1.1 Background

A seroma is caused by a collection of straw coloured fluid.  The serum can accumulate in an area of the body tissue damage, eg. axillary surgery.  If it does not drain internally it can collect under the skin causing discomfort and swelling.^[1]

Approximately 50% of in-patients with closed suction drain have an incidence of post-operative seroma formation, which may require further aspiration after axillary clearance.^[2]

Another study demonstrated that axillary node dissection can be managed with or without a drain.  However, more aspirations in the no drain group were required (50%) compared to the drain group (8.3%).^[3]

Patients should receive information about seromas before their surgery and again after removal of exudrain. Bowman et al 2002 study found that staff continuity and particularly the presence of a special trained nurse for wound control and for psychosocial support were much appreciated.

1.2 Aim/purpose

For the Breast Care Team to

1. Assess the need to drain the seroma.

2. Safely drain the seroma.

1.3 Patient/client group

Patients who have undergone axillary surgery as part of breast surgery.

1.4 Exceptions/ contraindications

The Breast Care Team should avoid aspiration if collection of fluid is < 50ml, if the patient is taking anti-coagulants or if there is evidence of infection or inflammation.

1.5 Options

None.

2.1 Staff & equipment

Seroma assessment and drainage is considered to be an advanced practice within this Trust.

The Breast Care Team following training and assessment are only allowed to 'perform' this procedure.

The process for undertaking these advanced practices is:-

1. Supervised practice. 

2. Practice assessment. 

3. Observed practice.

 In line with guidelines laid down by the NMC on standards for records and record keeping, there must be a current and appropriate plan of care for patients requiring seroma drainage.^[5]

 2.2 Method/procedure

 Equipment required: 

 If patients have any concerns at all they should contact the Breast Specialist Nurse.

 2.3 Potential complications / Risk Management

 Infection

The Breast Care Team may be able to detect infection within the seroma fluid.  It is essential to observe the colour of the fluid drained.  If the specimen is cloudy, send a specimen for culture and sensitivity and record in patient notes.  The patient or their general practitioner will need to be notified if antibiotics are appropriate or not.

 If the patient experiences any difficulty in breathing after seroma drainage they should contact either the Breast Care Team, GP and A & E department.  They may require a CXR and medical treatment.

 2.4 After care

1. The patient can remove the adhesive dressing after 24 hours. 

2. The Breast Care Team will make the patient a further appointment for aspiration of seroma if required. 

3. The amount and type of fluid will be recorded in the Breast Care Department patient notes.

4.1 Audit Indicators

Standard Statement –

All patients who experience a seroma post breast surgery with axillary intervention should receive care according to the Trust Protocol.

 Structure

1. Patients should have the opportunity to discuss the treatment and aims of seroma drainage with the breast specialist nurse. 

2. Patients should receive verbal and written information about seromas and their treatment. 

3. Patients should receive care according to seroma protocol. 

4. Seroma drainage should be performed by a competent member of the Breast Care Team. 

5. Reiterate contact numbers for Breast Care Team.

Process

1. The patient will be welcomed to the breast care department clinical room. 

2. Anxieties of the patient should be addressed. 

3. The procedure should be explained to the patient. 

4. An explanation of what the patient might experience should be given. 

5. The procedure should be carried out according to seroma protocol. 

6. Throughout the drainage procedure the patients comfort and anxieties should be addressed.

 Outcome

1. The patient has received the care according to the seroma protocol. 

2. The seroma has been assessed and drained (if necessary) by a competent member of the Breast Care Team. 

3. The patient's physical and psychological needs were met. 

4. The patient has received information pertaining to their aftercare. 

5. The drainage of the seroma was carried out using an aseptic technique. 

6. All care documented in breast care notes.

 4.2 Audit design

1. The patient has received the written and verbal information according to their needs and to ensure safe administration. 

2. The patient has received the care according to the protocol, Trust Guidelines and their own needs. 

3. The seroma has been assessed and drained by a competent member of the Breast Team. 

4. The patient was well informed throughout the process. 

5. The patient was given opportunities to express anxieties and needs during their stay. 

6. The patient was given aftercare information and contact numbers.      

4.3 User Involvement

A patient survey will be conducted to establish if their informational needs were met.

4.4 Risk Management

Factors Associated with Seroma Drainage

5.1  Sources of information

1.   Sampson V., Fenlon D. (2000) The Breast Cancer Book, London: Vermilion.

2.   Petrek J A, Peters M M, Nori S, (1990) Axillary lymphphadenectomy. Arch. Surg. 125; 378-82

5.   Nursing and Midwifery Council, The Code of Professional Conduct & Ethisc May 2008.

5.2 Summary of evidence, review and recommendations

The information contained within these guidelines have been collated from reputable services.  Attention has been paid to ensure seroma drainage is safe for both patients and staff.  Breast Specialist Nurses draining seromas is a relatively new practice and the evidence to support this is limited.    A literature search on Medline and a literature review reflected this.

An annual review to ensure safe practice and competence of the Breast Specialist Nurse is essential.

Seroma formation and drainage can bring about patient anxiety and may delay further treatment.  It is vital the Breast Specialist Nurse spend time in explaining the procedure and address the patient's anxieties.