Care of the Patient
with an EVD or Lumbar
Drain
Lauren Walker RN, BSN, CCRN
Objectives
• Review prerequisite nursing knowledge necessary for competent care of a
Lumbar or EVD drain.
• Review EVD and Lumbar equipment, monitors, patient positioning, and
management.
• Discuss neurologic assessment with a Lumbar Drain or EVD.
• Analyze possible complications of specific drains and pressure monitoring.
• Discuss procedure for sending CSF for testing.
• Return-demonstration of management and care of the Lumbar drain and
EVD.
CSF and
Ventricular
System
• CSF is a colorless, clear fluid produced by choroid plexus in third and
fourth ventricles.
– Functions as a cushion for brain and spinal cord
• 500-600 ml CSF produced daily
• 125-150 ml circulates in the ventricular
system and subarachnoid space
at one time
(remainder is reabsorbed)
• Brain has four CSF filled and
interconnected ventricles
Intracranial
Pressure
• Intracranial Pressure (ICP) is the pressure exerted by the brain content:
– Brain Tissue (85%)
– Cerebral Spinal Fluid (CSF) (10%)
– Intravascular blood (2-11%)
• Cerebral Autoregulation: The ability of the cerebral vessels to constrict
and dilate as needed to maintain adequate cerebral perfusion
– Impaired with brain injury and the cerebral blood flow becomes
passively dependent on blood pressure
• Monro-Kellie Hypothesis: an increase in one component must be offset by
an equal decrease in one or more components otherwise an increase in
ICP will result
ICP
Pressures
Normal ICP 0-10 mmHg
• Increased ICP occurs when the intracranial volume exceeds
the brain’s ability to compensate for increased volume
• Sustained ICP above 20 mmHg is considered a neurologic
emergency
• When the brain suffers an insult or injury, changes occur that
affect cerebral hemodynamics, including changes in ICP,
cerebral blood flow, and oxygen delivery
Cerebral Perfusion Pressure
• Cerebral Perfusion Pressure (CPP): Pressure at
which the brain is perfused
– About 15-20% of cardiac output
CPP = Mean Arterial Pressure (MAP) – ICP.
• Normal CPP 60-80 mmHG
• CPP less than 50mmHg will result in cerebral
ischemia and tissue death
Causes of
Increased
ICP
• Contusions
• Hematomas
• Tumors
• Infarcts
• Coughing
• Endotrachial suctioning
• Hypercarbia
• Fluid overload
• Hypoxia
• Mechanical ventilation (PEEP)
• Increased CSF Production
• Valsalva maneuver
• Metabolic disturbances
Indications
for
Measuring
ICP
•
TBI with GCS of less than or equal to
8
– with an abnormal CT scan results
– Normal CT scan results with
hypotension, posturing, and
older than 40.
•
Fulminant hepatic failure with
encephalopathy
•
Ischemic Stroke with massive edema
•
Meninigitis
•
ICH
•
Cysts
•
SAH
•
Hydrocephalus
•
Cerebral Edema
•
Congenital anomalies
•
Mass
•
Craniosynostisis
ICP Monitoring
and the EVD
• Intraventricular catheters are the gold standard for measuring ICP
– Placed directly in the ventricle
(typically in the anterior horn of the lateral ventricle through a burr hole in the skull)
– Attached to a pressure transducer
• An external ventricular device (EVD)
– Has ICP monitoring capabilities
– Can also assist with controlling increased ICP by CSF drainage
• The main disadvantage to an EVD is that it is the most invasive device
because it penetrates the meninges and brain
ICP
Monitoring
and Lumbar
Drains
• Lumbar drainage devices (LD) are closed sterile systems that allow
the drainage of CSF from the subarachnoid space.
• LD are inserted via a specialized spinal needle into the lumbar
subarachnoid space at the L2–L3 level or below
– avoids injury to the spinal cord
• In the lumbar CSF space, the spinal catheter will be alongside the cauda
equina
– Consists of the ventral and dorsal spinal nerve roots that descend from
the spinal cord and exit the spinal canal at lumbosacral levels
Lumbar
Space
←
→ ←
→
←
Dural Tube
L1 pedicle
Conus Medularis
L2 pedicle
Spinal Cord
ends at L1-L2 at
Conus
Medularis
Sacrum
→
Cauda Equnia
LD is inserted in
lumbar subarachnoid
space: L2 to L3 space
avoiding injury to
spinal cord
Indications
for a Lumbar
Device
•
Postoperative or traumatic dural fistula (CSF leak)
•
Treatment of shunt infections
•
Diagnostic evaluation of idiopathic normal pressure hydrocephalus
•
Reduce ICP during a craniotomy
•
Adjuvant therapy in the management of TBI
•
Thoracoabdominal AAA to improve spinal cord perfusion
•
Manage nontraumatic subarachnoid hemorrhage to prevent vasospasm
•
Manage increased ICP associated with cryptococcal meningitis
Patient Care
with LD
• Patient positioning is crucial to prevent complications
– The head of the bed, height of drainage chamber, and changes in
patient positioning must be monitored closely to prevent sudden
overdrainage.
– Patients may turn from side to side without significant impact on
drainage unless the catheter is found to be positional.
– Nursing staff should monitor which positions result in variances in
drainage rate from the LD and plan patient care
• Perform a complete motor and sensory exam with neuro exam
– Assess for s/s of meningeal irritation
• Photophobia, neck stiffness, N/V, HA, bowel and bladder function
Expected
Outcomes of
ICP Monitoring
and CSF
Drainage
• Avoid secondary injury
• Patient will maintain CPP of approximately 60-70 mmHG
• WBC will be within expected limits
• CSF cell count, protein, glucose and culture will be within expected limits
• Patient/family will receive information and reinforcement regarding ICP
monitoring and CSF drainage
• Visitors will verbalize understanding of limiting movement of patient
Patients who require an EVD or LD
should be closely monitored by
nurses trained and competent in
assessment and management of
both the drain and the neuroscience
patient population
Nursing
Management
and
Assessment
Maintain optimal cerebral tissue perfusion
• Perform and document neuro assessment every hour and PRN and note
trends.
Notify physician for changes in neuro status and CPP less than 60mm Hg for
more than 5 minutes.
•
Monitor Hourly:
– Vital Signs: BP, pulse, respiration and temperature.
– Pupil size and reaction
– Glasgow coma scale
– ICP
– MAP
– CPP = MAP – ICP
Nursing
Management
and
Assessment
Monitor the patient every hour and as necessary for symptoms
of increasing ICP
• Change in level of consciousness:
– Headache
– Restlessness/agitation
– Nausea/Vomiting
– Seizure activity
– Visual changes
– Changes in LOC
– Changes in pupillary responses
– Labored respirations and/or pattern
– Changes in motor strength
– Cushing’s Triad: Increasing BP with a widening pulse pressure,
decreased HR, irregular respirations
Nursing
Management
and
Assessment
Assessment of the EVD/Lumbar Drain hourly
•
Inspecting EVD from insertion site along the entire drainage system
– Check for cracks in the system or fluid leaking from the insertion site
– Dressing is intact
•
Hourly assessment of CSF drainage amount, color, and clarity.
•
Ensure the system is appropriately clamped or open depending on order.
•
Check patient position to ensure transducer is at the ordered reference level.
– If the patient is very active and moving around in bed, it is imperative to
frequently assess that the drain is leveled appropriately to prevent over- or
under-drainage.
Nursing
Management
and
Assessment
Facilitate venous return:
• Patient’s head may be elevated according to the discretion of
the attending and neurosurgeon.
• The head position must remain neutral, may use soft cervical
collar or sandbags, if necessary.
• Prevent hip flexion greater than 90 degrees.
• Instruct family members regarding the plan of care and the
need to limit stimulation of patient r/t head injury.
Nursing
Management
and
Assessment
• Identify activities that alter intracranial pressure
– lights, noise, repositioning
• Arrange nursing care to minimize elevation in ICP (cluster care)
• Assess ICP waveform continuously
• Body temperature should remain below 38 C.
• Assure prescribed seizure prophylaxis is instituted if indicated.
Nursing
Management
and
Assessment
• Monitor labs, as ordered.
– Maintain HCT greater than 25%.
– If patient is receiving Mannitol, obtain Serum Osmolarity every 6
hours. (Notify MD prior to administering if serum osmo > than 310).
• Record I/O every hour.
– If urine output is greater than 200 mL for 2 hours and specific gravity is
less than 1.005, not associated with Mannitol dosing, notify
neurosurgeon
Managing
Complications
• If the ICP is greater than 15 mmHg, rises abruptly or is greater than
parameters determined by the MD and/or the CPP is less than 60 mmHg
for more than 5 minutes and notify MD:
– Remove any stimulus from the patient.
– Reposition head to neutral position.
– Confirm adequate volume status (CVP 7-13). If low, obtain order for
volume replacement or follow Traumatic Brain Injury Protocol as
ordered.
– Medicate with medications as ordered after assessing patient LOC.
EVD
Complications
• An absence of an ICP waveform
– May be the result of air bubbles, clots, or debris within the drainage
tubing or across the transducer.
– A malfunctioning pressure cable, module, or transducer may also
result in the loss of the ICP waveform
• Infections
– Manipulation and accessing of drainage tubing can be a source of
contamination
– Drainage tubing accidentally becomes disconnected: every effort
should be made to maintain the sterility of the ventricular catheter.
• New sterile EVD tubing should be obtained and connected
– An occlusive dressing is placed to cover both incisions
EVD
Complications
• CSF Overdrainage
– EVD: Maintain the drip chamber at the prescribed zero reference and
pressure levels
– Family and Pt education!!
• changing the bed position is to be performed only with
assistance.
• Raising the level of the bed with an can result in a large increase in
CSF drainage.
– Clamp the device any time there is a patient response or procedure
that may cause CSF Overdrainage
– Clamp for coughing, vomiting, suctioning, or repositioning.
Lumbar Drain
Complications
•
Overdrainage
– Movement and repositioning of the patient
– Not frequently observing the amount draining
•
Infection at insertion site
– Manipulation of catheter and tube could be a source of contamination
– Non-occlusive dressing
•
Tube Dislodgement
•
Lower extremity weakness
•
Changes in bowel and bladder patterns
– Could indicate a nicked nerve
•
Tracking in tubing
– Bleeding in spinal cord
Management of the EVD and
Lumbar Drain
Zeroing the
Transducer
EVD
•
Raise or lower the system measured to the tragus of the ear
•
Lower the Buretrol to the “zero point” on the system by pinching the tabs together
above the buretrol and lowering into alignment with zero on the device
•
Turn the stopcock “off” to the patient (open to the Buretrol/transducer)
•
Do Not open the transducer to air (the transducer will be opened to air
automatically through the vent on top of the Buretrol).
•
Highlight the ICP box on the GE monitor screen and select “zero ICP” on the drop
down menu choices. Wait for a “0” to appear on the monitor for the ICP reading.
•
Replace the Buretrol to the position on the pole mount that has been ordered by
the physician.
•
Zero the ICP every 12 hours
Leveling EVD
• The transducer on the set-up is leveled to the patient’s
external auditory meatus.
• The “pressure level” indicator (located on the drip chamber of
the collection system) is aligned to the ordered cm H2O above
the external auditory meatus.
• If continuously draining CSF, turn the drain off to the patient
momentarily to obtain the ICP reading.
Level to
Tragus of Ear
for EVD
Leveling EVD
Obtaining an
ICP Tracing
• Turn stopcock “off” to the drain and “open” to the transducer
to obtain an accurate ICP numerical value and waveform.
• The ICP numerical value and waveform should be obtained
every hour.
– If there is an increase in intracranial pressure, then the
value should be obtained more often (i.e., Q15 minutes).
Draining CSF
• For Continuous ICP Measurements:
– Keep the EVD stopcock “off” to drain and “open” to the transducer for
continuous ICP monitoring.
– If ordered by MD, when the ICP reaches a specified pressure, “open”
the stopcock to drain CSF for a short time period.
• Continuous CSF Drainage/Intermittent ICP Monitoring
– The EVD stopcock is “off” to transducer
– The amount of CSF drainage is controlled by raising the pressure level
on the graduated burette above the Foramen of Monro, which is the
zero reference level.
The EVD device does not allow practitioner’s to drain CSF and monitor ICP
simultaneously.
Lumbar
Drain
Zeroing
• There is no such thing 
• We are not measuring ICP with a Lumbar Drain
• No transducer on system
• No need for zeroing!
(One less thing for you to do!)
LD Leveling
• The transducer on the set-up is leveled to the patient’s
shoulder or iliac crest (per MD order)
• The “pressure level” indicator (located on the drip chamber of
the collection system) is aligned to the level at which it drains
the order volume
Iliac Crest
↓
LD Drainage
• 1. Draining to a specific volume: MD orders a specific amount of
CSF to be drained at a particular time period
– Manipulation of the drain to achieve specific amount
• 2. Draining at a specific level: MD orders level of the pt’s body
– Continuous drainage (ICU monitoring)
• 3. Draining at a specific pressure: MD orders a specific pressure for
draining
– System drains only when the pressure exceeds the pressure
pressure
– Usually for shunt infections/malfunction
– ICU Monitoring
Emptying the
Buretrol
• Measure and record amount of drainage in the Buretrol every hour.
• Turn the stopcock at the transducer “off” to patient.
• Open the stopcock between Buretrol and the collection bag, fluid should
flow from Buretrol into collection bag.
• Turn the stopcock between the Buretrol and the collection bag “off”
toward Buretrol.
• Open the transducer stopcock to patient to obtain readings.
Changing the
Drainage Bag
•
The collection bag is changed when about three quarters full.
•
Wear sterile gloves and a mask.
•
Cleanse the stopcock below Buretrol with Betadine (Scrub connection for 30
seconds).
•
Assure the stopcock between the Buretrol and the collection bag is “off” toward
Buretrol.
•
Using sterile handling technique, disconnect the drainage collection bag from the
Buretrol stopcock and detach bag from the system panel. (Handing the full bag off
to a second person is recommended.)
•
Connect a sterile replacement collection bag to Buretrol stopcock and attach to
system panel.
•
Cap off the open port of the full collection bag and dispose in red trash bag.
Obtain CSF
Sample
• MD: will obtain CSF cultures from the distal stopcock and is required to
use a lab label to label the specimen prior to leaving the patient’s room.
• RN is requested to obtain the CSF culture: will be obtained from the
specimen collection port on the Buretrol drainage collection chamber.
• Equipment:
– Non-sterile gloves
– Betadine solution/swab/applicator
– Sterile gloves
– Sterile 10 mL luer-lock syringe
– Sterile container (e.g., urine C&S container)
– Lab label
CSF
Collection
Cont.
•
A mask and sterile gloves are required during all CSF specimen collections.
•
Don non-sterile gloves.
•
Specimen port is scrubbed with Betadine for 30 seconds. Allow to air dry.
•
Remove nonsterile gloves and wash hands.
•
Set up for sterile specimen collection (open and maintain sterility of syringes,
specimen container and gloves).
•
Don sterile gloves.
•
Attach luer-lock syringe to cleansed and dry needleless access port.
•
CAUTION: DO NOT insert a needle into the needleless sampling port.
CSF
Collection
Cont.
• Turn stopcock OFF to the drainage collection bag and withdraw equal to or
greater than 1 mL
(absolute minimal sample for microbiology laboratory specimen of 0.5 mL).
• NOTE: The hand used to turn the stopcock is no longer sterile; do not
touch syringe or specimen container with the contaminated hand.
• Maintain sterile technique, remove syringe from the stopcock and expel
the CSF sample into the sterile container.
• Close container and assure labeling.
• Discard syringe in sharps receptacle, discard used supplies.
• Send specimen to the laboratory.
Dressing
Changes
Dressings at the ventriculostomy insertion site must remain dry.
• Dressings are changed routinely every 72 hours and prn if the
dressing becomes damp or otherwise ordered by the physician.
• Wearing a mask, cap and gloves, use sterile technique to change
the dressing. Use betadine swabs to cleanse the catheter insertion
site.
• Re-dress the insertion site of the transduced ventricular catheter
with a sterile 2x2 dressing and secure with an occlusive dressing.
Patient
Transport
• Clamp the EVD during transport, when repositioning
or with any patient movement that would cause the
zero point of the EVD/LD to be lower than the
reference point.
• Re-zero, level and re-open the EVD/LD after patient
transport or movement is completed.
Waveforms
• ICP waveform analysis identify patients who are at risk for increases in ICP
and decreases in CPP
• The ICP waveform has three components: pulse, respiratory, and “slow
waves”
• Pulse: consists of three peaks, decreasing in height
• Pulse waves represent arterial pulsations in large cerebral vessels as they
produce a fluctuation in the volume within the ventricles
– P1, the first and sharpest peak, “percussive wave” and results from
arterial pressure being transmitted from the choroid plexus.
– P2, the second peak, referred to as the“tidal wave,” varies in
amplitude with brain compliance
– P3 represents the “dicrotic wave” and is caused by closure of the
aortic valve
Waveforms
Cont.
• As the ICP increases the amplitude of P1, P2, and P3 all
increase
– If ICP continues to rise, P2 becomes more elevated than P1
until eventually P1 may disappear within the waveform
• Constriction of cerebral blood vessels (Seen with hypocapnia
or vasospasm) will exhibit a decrease in the amplitude of the
waveform
• Patients who have undergone a craniectomy (bone flap
removal) will have a dampened waveform
Waveforms
Waveforms
Rounding of ICP waveform due to aneurysmal
vasospasm
References
American Association of Neurosciences Nurses. (2011). Care of the patient undergoing
intracranial pressure Monitoring/External ventricular drainage or lumbar drainage.
AAN clinical practice guideline series. Glenview, IL: Codman and Shurleff.
http://www.aann.org/pubs/content/guidelines.html.
Barker, E. (Ed.). (2008). Neuroscience nursing, A spectrum of care (3rd ed.). St Louis,
MO.: Mosby Elsevier.
Buchbinder, D. (2012). AO Surgical Reference. Retrieved April 18, 2012, from
https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xB
z9CP0os3hng7BARydDRwML1yBXAyMvYz8zEwNPQwN3A_2CbEdFAEfu4iM!/?show
Page=rehabilitation&bone=CMF&segment=Cranium&classification=93Skull+base,+Temporal+bone+(lateral+skull+base)&treatment=&method=Delayed+
management+of+hearing+loss&implantstype=&approach=&redfix_url=128991291
3263.
Inova Health System. (2011). Critical care standard 2.400 intracranial pressure
monitoring- procedure and protocol. Unpublished manuscript.
Wiegand, D. (Ed.). (2011). AANC procedure manual for critical care (6th ed.). St. Louis,
MI: Elseview Saunders.