ICID > Clinical Management > General Surgery > Seroma Drainage  
 

Seroma Drainage 

  •  
  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    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. Clinical Management

    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: 

    Trolley 
    50ml syringe Sterile disposable gloves
    Alcohol swab Disposable apron 
    21G needle  Inco sheet 
    3 way tap   
    Receiver   
    Micropore tape   
    Sterile gauze  
                              

    Procedure

    Rationale

    Assess patient

    Ascertain "degree" of seroma and if this indicates drainage.

    Position patient comfortably usually in semi-

    reclining or sitting position.

     

    Explain procedure to patient and obtain verbal consent.

     

    Prepare equipment.

     

    Wash hands

    Minimise risk of infection.

    Prepare sterile field on dressing trolley with additional gauze.

    Ensure asepsis is maintained.  Be prepared for leakage of a body fluid.

    Put on disposable gloves

    Be aware of contamination by body fluids.

    Prepare 50 ml syringe and 21G needle and three way tap.

    Large bore needle facilitates aspiration.  Large syringe reduces disconnection required.

    Cleanse patients skin using alcohol swab and allow to dry.

    Achieve full asepsis.

    Insert needle into lower aspect of the seroma – at an angle of < 50 degrees.

    Gravity assists aspiration.  Ensuring chest wall is not punctured.

    Aspirate seroma noting amount and type of fluid.

    Accurately record for progress and audit purposes.

    If seroma does not immediately aspirate – gently move needle within fluid.

    Seromas can be loculated.

    If aspiration is unsuccessful another puncture site can be used, maximum 3 attempts.

     

    Use new needle for each further attempt.

    Maintain asepsis.

    When aspiration complete cleanse skin of any lymphocele leakage.

    Maintain asepsis.

    Apply dry dressing – gauze and then 20 x 20 absorbant pad and fix firmly.  Arrange dressing to achieve some pressure.

    Pressure for 24 hours may assist skin flaps to adhere to chest wall and reduce further collection of lymphocele.

    Ensure patient feels comfortable.

     

    Inform patient when to remove dressing and when to resume arm exercises and ascertain next appointment.

    Keep patient informed to reduce anxiety.

    Document in patient held record.

    Maintain accurate records.

     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.


    3. Patient Information

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

    4. Audit

    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

     

    Factors Risk Management

    Administration Factors

     

    Nursing staff inexperienced in the drainage of seromas.

    As part Clinical Nurse Specialist Advanced Practice Training they will receive sufficient training in seroma drainage in patients who have undergone axillary surgery.

    Consent not obtained

    Nursing staff to check that informed consent has been obtained.

    Information on incidence of seroma not given.

    Refer to patient held diary.

    Environment conducive to the drainage of seromas.

    Appropriate work space available for the drainage of seromas.

    Treatment Delivery Factors

     

    Accidental needle damage to pleura.

    Patient to inform GP / A&E of any breathing difficulties.

    Risk of infection.

    Assessing wound for signs of inflammation, medical referral if appropriate.

    Inappropriate preparation of aseptic field.

    Aseptic technique to be used in the drainage of seromas.

    Physiologic Factors

     

    During seroma treatment

    Limitations on exercising and arm mobility.

    Patient Characteristics

     

    Patient extremely anxious or depressed.

    Arrange counselling.

    5. Evidence Base

    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

    3.   Zavostky J, Jones R C, Brenna M B, (1984) Evaluation of axillary lympadenectomy without axillary drainage for breast conserving therapy. Ann. Surg. Oncol. Obstet. 158; 327-330

    4.   Boman L, Lindgren A, Sandelin K (2002) Women's pereptions of seroma and their drainage following mastectomy and axillairy lymph node disection. Eur. J Oncol Nurs. Dec; 6(4): 213-9

    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.


    6. Appendices



    Document Owner Shirley Holmes 
    Department
    Review Date
    Document Status
    Revision Number
    2.0