EXTERNAL VENTRICULAR

DRAINAGE

Prepared by : aseem Aljanabi

Pediatric Clinical Instructor
 Objectives

To appropriately manage the patient with an

external ventricular drain (EVD)
1. 2. General care of the patient with an EVD -
maintaining security and function
2. 3. Movement of the patient with an EVD
safely
3. 4. Emptying the EVD drainage bag cleanly
• Introduction
An External Ventricular Drainage (EVD) is
the temporary drainage of cerebrospinal
fluid (CSF) from the fluid filled cavities of the
brain (lateral ventricles) to a closed
collection system outside the body.
Outline
• Introduction
• Indications
• Types of EVD system
• Insertion of external ventricular drainage
• Drain management
• Complication
• Conclusion
Indications
• To relieve raised intracranial pressure
(ICP).
• To divert infected CSF
• To divert bloodstained CSF following
neurosurgery / hemorrhage.
• To divert the flow of CSF
• For ICP monitoring
• For Irrigation?
The direction of irrigation and drainage of the ventricular system
• Types of EVD system
• New ventricular catheter
– New catheter placed into the ventricle through a small hole (burr hole)
made in the skull
– The new catheter is tunnelled under the scalp, and connects to an
external drainage system
– This system does not have a pressure valve so drainage depends upon
gravity.
• Externalisation of existing shunt system
– Externalised at the distal end and connected to an external drainage
system.
– This shunt system will contain a pressure valve, which controls the
amount of drainage from the ventricles.
Drain Management:
Positioning of Drain
• The system must be positioned accurately, to ensure
desired amount of CSF
1. The level of the ventricles must be estimated:

2.The midpoint of this line is the zero point for the EVD
system.
The difference in height between the patient’s ventricles and the drip chamber
creates both a pressure gradient and a safety valve.
The height of the drip chamber equates to the pressure inside of the head or intracranial
pressure (ICP).
Drain Management: Positioning of
Drain
Neurosurgeons will specify and prescribe a
drain height post-operatively and that the
drain height is to be either:
– Maintained OR
– Altered, to drain a certain amount of CSF an
hour.
The flow chamber of the EVD system must be aligned at the cm mark
prescribed by the neurosurgeon (initially this is generally 10cm).
Position of EVD System

The position of drain should be indicated on the patient’s fluid chart

Drain Management:
Drainage
• Once the drain is connected and positioned an initial
assessment of CSF drainage should be made. (To
ensure CSF is draining at the correct rate.)
• Subsequently hourly checks should be made of:
– Amount of drainage.
• To ensure CSF drainage rate is as prescribed.
• A sudden increase in drainage may result from inaccurate zeroing of
the drain or could signify a rise in ICP.
• A decrease in drainage could also indicate inaccurate zeroing of the
drain or that the tubing may be kinked, blocked, disconnected or the
ports are closed
Drain Management:
Drainage
• Subsequently hourly checks should be
made of:
– Colour of CSF - should be colourless.
• Bloodstained CSF could indicate blood in the
ventricles
• Cloudy CSF may indicate the presence of an
infection
– Exit site.
• To ensure CSF is not leaking.
• Drain Management: Drainage
• An approximate guide to CSF drainage

CSF drainage must be observed regularly (having the flow

chamber facing the nurse at the bedside will ensure regular
observation), and recorded hourly on the ICU chart.
CSF is produced continuously by the choroid plexus of the two lateral ventricles
at a rate of approximately 20-25ml per hour, or 500mls per day (Hickey, 1997)
• Drain Management: Drainage
• Drainage of more than 50mls/hour is considered
excessive, however this may be acceptable in
patients with gross hydrocephalus
• The presence of blood may indicate
haemorrhage.
• The sudden presence of blood in the EVD must
be reported to a neurosurgeon immediately
Drain Management: Drainage
• Description the colour of CSF
– 1. Clear and colourless
– 2. Xanthocromic – discoloured CSF usually
yellow, orange or brown due to the breakdown of
RBC’s from previous haemmorhage
3. Blood stained – as a result of recent
haemmorhage or surgery
CSF may also be described as turbid (cloudy)
which occurs due to the presence of increased
WBC’s as a result of CNS infection e.g.
Meningitis.
• Drain Management: Drainage
• The drainage tubing must be checked for patency at
the beginning of each shift and again at regular
intervals thereafter.
• Observe the tubing to establish whether or not the
level of CSF in the tube is oscillating
• If the level is not oscillating the flow chamber may be
dropped to below the foramen of Monro for a brief
period only to check whether CSF drains into the
chamber.
• Once this has been observed the flow chamber must
be re-aligned to prevent over-drainage of CSF.
• If at any time an EVD appears to be blocked, a
neurosurgeon must be contacted immediately as it
may be necessary to flush the system
Drain Management:
Clamping The EVD
• It may be necessary to clamp the system for
short periods.
• An example of such an occasion is during the
moving and handling or repositioning of patients.
• It must be clamped for no more than 30 minutes
at a time.
• Following administration of the drug (intrathecal
antibiotics) the EVD must be clamped for 60
minutes to allow for absorption of the drug
• When moving or repositioning
the patient
• Clamp drain

• Re-zero drain

• Unclamp drain immediately

Drain Management
• children, to clamp the drain if:

– Moving their child

– If their child is crying excessively.

• To prevent over drainage of CSF.

• The drain should not be clamped for longer than 1 hour.

• This to minimise risk of blocked catheter and to prevent
raised intracranial pressure
Drain Management: Intracranial
Pressure
• It is possible to monitor intracranial
pressure through the ventricular catheter
using a continuous closed monitoring
system with a non-flush transducer device.
• Careful technique and handling is
essential to prevent infection.
Drain Management:
To obtain a CSF specimen
• Clean injection port on EVD system
• Insert syringe into port
• Slowly withdraw 2 mls of CSF, remove syringe &
discard
• Insert second syringe into port
• Slowly withdraw 2 mls of CSF
• Place CSF into each universal specimen container
• Open clamps on drainage system close to
injection port
Drain Management:
Exit Site Care
• If exit site is dry it should be dressed with a sterile dressing.
• Change the dressing weekly unless contaminated.
• The dressing should be changed if it becomes contaminated
with CSF or blood.
• If the exit site is oozing it should be dressed with sterile gauze
pads and surgical tape.
• A microbiological swab may need to be taken for culture &
sensitivity.
• Check exit site hourly for:
– Redness
– Inflammation
– Oozing of blood
– Leakage of CSF
• Loop catheter once at exit site under dressing.
Drain Management:
CSF Sampling
• CSF samples should be taken:
– Every 24 hours, according to microbiological
advice, until the CSF is sterile/infection free
– Every 72 hours for infection free CSF
• Fluid and Electrolyte Balance
• Cerebrospinal fluid (CSF) losses should be replaced
ml/ml unless otherwise indicated.
• The losses are usually replaced with intravenous 0.9%
sodium chloride.
• Oral sodium chloride can be used.
• Cerebrospinal Fluid (CSF) losses and intravenous fluid
replacement should be recorded hourly on a fluid
balance chart and reviewed every shift by the nurse in
charge.
Complication
Conclusion
• Maintain sterility when handling EVD
• Accurate charting of amount and pattern of drainage
• To convert to internal CSF diversion system as early as
possible
• Single broad spectrum antibiotics as prophylaxis is
useful to prevent CSF infection
• Regular change EVD does not change CSF infection
rate
• Antibiotic-impregnated shunt catheters may lower CSF
infection rate
• ICP intracranial pressure:
is the pressure within the skull. Normal ICP is up
to 15 mmHg.
Values > 20 mmHg may need treatment. Refer
to “Guidelines for Management of Severe Head
injury”.
• Prior to moving the patient from the bed,
ensure that the ventricular catheter and
drainage device are well secured and free
from all cables/lines to prevent inadvertent
removal
SIGNS OF INCREASED ICP
•Shallow breathing •Headache •Nausea
•Vomiting •Increased blood pressure
•Decreased mental abilities •Confusion about
time,
location and people
•Double vision •Pupils that don’t respond to
changes in light •Seizures •Loss of
consciousness
Definition: The pressure that is exerted on to the brain
tissue by external forces, such as cerebrospinal fluid
(CSF) and blood. • Normal ICP: adults: 10-15 mm Hg /
.135-200 mm of water
children: 3-7 mm Hg •
infants: 1.5-6 mm Hg •
neonates: <-2 mm Hg •