External Ventricular and Lumbar Drains Indications,
Procedures, and Patient Care, 1st Edition
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External Ventricular iii
and Lumbar Drains
INDICATIONS, PROCEDURES,
AND PATIENT CARE
REDI RAHMANI, MD
Department of Neurosurgery
University of Rochester
Rochester, New York
MICHAEL T. LAWTON, MD
Department of Neurosurgery
Barrow Neurological Institute
St. Joseph’s Hospital and Medical Center
Phoenix, Arizona
G. EDWARD VATES, MD, PhD
Department of Neurosurgery
University of Rochester
Rochester, New York
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
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DEDICATION
To my parents, who taught me that with hard
work and honesty, any goal is achievable.
—Redi Rahmani, MD
To all my residents—past, present, and future—
who help me manage this underappreciated
aspect of neurosurgical care.
—Michael T. Lawton, MD
To the neurosurgery residents—past, present,
and future—at the University of Rochester.
—G. Edward Vates, MD, PhD
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CONTENTS
Foreword ix
Preface xi
Acknowledgments xiii
1 Indications 1
2 Anatomy 21
3 Procedure Preparation 33
4 Procedure 59
5 Postplacement Care 95
6 Complication Management 129
Index 151
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FOREWORD
Cerebral spinal fluid (CSF) diversion via external ventricular
drain (EVD) or lumbar drain (LD) placement is frequently
the first-line neurosurgical intervention for patients with
acute brain injuries. Drain placement allows for emergent
relief of brain compression and intracranial hypertension,
at times stabilizing a patient for the operating room or even
preventing the need for further neurosurgical intervention.
These procedures provide the benefits of CSF drainage,
intracranial pressure monitoring, and intrathecal medication
administration. With proper insertion and management,
these drains can remain in place for up to 21 days with mini-
mal infection risk.
The often life-saving procedure of CSF drain placement
is the most visible neurosurgical procedure to other medical
services when collaboratively managing patients with brain
injuries. Many such patients are admitted to the intensive care
unit for close monitoring and management. Intensivists and
the intensive care team must have expert knowledge of the
placement techniques, potential risks, troubleshooting tactics,
and ongoing management of CSF drains to prevent infection,
provide effective communication with the neurosurgical team,
and yield the best possible outcomes for the patients. EVD and
LD weaning and clamping trials can lead to neurologic deterio-
ration if the patient is not appropriately monitored. Therefore,
a collaborative approach to EVD or LD management is most
beneficial.
Drain placement is commonly the first neurosurgical pro-
cedure performed by neurosurgery trainees, and they will likely
place well over 100 drains throughout a busy neurosurgery
residency. These procedures, done at the bedside of an actively
deteriorating patient, are often associated with high stress for
the clinician. Dr. Rahmani and his notable colleagues adeptly
describe the thrill and terror associated with such a procedure
in the Introduction.
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x Foreword
This book is a superlative handbook that details the intricacies of CSF
drainage. Perched at the intersection of neurosurgery and neurocritical
care, External Ventricular and Lumbar Drains: Indications, Procedures,
and Patient Care guides all clinicians who interact with CSF drainage
devices to best practices. We applaud the authors for their dedication to
this essential yet often-overlooked topic.
Debra E. Roberts, MD, PhD
Medical Director, Neurocritical Care
Fellowship Director, Neurocritical Care
University of Rochester Medical Center
Rochester, New York
Webster H. Pilcher, MD, PhD
Ernest and Thelma Del Monte Distinguished
Professor of Neuromedicine
Chair, Department of Neurosurgery
University of Rochester Medical Center
Rochester, New York
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PREFACE
Learning to place an external ventricular drain (EVD) has long
been considered a rite of passage for those training to become
neurosurgeons. Although I have placed many EVDs in my
career, I can still recall placing my first one as an intern. Before
me in the emergency department lay a moribund patient with
a large ventricular hemorrhage from a ruptured intracranial
aneurysm. My nervousness translated to ice-cold fingers that
felt unable to perform the procedure correctly and made me
think I was not moving fast enough. My ears rang with the
hum of monitors, alarms, the ventilator, and the medical staff
around me talking. My mind raced as I reviewed the steps of
the procedure and the equipment checklist.
At this point, a crowd of onlookers had gathered in the
emergency department. Nursing students and battle-hardened
critical care nurses alike had congregated to watch the neu-
rosurgeon “save the patient’s life.” For many, this experience
would be the closest that they would ever come to seeing what
we do as neurosurgeons in such a dramatic fashion. With so
many eyes upon me, I wondered if they realized that I felt like
an imposter. This person who had been sent to save the patient
had minimal experience and practically no idea of what he was
doing. Could they not see my hesitation and my every blunder?
As I made the first cut, blood gushed from the scalp feed-
ers. This incision, which I had been taught was more than suf-
ficient for the entire procedure, seemed grossly inadequate
because the pool of briskly flowing blood offered no glimpse
of the underlying bone. Two gauze pads later and with no
progress yet in controlling the bleeding, I felt the eyes of the
onlookers burning into my forehead while a cold sweat envel-
oped me. Despite the bleeding, I decided to press forward with
the drilling.
To this day, the push-pull routine of the drill feels unnatu-
ral. It requires all the strength in your hands, yet must be gentle
enough at just the right moment so that you do not plunge into
the underlying brain. The “release” of the drill as the inner cor-
tex opened was my first small victory in what seemed to be an
eternity since the procedure had started.
After the dura was opened and placement of the EVD
began, the moment of truth arrived. For the first time in my
life, I felt the parting of brain tissue at the tip of the drain. The
resistance from the density of the white matter and the wall
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xii Preface
of the ventricle engendered self-doubt that I had completed an accurate
trajectory. Was I just blindly wandering around in this patient’s brain? But
I summoned the fortitude to press forward, never more in tune with the
pads of my fingers, until I felt the unmistakable “pop”—the ultimate vic-
tory. Blood-tinged cerebrospinal fluid began emanating from the end of
the drain. Without a word, everyone watching understood that the proce-
dure had been successful.
The EVD bedside procedure, like the placement of the lumbar drain
(LD), is one of the most frequently performed procedures conducted by
neurosurgeons and neurosurgery residents, often in life-saving circum-
stances. Having performed more than 100 of these procedures myself, I
believe that placing these two types of drains is also the most common
point of contact between neurosurgeons and the practitioners of other
medical specialties. Many of the neurosurgeon’s daily interactions with
other members of the medical team involve troubleshooting and manag-
ing EVDs and LDs.
This book is intended to be the definitive manual for the placement
and management of both types of drains. In its chapters, my coauthors and
I enumerate the planning and procedure stages for each drain and then
examine the problems that arise and how to troubleshoot them. Relevant
examples from our training, experience, and background are provided to
enhance the lessons we aim to teach.
Our goal is not to remove neurosurgeons from the equation and allow
other members of the medical team to place and manage EVDs and LDs
independently but instead to convey the rationale of their management.
Therefore, this book is intended for more than junior neurosurgery resi-
dents who are just learning how to place these drains. It has also been writ-
ten for emergency, critical care, interventional radiology, anesthesia, and
neurology residents, fellows, advanced practice providers, and attendings,
as well as for critical care nurses, transport medics, and medical students
who may be assisting with patient care.
The three of us hope you will both enjoy and learn from this book. We
welcome your feedback on how to improve its content in later editions.
Redi Rahmani, MD
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ACKNOWLEDGMENTS
We thank the staff of Neuroscience Publications at Barrow Neu-
rological Institute for assistance with manuscript preparation,
including Samantha Soto and Laura Repak for assistance with
manuscript preparation and coordination, Aaron Cole and
Cassie Todd for medical illustrations, and Paula Card Higgin-
son and Lynda Orescanin for editorial assistance. We also thank
Mary Ann Clifft (EditWrite, LLC) for editorial assistance and
Aleta Pennington for proofreading. We are grateful to Jeanette
S. McCorry, PA-C; Nathaniel R. Ellens, MD; Jessica Hasenauer,
RN, BSN, CCRN; Catherine R. G. Jay, MD; Catherine A. Gar-
gan, RN, BSN, CNRN, CCRN; Lauren M. Paganin, RN, BSN,
CCRN; Andrew Tsavaris, CANPC-AG; Gurkirat S. Kohli, MD;
Taylor J. Furst, MD; Derek D. George, MD; Clifton Houk, MD;
Gabrielle C. Santangelo, MD; Catherine E. Wassef, MD; David
A. Paul, MD; Thomas A. Pieters, MD; Visish M. Srinivasan,
MD; Joshua S. Catapano, MD; Irakliy Abramov, MD, PhD; Lea
Scherschinski, MD; Katherine Karahalios, MS; Mohamed A.
Labib, MD, CM; and Stephen S. Susa, BA for their help draft-
ing the content and obtaining the clinical images.
DISCLOSURES: The authors have no personal, financial, or
institutional interest in any of the drugs, materials, or devices
described in this book.
FINANCIAL SUPPORT: None
FRONT MATTER PERMISSION LINES: Cover art by Aaron
Cole, MS. Barrow Neurological Institute holds the copyright
to all diagnostic images, photographs, intraoperative videos,
animations, and art (including the cover art) used in this work
and the accompanying digital content, unless otherwise stated.
Used with permission from Barrow Neurological Institute,
Phoenix, Arizona.
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External Ventricular
and Lumbar Drains
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