1.1 Background

Formation of a seroma most frequently occurs after mastectomy and axillary surgery. Prolonged drainage is troublesome as it increases the risk for infection and can significantly delay adjuvant therapy. Seroma has been defined as serous fluid collection under the skin flaps or in the axillary dead space following mastectomy and/or axillary dissection. No patient or tumour factors seem to affect seroma formation except body mass index and body weight. Consensus is lacking among studies/trials with different groups producing conflicting evidence. Besides a few established factors such as body mass index, the use of electrocautery for dissection, early drain removal, low vacuum drains, obliteration of dead space, and delayed shoulder physiotherapy, most of the hypothesized causes have not been demonstrated consistently. Thus, seroma remains a threat to both the patient and surgeon. Recurrent transcutaneous aspiration remains the only successful management. ^[1]

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 cancer surgery.

1.4 Exceptions/ contraindications

The Breast Care Team should avoid aspiration if collection of fluid is < 50 mls, 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 expanded nursing practice within this Trust.

The Breast Care Team following training and competency based expanded practice assessment are then allowed to 'perform' this procedure.

The process for undertaking advanced practice is:-

1. Supervised practice.

2. Practice assessment.

Observed practice.

In line with NMC The Code 2015 (2) guidelines keep clear and accurate records relevant to your practice. There must be a current and appropriate plan of care for patients requiring seroma drainage. ^[2]

2.2 Method/procedure

Equipment required:

Trolley

50 ml luerlock syringe        Disposable gloves

Disinfection wipe              Disposable apron

21G needle / 16G cannula   Inco sheet

3 way tap

Receiver

Dressing Tape

Gauze

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 Somerset Cancer database. 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 dressing later that day.

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 on the Somerset Cancer database.

Seroma drainage is discussed in the patient information booklet given pre-operatively, this includes contact numbers.

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 a clean technique.

6. All care documented on the Somerset Cancer database.

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

Patient verbal feedback documented as appropriate on the Somerset Cancer database.

4.4 Risk Management

Factors Associated with Seroma Drainage

5.1 Sources of information

1. Srivastava V1, Basu S, Shukla VK.( 2012) Seroma formation after breast cancer surgery: what we have learned in the last two decades. Journal Breast Cancer.15(4): 373–380. Published online 2012 Dec 31. doi: 10.4048/jbc.2012.15.4.373 {accessed November 2015}

2. Nursing and Midwifery Council, The Code March 2015

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. . An annual appraisal 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 explainingthe procedure and address the patient's anxieties.