospital Guideline 2013, Abdominal Paracentesis in Chronic Liver
Disease.

2018 and Imaging
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Definition of Terms
Ascites: fluid that builds up in the abdomen or chest cavity

CSF: Cerebrospinal fluid
EVD: External ventricular drain
Loculation: the presence of numerous fluid filled small spaces or cavities that may make
complete drainage of fluid difficult
Pleural Effusion: build up of fluid between the layers of tissue that line the lungs and chest
cavity
Pleurodesis: procedure that causes the membranes around the lung to stick together and
prevents the build up of fluid in the space between the membranes. This procedure is done
in cases of severe recurrent pleural effusion, usually from cancer, to prevent or reduce the
re-accumulation of fluid
Pneumothorax: air in the space between the lungs and chest wall
Re-expansion pulmonary oedema: accumulation of fluid in the lung associated with very
rapid drainage of a pleural effusion

Search Terms
Drain, Drainage, Drainage tube care, Wound care: closed drainage, Closed drainage, Suction,
Radiological drainage catheter, Wound drain, Pleural drainage, Peritoneal drainage, External
ventricular drain, Cerebrospinal fluid, ascetic tap, ascites, paracentesis

2018 and Imaging
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Attachments
Attachment 1 - Management of a Radiologically Inserted Drainage Catheter

Attachment 2 - Resources for radiologically inserted drainage catheter
catheter systems
Attachment 4 - Resources for indwelling pleural/peritoneal drainage catheter system
Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services
specifically for its own use. Use of this document and any reliance on the information contained therein by any
third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Policy Team ONLY to complete the following:

Date Amended Section Amended Divisional Approval Final Approval
19/12/2017 Section 5 – Therapeutic Daniel Wood, ED Surgery CHHS Policy Committee
Ascitic Tap/Paracentesis and Oral Health
This document supersedes the following:

Document Number Document Name
1.1 Community Care Wound Drain Management
CHHS12/267 Indwelling pleural/peritoneal Drainage Catheter System Management (currently using
PleurX)
No document number Management of Percutaneous Radiolofical Drainage catheters
CHHS12/203 Extraventricular Drain (EVD) management
CHHS13/444 Sampling of cerebrospinal fluid from external ventricular drains (EVD’s) – Adult only

2018 and Imaging
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Attachment 1 - Management of a Radiologically Inserted Drainage Catheter
Percutaneous Radiologically Inserted Drainage Catheter Management

Flow Chart
*The flow chart below is a summary only, refer to the procedure for complete details
 Assess and observe insertion site and dressing

integrity
 Check medical order for flushing of the catheter
 Apply a 3-way tap to the catheter using a sterile

technique if a drainage bag is attached
 Flush the catheter if ordered
1) Carefully remove dressing to avoid pulling on the

catheter
2) Carefully remove the catheter from the Statlock®
and tape the catheter to the patients skin to
prevent catheter dislodgment
3) Remove and discard Statlock®
4) Measure the catheter - insertion site to hub
5) Apply new StatLock® using a sterile technique
6) Attend to dressing using a sterile technique
including the application of gauze and an occlusive
dressing over catheter insertion site and StatLock®
Change needleless injection cap weekly if the

catheter is being flushed using a sterile technique
Change drainage bag weekly

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Attachment 2 - Resources for radiologically inserted drainage catheter
Canberra Hospital Medical Imaging Department

Angiography Suite T: 6244 2408 (business hours).
Medical Imaging Main Reception T: 6244 2159 (24 hours per day/7 days per week).
For community patients referrals are to be faxed by the to the Angiography Booking Clerk
F: 6244 2494. The Angiography Booking Clerk is available to process referrals during
business hours. It is recommended to follow up the fax with a telephone call T: 6244 2408 to
confirm receipt of the fax and confirmation of the booking.
Cook Medical Interventional Radiology

Product Representative T: 0488 060 621
T: 1800 777 2222
T: 07 3841 1188
F: 07 3841 1288
E: Cau.CustServ@CookMedical.com
W: www.cookmedical.com
Consumables product information

*PICS Description Unit of Issue
11206 Connecting tube Cook CTU14.0-30-ST) each
*ACT Health Supply Services - Purchasing and Inventory Control System (PICS)
StatLock® Universal Plus Catheter Stabilization Device

PICS Bard Reference Number Unit of Issue StatLock® Description
37560 VUPD68 Box/25 Universal Plus, Small (6 - 8.5Fr)
37561 VUPD1012 Box/25 Universal Plus, Medium (10 - 12Fr)
37562 VUPD1214 Box/25 Universal Plus, Large (12 - 14Fr)
37563 VUPD1416 Box/25 Universal Plus Extra, Large (14 - 16Fr)

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catheter systems
Equipment for discharge

PleurX® bottles x 3
PleurX® drainage line set x 1 (provided by the hospital)
PleurX® Patient Education DVD
Medical Orders
The medical orders are to be documented on ‘MO’s Order for Percutaneous Radiological
Drain Management’ or ‘Treatment Orders’ form.
Suture removal
Not all patients have sutures that require removal; in some cases the sutures are dissolvable.
Not all patients have a sutured wound from the drain being tunnelled; in some cases the
sutures are internal or dissolvable. If the patient has sutures that require removal the
recommend orders are:
‘Removal of sutures day 7 from the tunnelled site’
‘Removal of sutures day 21 from the drain site’
(Source CareFusion Account Manager / Product Representative T: 0433 032 795)
Drainages
Generally the:
Chest is drained up to 1 litre at a time PRN
Peritoneum is drained up to 2 litres at a time PRN
A summary of:
Drainages including frequency, volume and colour
Patient/carer education in drain management

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Attachment 4 - Resources for indwelling pleural/peritoneal drainage catheter system
Lung Cancer and Mesothelioma Nurse Care Coordinator

T: 6244 3895 / 0466 169 952
*PICS CareFusion Unit of Description

Cat. No. Issue
16096 50-7500B 10 Drainage Kit – 500ml vacuum bottle and procedure pack
25973 50-7510 10 Drainage Kit – 1000ml vacuum bottle and procedure pack
16101 50-7235 10 Replacement valve cap
16100 50-7225 10 PleurX® Drainage Line Set
n/a 50-7205B 10 Vacuum bottle – 500ml, with drainage line
n/a 50-7210 10 Vacuum bottle – 1000ml, with drainage line
10257 N/A 5 Post-op sterile drainage bag with window
41157 N/A 50 No sting barrier film wipe
*ACT Health Supply Services - Purchasing and Inventory Control System (PICS)
Resource kit (to be kept with patient)

 PleurX® Drainage Line Set (supplied by the hospital)
CareFusion
Account Manager NSW/ACT M: 0433 032 795
Customer Service T: 1800 110 511 F: 1800 113 317
E: customerservice-au@carefusion.com

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Drain Management Procedure

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CHHS15/052

Canberra Hospital and Health Services

Doc Number Version Issued Review Date Area Responsible Page

Potential complications of pleural drainage....................................................................27

Doc Number Version Issued Review Date Area Responsible Page

Section 1 – Wound drains

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1.1 Capillary action drains

Shortening and removing a capillary action drain

Doc Number Version Issued Review Date Area Responsible Page

1.2 Closed Drainage Systems/ Low suction drains

Note: The drainage bags are not interchangeable

1.2.1 Redressing insertion site

1.2.2 Emptying Bellovac/Exudrain/Handyvac bulb or bellow and recharge vacuum

Doc Number Version Issued Review Date Area Responsible Page

1.2.3 Changing of drainage bag

1.2.4 Removing closed drainage system/low suction drain

Doc Number Version Issued Review Date Area Responsible Page

Back to Table of Contents

Doc Number Version Issued Review Date Area Responsible Page

Section 2 – Radiologically inserted drains

Notify the MO/Specialist/Registrar if:

2.1 Drainage catheter securement and dressing

StatLock® Universal Plus

Doc Number Version Issued Review Date Area Responsible Page

10. StatLock® Removal Technique:

2.2 Flushing of a radiologically inserted drainage catheter

Nephrostomy drainage catheter

 Gown (non sterile)

2.3 Aspirating then flushing of a biliary catheter

2.4.1 Needleless injection cap change

Doc Number Version Issued Review Date Area Responsible Page

 Disposable plastic blue sheet

2.5 Drainage bag change

Doc Number Version Issued Review Date Area Responsible Page

2.6 Removal of a radiologically inserted drainage catheter

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20. Educate patient/carer to:

Back to Table of Contents

This section provides procedural information in the management of recurrent pleural

Patient / Caregiver Education

3.1 Draining fluid

Doc Number Version Issued Review Date Area Responsible Page

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18. Drain fluid:

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Potential complications of pleural drainage

Potential complications of peritoneal drainage

Back to Table of Contents

Doc Number Version Issued Review Date Area Responsible Page

The purpose of EVD is to:

Doc Number Version Issued Review Date Area Responsible Page

Nursing Management of an EVD

 Maintain head to body alignment

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4.1 Measurement of cerebrospinal fluid (CSF)

4.2 Redressing insertion site

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4.3 Change of drainage bag

4.4 Sampling of cerebrospinal fluid from EVD - Adults

Doc Number Version Issued Review Date Area Responsible Page

CSF does not flow freely into specimen jar