Care of the Patient
with an EVD or Lumbar
Drain
Lauren Walker RN, BSN, CCRN
CSF and
Ventricular
System
• CSF is a colorless, clear fluid produced by choroid plexus in lateral and
third ventricle
– Functions as a cushion for brain and spinal cord
• 500-600 ml CSF produced daily
• 3 cycles of CSF, made then absorbed, made then absorbed, etc in a 24hr
period
• 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
We want ICP to be less than 20!
• Increased ICP occurs when the intracranial volume exceeds
the brain’s ability to compensate for increased volume
• Sustained ICP above 25 mmHg is considered a neurologic
emergency
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 40-60 (Kids, depends on age)
• Normal CPP 80-90 mmHG (Adults)
• CPP below set parameter 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
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
Expected
Outcomes of
ICP Monitoring
and CSF
Drainage
• Avoid secondary injury
• Patient will maintain adequate CPP
• WBC, CSF cell count, protein, glucose and culture will be within expected
limits
• Patient/family will receive education!
• Visitors will verbalize understanding of limiting movement of patient
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, ICP, and CPP 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
•
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.
• 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
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
EVD
Complications
• CSF Overdrainage
– 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.
– Raise the drain any time there is a patient response or procedure that
may cause CSF overdrainage
– Clamp for coughing, vomiting, suctioning, or repositioning.
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
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
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.
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.
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.
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
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
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 NP/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 preset
pressure
– Usually for shunt infections/malfunction
– ICU Monitoring
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.