Patient positioning
|
Headboard angle between 15 and 30º |
Leveling the headland angle between 15 and 30º in line with the system level ensures proper functioning and reliability of monitoring(1818 Flores GP. Critérios para banho de leito em unidade de terapia intensiva adulto: construção de um protocolo assistencial. [Dissertação] [Internet]. Universidade do Vale do Rio dos Sinos. 2016 [cited 2018 May 20]. Available from: http://www.repositorio.jesuita.org.br/handle/UNISINOS/5279 http://www.repositorio.jesuita.org.br/ha...
-1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
); |
Moderate |
Keeping head in neutral position aligned to cervical |
The aim is to facilitate venous return, reducing CSF without interfering with the EVD drainage system(1818 Flores GP. Critérios para banho de leito em unidade de terapia intensiva adulto: construção de um protocolo assistencial. [Dissertação] [Internet]. Universidade do Vale do Rio dos Sinos. 2016 [cited 2018 May 20]. Available from: http://www.repositorio.jesuita.org.br/handle/UNISINOS/5279 http://www.repositorio.jesuita.org.br/ha...
-1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
); |
Moderate |
Repositioning at "zero point" |
The system review must be carried out in order to avoid any change in the drain back pressure(55 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620...
). For example, if the transducer is above the interventricular foramen, a false CSF will be recorded as well as insufficient drainage of CSF, with an unnoticed ICH that may cause ventricular collapse or subdural collection(1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
). |
Low |
EVD drainage
system positioning
|
Flow level height |
The height of the flow level of CSF by convention corresponds to a horizontal line that runs from the interventricular foramen to the counter pressure prescribed by the neurosurgeon, usually between 10 and 20 cmH2O(55 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620...
,1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
-2020 Hill M, Baker G, Carter D, Henman LJ, Marshall K, Mohn K, et al. A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. J Neurosci Nurs. 2012;44(4):188-93. https://doi.org/10.1097/JNN.0b013e3182527672 https://doi.org/10.1097/JNN.0b013e318252...
). This means that if it is 10 cmH2O, EVD is 10 cm from foramen and, to drain CSF, pressure of ventricles must be at least 10 cmH2O; |
Low |
System clamping |
The clamped system must be kept as short as possible. However, clamping of up to 30 minutes is considered safe, considered a sufficient period to perform intra-hospital transports, exams and changes in patient positioning(55 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620...
), unclamping and verifying the complete system in sequence(1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
,2121 Chaikittisilpa N, Lele AV, Lyons VH, Nair BG, Newman SF, Blissitt PA, et al. Risks of routinely clamping external ventricular drains for intrahospital transport in neurocritically ill cerebrovascular patients. Neurocrit Care. 2017;26(2):196-204. https://doi.org/10.1007/s12028-016-0308-0 https://doi.org/10.1007/s12028-016-0308-...
); |
Low |
Dressing change
|
Frequency of dressing assessment |
To verify the appearance of the dressing every 6 hours, if there is moisture indicative of leakage of CSF or signs of inflammation when inserting the catheter(2020 Hill M, Baker G, Carter D, Henman LJ, Marshall K, Mohn K, et al. A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. J Neurosci Nurs. 2012;44(4):188-93. https://doi.org/10.1097/JNN.0b013e3182527672 https://doi.org/10.1097/JNN.0b013e318252...
); |
Low |
Use of gauze dressing |
Dressing should be performed with 0.9% saline and alcoholic chlorhexidine every 24 hours or earlier if necessary, paying attention to and recording the appearance of the insertion, covering with sterile gauze and bandage(2222 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000...
); |
Moderate |
Use of transparent film dressing |
When transparent film is impermeable, dressing should be applied weekly or earlier if necessary either by compromising the integrity of the dressing or detachment, in order to minimize direct contact between catheter and external environment(2020 Hill M, Baker G, Carter D, Henman LJ, Marshall K, Mohn K, et al. A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. J Neurosci Nurs. 2012;44(4):188-93. https://doi.org/10.1097/JNN.0b013e3182527672 https://doi.org/10.1097/JNN.0b013e318252...
,2222 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000...
-2323 Flint AC, Rao VA, Renda NC, Faigeles BS, Lasman TE, Sheridan W. A simple protocol to prevent external ventricular drain infections. Neurosurgery. 2013;72(6):993-9. https://doi.org/10.1227/NEU.0b013e31828e8dfd https://doi.org/10.1227/NEU.0b013e31828e...
). |
Low |
EVD drainage bag and catheter care
|
Aseptic technique for handling |
Handling must be kept to a minimum in order to ensure that the risk of infection is minimized and the touch of the EVD components, whether in the cannula or in the bag, are considered aseptic procedures(2424 Humphrey E. Caring for neurosurgical patients with external ventricular drains. Nurs Times [Internet]. 2018 [cited 2018 May 20];114(4):52-6. Available from: https://www.nursingtimes.net/clinical-archive/neurology/caring-for-neurosurgical-patients-with-external-ventricular-drains/7023833.article https://www.nursingtimes.net/clinical-ar...
); |
Low |
Limit capacity to despise the contents of the bag |
The drainage bag must be emptied when it reaches 2/3 or 3/4 of its volume capacity. When very full, it can become heavy and may alter or even interrupt the operation of the CSF drainage system(2424 Humphrey E. Caring for neurosurgical patients with external ventricular drains. Nurs Times [Internet]. 2018 [cited 2018 May 20];114(4):52-6. Available from: https://www.nursingtimes.net/clinical-archive/neurology/caring-for-neurosurgical-patients-with-external-ventricular-drains/7023833.article https://www.nursingtimes.net/clinical-ar...
). This same care must be applied to the drip burette; |
Low |
Watching for signs of catheter obstruction |
It is important to note that the flow of the dropper from the system is well positioned. If there is minimal or no drainage, the system must be checked for folds, obstructions or any clamping. Drainage reduction can cause hydrocephalus remodeling or indicate other possible complications, including catheter traction or CSF leak(1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
). |
Moderate |
In cases of catheter traction |
Do not try to reposition it, or even aspirate or administer solutions when it is obstructed, but communicate with the neurosurgery staff whenever there are any changes, due to high risk of infection and complications(1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
). |
Moderate |
CSF care
|
Monitoring the level of consciousness |
Careful assessments of the level of consciousness should be performed using the updated Glasgow Coma Scale, especially in cases of confused or cognitively impaired patients, in order to ensure that catheter remains properly fixed and is not accidentally pulled in cases of psychomotor agitation. Moreover, early neurological deterioration and signs of lowering of the sensorium due to excessive CSF drainage should be monitored and detected(2222 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000...
); |
Low |
CSF drainage flow |
Drainage flow varies according to the height of the collecting system in relation to "zero point" (usually 20 cmH2O) and usually stays between 5 and 10 ml/h or, in some cases, up to 15 ml/h. The volume of CSF drained in ml should be recorded every 6-hour shift, calculating the total of 24 hours. Excess drainage can cause ventricular collapse, rupture of vessels and even subdural hematoma(1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
); |
Moderate |
Characteristics of drained CSF |
The nursing staff must be aware of any changes in the color of the drained CSF, which can change according to patients' clinical pathologies. For instance, if there is blood in CSF, it can be indicative of cerebral hemorrhage or if it looks cloudy or with sediment it can indicate an infectious process. Therefore, it is important to communicate with the nurse and the neurosurgery staff whenever an atypical CSF stain is identified(1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
). |
Moderate |
CSF
measurement
|
Clamping the system to measure CSF |
When the EVD system is open, the transducer may not represent the CSF wave correctly. Therefore, the system must be clamped for 1 minute so that the wave analysis is more accurate, taking care to unclamp the system immediately afterwards(1919 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1....
). |
Moderate |
Administration of
medication in the
catheter
|
Clamping the system after administration |
When drugs are introduced by the neurosurgery staff through the EVD catheter, such as tissue plasminogen activator for cases of intraventricular hemorrhage or antibiotics for ventriculitis, the system should be clamped for about 1 hour after administration so that it is not drained with excess CSF(55 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620...
). |
Low |
CSF collection
|
CSF collection periodicity |
It should be performed only when necessary, especially in cases in which infection is suspected, which is why routine collection is not indicated(2222 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000...
); |
Moderate |
CSF collection site |
It is recommended that the sample be collected at the distal port, as it minimizes the risk of infection of the system and can bring a more accurate diagnosis, in addition to being considered safe and easy for collection(2222 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000...
). However, when the sample is collected in this way, all CSF volume present in the drip chamber/burette must be collected and tested for an accurate leukocyte count. Collection in the bag should be avoided due to the rapid degradation of CSF components. It is also noteworthy that this procedure is performed by the neurosurgery staff(55 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620...
). |
Low |
Mobilization
of patients
with EVD
|
Early mobilization |
Early mobilization is considered a viable and safe alternative when patients are stable. Such mobilization does not alter CSF and PPC parameters in patients with EVD(2525 Kumble S, Zink EK, Burch M, Deluzio S, Stevens RD, Bahouth MN. Physiological effects of early incremental mobilization of a patient with acute intracerebral and intraventricular hemorrhage requiring dual external ventricular drainage. Neurocrit Care. 2017;27(1):115-9. https://doi.org/10.1007/s12028-017-0376-9 https://doi.org/10.1007/s12028-017-0376-...
) and, when in favorable clinical conditions (MAP> 80 mmHg and CSF <20 mmHg), it can be safely tolerated and minimal risks to patients, which may decrease the time of hospitalization and adverse events(2626 Shah SO, Kraft J, Ankam N, Bu P, Stout K, Melnyk S, et al. Early ambulation in patients with external ventricular drains: results of a quality improvement project. J Intensive Care Med. 2018;33(6):370-4. https://doi.org/10.1177/0885066616677507 https://doi.org/10.1177/0885066616677507...
). |
Low |