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'''External ventricular drain''' ('''EVD'''), also known as an '''extraventricular drain''' or '''ventriculostomy''', is a device used in [[neurosurgery]] that relieves elevated [[intracranial pressure]] and [[hydrocephalus]] when the normal flow of [[cerebrospinal fluid]] around the [[brain]] is obstructed. This is a plastic tube placed by neurosurgeons and managed by ICU nurses and critical care paramedics to drain fluid from the ventricles of the brain and thus keep them decompressed, as well as to monitor [[intracranial pressure]]. An EVD should never be placed when a neurosurgeon isn't readily available, because immediate neurosurgical intervention will be needed if an unforeseen extraaxial bleed occurs, or if a major vessel is perforated.
An '''external ventricular drain''' ('''EVD'''), also known as a '''ventriculostomy''' or '''extraventricular drain''', is a device used in [[neurosurgery]] to treat [[hydrocephalus]] and relieve elevated [[intracranial pressure]] when the normal flow of [[cerebrospinal fluid|cerebrospinal fluid (CSF)]] inside the [[brain]] is obstructed. An EVD is a flexible plastic catheter placed by a [[Neurosurgery|neurosurgeon]] or [[Neurointensive care|neurointensivist]] and managed by [[intensive care unit]] (ICU) physicians and nurses. The purpose of external ventricular drainage is to divert fluid from the ventricles of the brain and allow for monitoring of [[intracranial pressure]]. An EVD must be placed in a center with full neurosurgical capabilities, because immediate neurosurgical intervention can be needed if a complication of EVD placement, such as bleeding, is encountered.


An EVD, which is a short-term drain of hydrocephalic fluid, can be converted to a [[cerebral shunt]], which is a long-term drain, if the person needs long-term drainage.<ref name="pmid_19035711">{{Citation |last=Rammos |first=S |year=2008 |title=Conversion of external ventricular drains to ventriculoperitoneal shunts after aneurysmal subarachnoid hemorrhage: effects of site and protein/red blood cell counts on shunt infection and malfunction |journal=J Neurosurg |volume=109 |issue=6 |pages=1001–1004 |pmid=19035711 |doi=10.3171/JNS.2008.109.12.1001 |postscript=.|display-authors=etal}}</ref>
EVDs are a short-term solution to hydrocephalus, and if the underlying hydrocephalus does not eventually resolve, it may be necessary to convert the EVD to a [[cerebral shunt]], which is a fully internalized, long-term treatment for hydrocephalus.<ref name="pmid_19035711">{{Citation |last=Rammos |first=S |year=2008 |title=Conversion of external ventricular drains to ventriculoperitoneal shunts after aneurysmal subarachnoid hemorrhage: effects of site and protein/red blood cell counts on shunt infection and malfunction |journal=J Neurosurg |volume=109 |issue=6 |pages=1001–1004 |pmid=19035711 |doi=10.3171/JNS.2008.109.12.1001 |postscript=.|display-authors=etal}}</ref>


==Kocher's point==
==EVD placement==
The tube is most frequently placed in [[Kocher's point]] with the goal of having the catheter tip in the frontal horn of a lateral ventricle. The catheter is normally inserted on the right side of the brain. An EVD (also called an intraventricular catheter, or IVC) is used to monitor pressure in patients with brain injuries, intracranial bleeds or other brain abnormalities that lead to increased fluid build-up. In draining the ventricle it can also remove blood from the ventricular spaces. This is important because blood is an irritant to brain tissue and can cause complications such as [[vasospasm]].
The EVD catheter is most frequently placed by way of a twist-drill craniostomy placed at [[Kocher's point]], a location in the [[frontal bone]] of the skull, with the goal of placing the catheter tip in the frontal horn of the [[lateral ventricle]] or in the [[third ventricle]]. The catheter is typically inserted on the right side of the brain, but in some cases a left-sided approach is used, and in other situations catheters are needed on both sides. EVDs can be used to monitor intracranial pressure in patients with [[Traumatic brain injury|traumatic brain injury (TBI)]], [[Subarachnoid hemorrhage|subarachnoid hemorrhage (SAH)]], [[Intracerebral hemorrhage|intracerebral hemorrhage (ICH)]], or other brain abnormalities that lead to increased CSF build-up. In draining the ventricle, the EVD can also remove blood products from the ventricular spaces. This is important because blood is an irritant to brain tissue and can cause complications such as [[vasospasm]].


== Ongoing care ==
== Ongoing care ==
⚫
The EVD is leveled to a common reference point that corresponds to the skull base, usually the [[Tragus (ear)|tragus]] or [[Ear canal|external auditory meatus]]. The EVD is set to drain into a closed, graduated burette at a height corresponding to a particular pressure level, as prescribed by a healthcare professional, usually a [[Neurosurgery|neurosurgeon]] or [[Neurointensive care|neurointensivist]]. Leveling the EVD to a set pressure level is the basis for [[cerebrospinal fluid]] (CSF) drainage; [[hydrostatic pressure]] dictates CSF drainage. The fluid column pressure must be greater than the weight of the CSF in the system before drainage occurs. It is therefore important that family members and visitors understand the patient's head of bed position cannot be changed without assistance.<ref name="aann.org">{{cite news |title= Care of the Patient Undergoing Intracranial Pressure Monitoring/ External Ventricular Drainage or Lumbar Drainage |work=AANN Clinical Practice Guideline Series |publisher=American Association of Neuroscience Nurses|accessdate=23 October 2012}}</ref>
The external ventricular drain (EVD) is leveled to a common reference point, usually the tragus.
⚫
The external ventricular drain is set on a graduated burette the pressure level of the EVD is prescribed by a healthcare professional, usually a [[neurosurgeon]]. Leveling the EVD to a set pressure level is the basis for [[cerebrospinal fluid]] (CSF) drainage; [[hydrostatic pressure]] dictates CSF drainage. The fluid column pressure must be greater than the weight of the CSF in the system before drainage occurs. It is important that family members and visitors understand the patient's head of bed position cannot be changed without assistance.<ref name="aann.org">{{cite news |title= Care of the Patient Undergoing Intracranial Pressure Monitoring/ External Ventricular Drainage or Lumbar Drainage |work=AANN Clinical Practice Guideline Series |publisher=American Association of Neuroscience Nurses|accessdate=23 October 2012}}</ref>


An example of a healthcare provider order regarding an EVD is: Level external ventricular drain to 15 [[Centimetre of water|cmH20]] above [[midbrain]], open to drain continuously, check and record [[cerebrospinal fluid]] drainage and [[intracranial pressure]] every hour.
An example of a healthcare provider order regarding an EVD is: set EVD open to drain to 15 [[Centimetre of water|cmH20]] above tragus, check and record [[cerebrospinal fluid]] drainage and [[intracranial pressure]] every hour.


The [[cerebral perfusion pressure]] (CPP) can be calculated from data obtained from the EVD and systemic blood pressure. In order to calculate the CPP the [[intracranial pressure]] and [[mean arterial pressure]] (MAP) must be available.<ref name="aann.org"/>
The [[cerebral perfusion pressure]] (CPP) can be calculated from data obtained from the EVD and systemic blood pressure. In order to calculate the CPP the [[intracranial pressure]] and [[mean arterial pressure]] (MAP) must be available.<ref name="aann.org"/>
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==Complications==
==Complications==
EVD is an invasive procedure. It is associated with several complications categorised as below:-
EVD placement is an invasive procedure. It is associated with several potential complications:


===Bleeding===
===Bleeding===


Commonly occurs along the EVD insertion tract or in the several layers of the meninges that prohibit passage into the brain. If drilling or dural puncture is not successful, you may dissect away dura and create a secondary bleed known as an epidural or subdural hemorrhage. This situation can be life-threatening, and requires neurosurgical care. The most dreaded bleeding complication is the realistic possibility of passing a catheter through a major aberrant vessel or existing aneurysm. If this happens, the likelihood of death is significantly increased, and may be immediate. The risk of hemorrhage is increased if the patient is having coagulopathy.
Bleeding can occur along the EVD insertion tract or in the several layers of the meninges that prohibit passage into the brain. If drilling or dural puncture is not successful, the surgeon may dissect away dura and create a secondary bleed known as an epidural or subdural hemorrhage. Bleeding from EVD placement can be life-threatening and can require neurosurgical intervention in some cases. The risk of hemorrhage with EVD placement is increased if the patient suffers from [[coagulopathy]].


===Mechanical===
===Mechanical===
Mechanical complications from EVD placement can be categorized into:
It can be sub-classified into:-
*Malplacement
If the EVD is not placed with the tip of the catheter in the lateral or third ventricle, it is considered malplaced. If the catheter crosses critical brain regions such as the internal capsule or the upper brainstem, malplacement can be symptomatic.
*Obstruction
*Obstruction
Obstruction/occlusion of EVD commonly due to fibrinous/clot like material or kinking of the tube. The brain can swell due to pressure build up in the ventricles and permanent brain damage can occur. Physicians, nurses, and Critical Care Paramedics often have to adjust or flush these small diameter catheters to manage medical tube obstructions and occlusions at the intensive-care bedside.<ref name="pmid18728595">{{cite journal|vauthors=Kakarla UK, Kim LJ, Chang SW, Theodore N, Spetzler RF | title=Safety and accuracy of bedside external ventricular drain placement. | journal=Neurosurgery | year= 2008 | volume= 63 | issue= 1 Suppl 1 | pages= ONS162-6; discussion ONS166-7 | pmid=18728595 | doi=10.1227/01.neu.0000335031.23521.d0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18728595 }}</ref> Pressure settings are generally measured in cmH2O. The equilibrium pressure of the EVD apparatus is adjusted based on cerebrospinal fluid output, ICP waveform, imaging including CT or MRI of the brain, and clinical response.
Obstruction/occlusion of EVD commonly due to fibrinous/clot like material or kinking of the tube. The brain can swell due to pressure build up in the ventricles and permanent brain damage can occur. Physicians or nurses may have to adjust or flush these small diameter catheters to manage medical tube obstructions and occlusions at the intensive-care bedside.<ref name="pmid18728595">{{cite journal|vauthors=Kakarla UK, Kim LJ, Chang SW, Theodore N, Spetzler RF | title=Safety and accuracy of bedside external ventricular drain placement. | journal=Neurosurgery | year= 2008 | volume= 63 | issue= 1 Suppl 1 | pages= ONS162-6; discussion ONS166-7 | pmid=18728595 | doi=10.1227/01.neu.0000335031.23521.d0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18728595 }}</ref>


*Migration
*Migration
During the EVD insertion, the EVD is tunneled subcutaneously and anchored with suture. However, it is common for the EVD to dislodge or migrate. This will cause the tip of the drain migrated away from its supposed position and provides inaccurate ICP measurement or total occlusion of the drain.
After EVD placement, the drain is tunneled subcutaneously and secured with [[Surgical suture|surgical sutures]] and/or [[Surgical staple|surgical staples]]. However, it is possible for the EVD to dislodge or migrate. This will cause the tip of the drain migrated away from its intended position and provide inaccurate ICP measurement or lead to occlusion of the drain.


*Infection
=== Infection ===
The EVD is a foreign body inserted into the brain, and as such it represents a potential portal for serious infection. Historically, the rate of infections associated with EVDs has been very high, ranging from 5% to >20%.<ref>{{Cite journal|last=Babu|first=Maya A.|last2=Patel|first2=Robin|last3=Marsh|first3=W. Richard|last4=Wijdicks|first4=Eelco F. M.|date=2012-02-01|title=Strategies to decrease the risk of ventricular catheter infections: a review of the evidence|url=https://www.ncbi.nlm.nih.gov/pubmed/22045248|journal=Neurocritical Care|volume=16|issue=1|pages=194–202|doi=10.1007/s12028-011-9647-z|issn=1556-0961|pmid=22045248}}</ref><ref>{{Cite journal|last=Beer|first=R.|last2=Lackner|first2=P.|last3=Pfausler|first3=B.|last4=Schmutzhard|first4=E.|date=2008-11-01|title=Nosocomial ventriculitis and meningitis in neurocritical care patients|url=https://www.ncbi.nlm.nih.gov/pubmed/?term=19156484|journal=Journal of Neurology|volume=255|issue=11|pages=1617–1624|doi=10.1007/s00415-008-0059-8|issn=0340-5354|pmid=19156484}}</ref> Infections associated with EVDs can progress to become a severe form of brain infection known as [[ventriculitis]]. Protocols designed to reduce the rate of EVD infections have been successful, applying [[infection control]] 'bundle' approaches to reduce the rate of infection to well less than 1%.<ref>{{Cite journal|last=Flint|first=Alexander C.|last2=Rao|first2=Vivek A.|last3=Renda|first3=Natalie C.|last4=Faigeles|first4=Bonnie S.|last5=Lasman|first5=Todd E.|last6=Sheridan|first6=William|date=2013-06-01|title=A simple protocol to prevent external ventricular drain infections|url=https://www.ncbi.nlm.nih.gov/pubmed/23467249|journal=Neurosurgery|volume=72|issue=6|pages=993–999; discussion 999|doi=10.1227/NEU.0b013e31828e8dfd|issn=1524-4040|pmid=23467249}}</ref><ref>{{Cite journal|last=Flint|first=Alexander C.|last2=Toossi|first2=Shahed|last3=Chan|first3=Sheila L.|last4=Rao|first4=Vivek A.|last5=Sheridan|first5=William|date=2016-12-21|title=A simple infection control protocol durably reduces external ventricular drain infections to near-zero levels|url=https://www.ncbi.nlm.nih.gov/pubmed/28012890|journal=World Neurosurgery|doi=10.1016/j.wneu.2016.12.042|issn=1878-8769|pmid=28012890}}</ref><ref>{{Cite web|url=http://www.cleanbrain.org/|title=EVD Infection Control|website=www.cleanbrain.org|access-date=2017-01-16}}</ref>
EVD is a foreign body inserted into human body. It can serve as an object for bacterial attachment and cause ascending infection.


===Neurological===
===Neurological===
Although not many neurological deficit has been reported, Chai et al. has reported an association of patient's coma and his EVD malplacement. In his report, the EVD was inserted too deep into the Fourth ventricle. The authors hypothesised that the patient's coma was due to the EVD irritation to his Recticular Activation System. The patient's consciousness improved after the EVD was adjusted.<ref name="pmid24101284">{{cite journal|vauthors=Chai FY, Farizal F, Jegan T | title=Coma due to malplaced external ventricular drain. | journal=Turkish Neurosurgery | year= 2013 | volume= 23 | issue= 4 | pages= 561–563 | doi=10.5137/1019-5149.JTN.5724-12.1 | pmid=24101284 }}</ref>
Although neurological deficits from passing the EVD catheter across the brain are uncommon, there can be an association of a patient's poor neurological status with EVD malplacement.<ref name="pmid24101284" /> In this report, the EVD was inserted too deep into the fourth ventricle, and the authors hypothesized that the patient's coma was due to irritation of the [[Reticular activating system|recticular activating system]]. The patient's consciousness improved after the EVD was adjusted.<ref name="pmid24101284">{{cite journal|vauthors=Chai FY, Farizal F, Jegan T | title=Coma due to malplaced external ventricular drain. | journal=Turkish Neurosurgery | year= 2013 | volume= 23 | issue= 4 | pages= 561–563 | doi=10.5137/1019-5149.JTN.5724-12.1 | pmid=24101284 }}</ref>


== References ==
== References ==

Revision as of 20:37, 16 January 2017

External ventricular drain
Drainage system showing bloody CSF due to intracranial hemorrhage.

An external ventricular drain (EVD), also known as a ventriculostomy or extraventricular drain, is a device used in neurosurgery to treat hydrocephalus and relieve elevated intracranial pressure when the normal flow of cerebrospinal fluid (CSF) inside the brain is obstructed. An EVD is a flexible plastic catheter placed by a neurosurgeon or neurointensivist and managed by intensive care unit (ICU) physicians and nurses. The purpose of external ventricular drainage is to divert fluid from the ventricles of the brain and allow for monitoring of intracranial pressure. An EVD must be placed in a center with full neurosurgical capabilities, because immediate neurosurgical intervention can be needed if a complication of EVD placement, such as bleeding, is encountered.

EVDs are a short-term solution to hydrocephalus, and if the underlying hydrocephalus does not eventually resolve, it may be necessary to convert the EVD to a cerebral shunt, which is a fully internalized, long-term treatment for hydrocephalus.[1]

EVD placement

The EVD catheter is most frequently placed by way of a twist-drill craniostomy placed at Kocher's point, a location in the frontal bone of the skull, with the goal of placing the catheter tip in the frontal horn of the lateral ventricle or in the third ventricle. The catheter is typically inserted on the right side of the brain, but in some cases a left-sided approach is used, and in other situations catheters are needed on both sides. EVDs can be used to monitor intracranial pressure in patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), or other brain abnormalities that lead to increased CSF build-up. In draining the ventricle, the EVD can also remove blood products from the ventricular spaces. This is important because blood is an irritant to brain tissue and can cause complications such as vasospasm.

Ongoing care

The EVD is leveled to a common reference point that corresponds to the skull base, usually the tragus or external auditory meatus. The EVD is set to drain into a closed, graduated burette at a height corresponding to a particular pressure level, as prescribed by a healthcare professional, usually a neurosurgeon or neurointensivist. Leveling the EVD to a set pressure level is the basis for cerebrospinal fluid (CSF) drainage; hydrostatic pressure dictates CSF drainage. The fluid column pressure must be greater than the weight of the CSF in the system before drainage occurs. It is therefore important that family members and visitors understand the patient's head of bed position cannot be changed without assistance.[2]

An example of a healthcare provider order regarding an EVD is: set EVD open to drain to 15 cmH20 above tragus, check and record cerebrospinal fluid drainage and intracranial pressure every hour.

The cerebral perfusion pressure (CPP) can be calculated from data obtained from the EVD and systemic blood pressure. In order to calculate the CPP the intracranial pressure and mean arterial pressure (MAP) must be available.[2]

Complications

EVD placement is an invasive procedure. It is associated with several potential complications:

Bleeding

Bleeding can occur along the EVD insertion tract or in the several layers of the meninges that prohibit passage into the brain. If drilling or dural puncture is not successful, the surgeon may dissect away dura and create a secondary bleed known as an epidural or subdural hemorrhage. Bleeding from EVD placement can be life-threatening and can require neurosurgical intervention in some cases. The risk of hemorrhage with EVD placement is increased if the patient suffers from coagulopathy.

Mechanical

Mechanical complications from EVD placement can be categorized into:

  • Malplacement

If the EVD is not placed with the tip of the catheter in the lateral or third ventricle, it is considered malplaced. If the catheter crosses critical brain regions such as the internal capsule or the upper brainstem, malplacement can be symptomatic.

  • Obstruction

Obstruction/occlusion of EVD commonly due to fibrinous/clot like material or kinking of the tube. The brain can swell due to pressure build up in the ventricles and permanent brain damage can occur. Physicians or nurses may have to adjust or flush these small diameter catheters to manage medical tube obstructions and occlusions at the intensive-care bedside.[3]

  • Migration

After EVD placement, the drain is tunneled subcutaneously and secured with surgical sutures and/or surgical staples. However, it is possible for the EVD to dislodge or migrate. This will cause the tip of the drain migrated away from its intended position and provide inaccurate ICP measurement or lead to occlusion of the drain.

Infection

The EVD is a foreign body inserted into the brain, and as such it represents a potential portal for serious infection. Historically, the rate of infections associated with EVDs has been very high, ranging from 5% to >20%.[4][5] Infections associated with EVDs can progress to become a severe form of brain infection known as ventriculitis. Protocols designed to reduce the rate of EVD infections have been successful, applying infection control 'bundle' approaches to reduce the rate of infection to well less than 1%.[6][7][8]

Neurological

Although neurological deficits from passing the EVD catheter across the brain are uncommon, there can be an association of a patient's poor neurological status with EVD malplacement.[9] In this report, the EVD was inserted too deep into the fourth ventricle, and the authors hypothesized that the patient's coma was due to irritation of the recticular activating system. The patient's consciousness improved after the EVD was adjusted.[9]

References

  1. ^ Rammos, S; et al. (2008), "Conversion of external ventricular drains to ventriculoperitoneal shunts after aneurysmal subarachnoid hemorrhage: effects of site and protein/red blood cell counts on shunt infection and malfunction", J Neurosurg, 109 (6): 1001–1004, doi:10.3171/JNS.2008.109.12.1001, PMID 19035711.
  2. ^ a b "Care of the Patient Undergoing Intracranial Pressure Monitoring/ External Ventricular Drainage or Lumbar Drainage". AANN Clinical Practice Guideline Series. American Association of Neuroscience Nurses. {{cite news}}: |access-date= requires |url= (help)
  3. ^ Kakarla UK, Kim LJ, Chang SW, Theodore N, Spetzler RF (2008). "Safety and accuracy of bedside external ventricular drain placement". Neurosurgery. 63 (1 Suppl 1): ONS162-6, discussion ONS166-7. doi:10.1227/01.neu.0000335031.23521.d0. PMID 18728595.
  4. ^ Babu, Maya A.; Patel, Robin; Marsh, W. Richard; Wijdicks, Eelco F. M. (2012-02-01). "Strategies to decrease the risk of ventricular catheter infections: a review of the evidence". Neurocritical Care. 16 (1): 194–202. doi:10.1007/s12028-011-9647-z. ISSN 1556-0961. PMID 22045248.
  5. ^ Beer, R.; Lackner, P.; Pfausler, B.; Schmutzhard, E. (2008-11-01). "Nosocomial ventriculitis and meningitis in neurocritical care patients". Journal of Neurology. 255 (11): 1617–1624. doi:10.1007/s00415-008-0059-8. ISSN 0340-5354. PMID 19156484.
  6. ^ Flint, Alexander C.; Rao, Vivek A.; Renda, Natalie C.; Faigeles, Bonnie S.; Lasman, Todd E.; Sheridan, William (2013-06-01). "A simple protocol to prevent external ventricular drain infections". Neurosurgery. 72 (6): 993–999, discussion 999. doi:10.1227/NEU.0b013e31828e8dfd. ISSN 1524-4040. PMID 23467249.
  7. ^ Flint, Alexander C.; Toossi, Shahed; Chan, Sheila L.; Rao, Vivek A.; Sheridan, William (2016-12-21). "A simple infection control protocol durably reduces external ventricular drain infections to near-zero levels". World Neurosurgery. doi:10.1016/j.wneu.2016.12.042. ISSN 1878-8769. PMID 28012890.
  8. ^ "EVD Infection Control". www.cleanbrain.org. Retrieved 2017-01-16.
  9. ^ a b Chai FY, Farizal F, Jegan T (2013). "Coma due to malplaced external ventricular drain". Turkish Neurosurgery. 23 (4): 561–563. doi:10.5137/1019-5149.JTN.5724-12.1. PMID 24101284.
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