- Department of Neuroscience, Winthrop University Hospital, USA
Department of Neuroscience, Winthrop University Hospital, USA
DOI:10.4103/2152-7806.157620Copyright: © 2015 Muralidharan R. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Muralidharan R. External ventricular drains: Management and complications. Surg Neurol Int 25-May-2015;6:
How to cite this URL: Muralidharan R. External ventricular drains: Management and complications. Surg Neurol Int 25-May-2015;6:. Available from: http://surgicalneurologyint.com/surgicalint_articles/external-ventricular-drains-management-complications/
Background:Insertion of an External Ventricular Drain (EVD) is arguably one of the most common and important lifesaving procedures in neurologic intensive care unit. Various forms of acute brain injury benefit from the continuous intracranial pressure (ICP) monitoring and cerebrospinal fluid (CSF) diversion provided by an EVD. After insertion, EVD monitoring, maintenance and troubleshooting essentially become a nursing responsibility.
Methods:Articles pertaining to EVD placement, management, and complications were identified from PubMed electronic database.
Results:Typically placed at the bedside by a neurosurgeon or neurointensivist using surface landmarks under emergent conditions, this procedure has the ability to drain blood and CSF to mitigate intracranial hypertension, continuously monitor intracranial pressure, and instill medications. Nursing should ensure proper zeroing, placement, sterility, and integrity of the EVD collecting system. ICP waveform analysis and close monitoring of CSF drainage are extremely important and can affect clinical outcomes of patients. In some institutions, nursing may also be responsible for CSF sampling and catheter irrigation.
Conclusion:Maintenance, troubleshooting, and monitoring for EVD associated complications has essentially become a nursing responsibility. Accurate and accountable nursing care may have the ability to portend better outcomes in patients requiring CSF drainage.
Keywords: External ventricular drain, hydrocephalus, intraventricular hemorrhage, ventriculostomy
Insertion of an external ventricular drain (EVD) is arguably one of the most common and most important lifesaving procedures encountered in the neurologic intensive care unit.[
CSF production approximates 0.2–0.4 mL/min or 500–600 mL a day.[
A freehand pass technique using surface landmarks is commonly used by surgeons to place an EVD.[
Management of EVD
Immediately obtained after insertion of an EVD, the mean opening pressure has significant prognostic implications and it influences the strategy and desired height of the collection system. The underlying pathology of the patient is also taken to consideration when determining the height of the collecting system. In the setting of an unsecured aneurysmal subarachnoid hemorrhage, the initial height of the collecting system is set “high” such that CSF is not drained too quickly in order to avoid rapid change in the transmural pressure across the aneurysm wall, which may predispose to rebleeding.[
After a desired height (cmH2O) of the collection system is determined, management of the EVD essentially becomes a nursing responsibility. Drainage can be continuous at a set level, fixed volume per desired time (i.e., every hour), or as needed according to ICP elevations.[
Intracranial pressure tracing should be inspected after the collecting system is appropriately leveled. If an EVD is open with continuous drainage, the stopcock at the level of the transducer should be turned “off” to the drain and “open” to the transducer in order to obtain an ICP reading.[
If clinically indicated, the EVD collection system may be accessed by physicians, and in some institutions by nurses, to withdraw CSF for the purposes of cultures and/or obtaining malignant cells, or to instill medications.[
Other important aspects of nursing management include monitoring for signs and symptoms of intracranial hypertension and inspecting the entire EVD system and insertion site for CSF leak, which is known to predispose to infection.[
Trouble shooting and complications
Despite appropriate maintenance and surveillance of an EVD, complications such as obstruction and infection may arise given the invasive nature of the device.
Obstruction of a ventriculostomy catheter is often due to cellular debris, such as blood clots and/or tissue fragments. Mechanical EVD failure such as kinking of tubing, failure of any part of the system such as a wet filter (which can occur with horizontal positioning of an unemptied or unclamped drip chamber) and/or migration of EVD catheter, and physiologic factors such over drainage or tight ventricles and/or CSF leak, may also result in obstruction.[
Dampening of the ICP waveform, reduction or absence of CSF flow and lack of pulsation of the CSF meniscus in drain tubing with respiration, insinuate catheter obstruction.[
EVD associated meningitis or ventriculitis is a common complication with an incidence of 0–22%.[
Maintenance, troubleshooting, and monitoring for EVD associated complications has essentially become a nursing responsibility. Accurate and accountable nursing care may have the ability to portend better outcomes in patients requiring CSF drainage.
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