External ventricular drainage management [Neurosurgery Wiki]

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====== External ventricular drainage management ======

{{ ::external_ventricular_drainage.png?300|}}

//J.Sales-Llopis//

//Neurosurgery Department, University General Hospital of Alicante, Spain//
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{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1XmaK3PTZdue71ObBlu9ueeB8XNGt_TxLtrcRA6CWzQSUNvIDJ/?limit=15&utm_campaign=pubmed-2&fc=20230228024441}}
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[[External ventricular drainage]] [[postoperative management]] is thought to influence long-term [[patient outcome]]s, rates of [[healthcare-associated ventriculitis]], the incidence of [[delayed cerebral ischemia]], the need for a [[ventriculoperitoneal shunt]], and [[intensive care unit]] (ICU), and [[hospital length of stay]]. 
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[[Evidence]] on the optimal management of [[external ventricular drainage]] remains limited. Additional [[multicenter]] [[prospective]] studies are critically needed to guide [[approach]]es to the [[management]] of [[EVD]]
((Chung DY, Olson DM, John S, Mohamed W, Kumar MA, Thompson BB, Rordorf GA. Evidence-Based Management of External Ventricular Drains. Curr Neurol Neurosci Rep. 2019 Nov 26;19(12):94. doi: 10.1007/s11910-019-1009-9. PMID: 31773310; PMCID: PMC7383112.)).

===== Nursing =====

[[Nursing]] should ensure proper [[zeroing]], [[placement]], [[sterility]], and [[integrity]] of the [[external ventricular drainage]] [[system]]. [[Intracranial pressure waveform]] analysis and close monitoring of [[cerebrospinal fluid drainage]] are extremely important and can affect the clinical outcomes of patients. In some institutions, nursing may also be responsible for CSF sampling and catheter irrigation.

[[Maintenance]], [[troubleshooting]], and [[monitoring]] for [[External ventricular drainage complications]] have essentially become a nursing [[responsibility]]. Accurate and accountable nursing care may have the ability to portend better outcomes in patients requiring CSF drainage
((Muralidharan R. External ventricular drains: Management and complications. Surg Neurol Int. 2015 May 25;6(Suppl 6):S271-4. doi: 10.4103/2152-7806.157620. PMID: 26069848; PMCID: PMC4450504.)).
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A study aims to assess the knowledge, attitudes, and practices of nurses from different departments regarding bedside EVD insertion in patients with acute hydrocephalus. EVD and intracranial pressure (ICP) monitoring competency checklists were developed, and a quasi-experimental, single-group, pre/post-test study was conducted at a university hospital in Jeddah, Saudi Arabia, in January 2018 during an educational program. The neurosurgery team determined program efficacy using pre/post-questionnaires. All attendees who agreed to fill in the pre- and post-survey and whose data were complete were included in the study. Results Of the 140 nurses who participated in the study, the data of 101 were analyzed. Knowledge level improved significantly between the pre- and post-test; for example, when asked about administering antibiotics before EVD insertion, the pre-test correct response rate of 65% increased to 94% in the post-test (p<0.001), and 98% considered the session informative. However, the attitude toward bedside EVD insertion did not change after the teaching sessions. This study emphasizes the importance of ongoing nursing education, hands-on training, and strict adherence to an EVD insertion checklist to achieve successful bedside management of patients with acute hydrocephalus
((Alomar SA, Bandah ST, Noman GA, Kadi M, Abulnaja GA, Abdullah G. The Impact of Nursing Education on Emergency Bedside External Ventricular Drain Insertion for Patients With Acute Hydrocephalus. Cureus. 2023 Jan 27;15(1):e34262. doi: 10.7759/cureus.34262. PMID: 36843801; PMCID: PMC9957584.)).
===== Mandatory Checks (Treatment Orders) =====

At the beginning of each shift it is the responsibility of the [[nurse]] RN caring for a patient with an EVD to complete the following mandatory [[safety]] [[check]]s:

The patient has a valid EVD order set on EMR that includes; height (value), height (units), reference point (e.g. Tragus), drainage (e.g. continuous), and notify RMO if [[drainage]] is greater than (mL/hr). 

Reportable limits are noted and adhered which are patient-specific. 

EVD drainage point is set at the prescribed level (as per Neurosurgeon documentation in [[post-operative orders]]). 

EVD [[transducer]] is leveled to the patient’s [[external auditory meatus]] (Tragus). 

EVD column is oscillating and patent. 

The Head dressing is dry and intact.

Report any signs of changes in the patient’s neurological condition to the Medical team.

===== Documentation =====

It is imperative that the [[management]] of the [[drain]] is documented hourly. 

Hourly documentation must include:

Drain status (e.g. clamped/unclamped). 

Drain leveled (e.g. tragus/ mid-sagittal line). 

Drain height (cmH2O). 

Hourly output (mL).
 
[[Cerebrospinal fluid appearance]] (e.g. rosé, clear, cloudy) 

Is the drain oscillating? 

Patient [[position]] (e.g. supine, lateral, sitting up in a chair). 

Patient state (e.g. alert, crying, settled, c/o headache). 

[[Dressing]] status (e.g. dry and intact, old ooze). 

[[Dressing]] intervention. 

====== Opening pressure ======

Immediately obtained after the [[ventricular drainage placement]], the mean [[opening pressure]] has significant prognostic implications and it influences the strategy and desired height of the [[cerebrospinal fluid collection]] system. 

===== Height =====

[[External ventricular drainage height management]].


===== Cerebrospinal fluid collection =====

[[External ventricular drainage cerebrospinal fluid collection]].


===== Monitoring =====


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
((Slazinski T, Anderson TA, Cattell E, Eigsti JE, Heimsoth S, Holleman J, et al. Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage. Am Assoc Neurosci Nurs. 2011;43:1–37.))

Noting the quantity, color, and clarity of CSF is also important. Clinically relevant scenarios can be detected by noting each of these factors such as an increase in the hourly output may signal intracranial hypertension, bright red bloody CSF may indicate aneurysm re-rupture, and cloudiness of CSF may indicate the presence of an infection, respectively
((Slazinski T, Anderson TA, Cattell E, Eigsti JE, Heimsoth S, Holleman J, et al. Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage. Am Assoc Neurosci Nurs. 2011;43:1–37.))
((Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002 Jan 10-23;11(1):47-53. doi: 10.12968/bjon.2002.11.1.12217. PMID: 11826320.))
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The available evidence supports adopting early clamp trials and intermittent cerebrospinal fluid (CSF) drainage. However, a recent survey demonstrated that most neurological ICUs employ the opposite approach of continuously open EVDs and gradual weaning. In this article, we review the literature and arguments for and against the different EVD approaches. We conclude that an early clamp trial and intermittent CSF drainage can be safe and result in fewer EVD complications and a shorter length of stay. Given the discrepancy between the available evidence and current practice, more studies on the optimal management of EVDs are warranted with the greatest need for multicenter prospective studies
((Chung DY, Mayer SA, Rordorf GA. External Ventricular Drains After Subarachnoid Hemorrhage: Is Less More? Neurocrit Care. 2018 Apr;28(2):157-161. doi: 10.1007/s12028-017-0443-2. PMID: 28929378; PMCID: PMC5858985.)).

===== Complications =====
[[External ventricular drainage complications]]