In some cases, the surgeon may use imaging to help the tube reach the right place in the brain. The surgeon then uses a small stitch suture on the skin of the scalp to hold the tube in place. A sterile dressing is put over the incision and stitch. The healthcare team will check the amount of fluid in the pouch often. While an EVD is in place, antibiotics may be given to help prevent infection. The CSF may also be checked regularly for signs of infection. Tell the healthcare team if your loved one has any symptoms that come back or get worse, such as nausea or confusion.
This is an internal tube that drains the extra fluid to a place inside the belly abdomen. This kind of tube can stay in place for a longer time. A VP shunt is put in place during a separate procedure.
The healthcare team will tell you more if your loved one needs this. All rights reserved. Skip to topic navigation. Skip to main content. You are here: Home. Related Reading. Search Our Health Library. Why is an EVD needed? How does an EVD work? Risks of an EVD All procedures have risks. The risks of an EVD include: Problems placing the tube in the right place in the brain Infection of CSF with bacteria or fungi Too much bleeding where the tube is inserted.
During EVD placement A neurosurgeon, a neurosurgery resident, or an intensivist will do the procedure. Excess Drainage If drainage exceeds reportable limits the Neurosurgeon must be contacted as the risk of excessive drainage can lead to collapsed ventricles, subdural haemorrhage or in some cases upward herniation.
This can be prevented in some instances by intermittently clamping the EVD if the patient has a transient increase in ICP e. Consider a pressure bandage. The Neurosurgery team must be contacted immediately to review the patient and implement the appropriate management.
The procedure is completed in the treatment room, under sterile conditions with appropriate pain relief, distraction and staff assistance. Post removal of the EVD, ensure the patient and wound site are observed and the dressing remains dry and intact.
Mandatory checks treatment orders At the beginning of each shift it is the responsibility of the RN caring for a patient with an ICP monitor to complete the following mandatory safety checks: Ensure the patient has a completed valid and correct treatment order on EMR.
Ensure the head dressing is dry and intact. Ensure reportable limits are set on monitor and adhered to. Report any signs of changes in patient condition to the medical team.
For an ICP monitor, the reading is taken directly from the ICP monitor this should also correlate with the bedside Phillips monitor- if not, you may need to enter the 3-digit reference code on the ICP transducer.
Turn monitor on and ensure appropriate ICP cords and transducer box are available Image coming soon 2. Set appropriate alarm limits including ICP limits Image coming soon 4.
Load paper for printing of ICP, located at the right-hand side of the monitor Image coming soon 5. Codman Monitor 1. Image coming soon 2. Check alarm is turned on via main menu Image coming soon Wash your hands and ensure a non-touch technique Image coming soon 3.
Turn the 3-way tap on the EVD system off to the rest of the system leaving the system open to the transducer only Image coming soon 4. Remove a cap white or yellow to open the transducer to the atmosphere Image coming soon 5. Press the button twice and the machine will beep once completed Image coming soon 6. The screen should say ICP zeroed, followed by the time and date Image coming soon 7. Image coming soon 8. Wait for the waveform to stabilize prior to documenting the reading approximately 1 minute.
Ensure the EVD is then reopened to allow continuous drainage. Dressing changes Dressings of the ICP site need to be observed hourly and documented in EMR flowsheets to enable early detection of any leak.
Infection As with any foreign body potential for infection is possible. Removal of ICP monitor line When it is determined that the patient can have the ICP catheter or device removed, this is performed by a member of the Neurosurgery team on the unit.
Lumbar drainage devices Lumbar drains can be indicated for insertion to assist with CSF leaks, evaluate the effect of reduced CSF pressure or as a temporary external shunt. References Adelson. Intracranial pressure monitoring. Paediatric Critical Care, 4 3 suppl. Hepburn-Smith, M. The Journal of neuroscience nursing: journal of the American Association of Neuroscience Nurses, 48 1 , 54— Caring for neurosurgical patients with external ventricular drains.
Nursing Times, 4 Institute for healthcare Improvement. Lewis, A. The Neurohospitalist, 7 1 , Doi: Medtronic, exacta TM external drainage and monitoring system quick reference guide. Medtronic Inc. Muralidharan R. External ventricular drains: Management and complications. Surgical neurology international, 6 Suppl 6 , S—S Intracranial pressure monitoring: Gold standard and recent innovations.
World journal of clinical cases, 7 13 , — Great Ormand Street Hospital. External Ventricular Drainage. Qalab, A. Paediatric external ventricular drains: experience from a tertiary care hospital of a developing country. External ventricular device guideline EVD.
Policies and Procedures; Skin and surgical antisepsis. It then passes into the cerebral aqueduct, a longer and narrower descending passageway, to reach the fourth ventricle, from where it enters the subarachnoid space through the median aperture Sakka et al, While CSF moves in one direction when passing through the ventricles, it moves in several different directions within the subarachnoid space Sakka et al, It is eventually absorbed by the arachnoid villi protruding structures that line the subarachnoid space and leaves the subarachnoid space to enter the venous bloodstream Waugh and Grant, The CSF cushions the brain and spinal cord, acting as a shock absorber and reducing the impact of outside knocks and jolts.
It also keeps the brain buoyant by reducing its density, thereby preventing its circulation being cut off by the impact of its weight Woodward and Mestecky, In addition, CSF enables homoeostasis by delivering important substances — such as hormones, oxygen and nutrients — to brain cells and removing waste Waugh and Grant, These functions rely on a constant flow of CSF being produced and absorbed in the correct amounts.
However, sometimes there is excessive CSF in circulation: this is known as hydrocephalus. Hydrocephalus is a broad term for any situation where there is too much CSF in circulation, for example because the choroid plexus secretes too much, there is an obstruction somewhere on its route, or there are problems with its absorption by the arachnoid villi.
Secretion is not in equilibrium with absorption, and CSF builds up. Hydrocephalus, from any cause, needs to be treated urgently as it can cause increased pressure in the ventricles either by build-up of CSF around an obstruction or by blood increasing the overall circulating volume in the ventricles and subarachnoid space. Increased ventricular pressure equates to increased intracranial pressure ICP in the skull overall Sakka et al, Raised ICP is critical because it reduces blood flow to the brain, starving it of oxygen, glucose and other vital substances.
Due to the limited space in the skull, untreated ICP will eventually lead to brain herniation, a medical emergency in which the brain shifts into any available space — usually downwards. It descends into the opening at the base of the skull, crushing the structures of the brain stem and impeding the vital functions they control, such as respiration and heart rate Woodward and Mestecky, Hydrocephalus is temporarily treated by insertion of an EVD. Also known as an external ventriculostomy Hammer et al, , the EVD is a small soft catheter inserted directly into one of the lateral ventricles Hickey, , usually of the right hemisphere, to drain excess CSF Fig 2.
The right hemisphere is the non-dominant hemisphere for language Grandhi et al, , so insertion into the right lateral ventricle reduces the risk of language dysfunction. Box 1 lists the clinical indications for EVD insertion.
To reduce the risk of infection, the catheter is initially tunnelled a few centimetres under the scalp before entering the skull. It is then inserted into the anterior horn of the ventricle the large C-shaped structure at the front by drilling a small hole in the skull burr hole and incising the meninges. The skin incision is then sutured, the catheter is sutured to the scalp and the wound covered with a sterile occlusive dressing Woodward et al, Patients requiring ongoing CSF drainage will have a cerebral shunt surgically inserted.
Shunts are thin tubes that drain CSF to other parts of the body such as the abdomen, heart or lung for absorption. A valve can be set at the desired pressure to allow CSF to escape whenever the pressure level is exceeded. Outside the skull, the catheter is connected to a drainage system consisting of a collection chamber hanging from an intravenous IV pole attached to the bed, a pressure scale also hanging from the IV pole and a drainage bag Fig 2.
Stopcocks between the collection chamber and drainage bag allow control of the entry of CSF and its drainage Fig 3. The collection chamber and pressure scale hang side by side. Pressure is measured in millimetres of water pressure cmH When the patient is lying on one side, this anatomical reference point becomes the bridge of the nose Woodward and Mestecky, The number above or below the zero point is the prescribed pressure level of the EVD determined by the neurosurgical team Woodward et al, In the.
If the collection chamber hangs from a higher point, it will drain CSF from a higher pressure in the ventricles than one hanging from a lower point.
The prescribed pressure level must be documented, and the collection chamber must be checked frequently to ensure it is neither too high which would cause under-drainage of CSF nor too low which would cause over-drainage Woodward and Waterhouse, The insertion of an EVD is a highly invasive procedure and carries a significant risk of infection Muralidharan, ; Chatzi et al, ; Wong, ; this risk increases the more frequently it is accessed by health professionals to obtain CSF samples Jamjoom et al, , and the longer the EVD is kept in situ Camacho et al, Touching EVD components, such as the stopcock or drainage bag, must be an aseptic procedure and handling must be kept to a minimum Woodward and Waterhouse, A sterile, closed drainage system should be maintained and the entry site dressing should only be changed if it becomes soiled or loose.
The neurosurgical team should be informed as soon as possible if the dressing may be wet from CSF leakage Woodward et al, as this poses an infection risk. The drainage bag should be changed when it is three-quarters full, as too much weight could disrupt drainage Woodward et al, The integrity of the entire EVD system must be checked at a minimum of every four hours, and damage or disconnection of any of the components reported as an emergency.
Patients must also be checked every four hours for early signs of infection such as an increase in temperature, pulse and respirations; cloudiness or debris in previously clear CSF indicates infection and should be reported to the neurosurgical team Woodward and Waterhouse, Patients might need to be monitored more frequently depending on the stability and status of their neurological and vital observations, so this requires clinical judgement.
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