Establishment of an External Ventricular Drain Best Practice Guideline

Abstract

External ventricular drains (EVDs) are commonly used to facilitate removal of cerebrospinal fluid in patients with neurologic dysfunction. Despite a high risk for infection (upward of 45%), many hospitals lack strict protocols for EVD placement and maintenance. In addition, EVD infections are typically not tracked with the same diligence as central-line catheter infections, because there are no widely accepted standards for routine management of EVDs. The purpose of this review is to provide a guide for the development of a standardized, best practice EVD protocol for catheter insertion, care, and maintenance to reduce ventriculostomy-related infections. A secondary goal of this review is to provide support for the future development of guidelines for the consistent tracking of EVD insertion and maintenance practices.At an academic medical center, an interdisciplinary team of nurses, advanced practice nurses, and neurointensivists reviewed recent medical and nursing literature as well as research-based institutional protocols on EVD insertion and maintenance from the United States and abroad to determine global best practices. The goal of this literature review was to identify key areas of focus in EVD insertion and maintenance as well as to identify recent studies that have shown success in managing EVDs with low rates of infection. The following terms were used in this search: EVD, externalized ventricular drains, EVD infections, EVD insertion, EVD Care and Maintenance, Nursing and EVDS. The following databases were utilized by each member of the interdisciplinary team to establish a state of the science on EVD management: American Association of Neurosurgical Surgeons, CINAHL, Cochrane, National Guidelines Clearinghouse, and PubMed. The following common EVD themes were identified: preinsertion hair removal and skin preparation, aseptic technique, catheter selection, monitoring of EVD insertion technique using a "bundle" approach, postinsertion dressing type and frequency of dressing changes, techniques for maintenance and cerebrospinal fluid sampling, duration of catheter placement, staff education/competence, and surveillance.

Risk Factors of External Ventricular Drainage-Related Infections: A Retrospective Study of 147 Pediatric Post-tumor Resection Patients in a Single Center

“…During the procedure, strict aseptic operation, avoidance of leakage and reflux of the drainage tube, prevention of liquid contact between the outlet of the drainage tube and the CSF collection bottle, and clamping the drainage tube should be conducted for prevention of intracranial infection. However, in the case of a patient who does not meet the indication for EVD removal, early application of broad-spectrum antibiotics can be considered for prophylaction (20).…”

Comparison of Ventricular and Lumbar Cerebrospinal Fluid Composition

“…Analysis of cerebrospinal fluid (CSF) is a common diagnostic tool used to evaluate various pathologies of the central nervous system (CNS). CSF sampling requires performing invasive procedures such as lumbar puncture, lumbar drain (LD), and ventriculostomy placement that can introduce the patient to many potential complications, including infections such as meningitis [1].…”

Older patients with Intraventricular Hemorrhage are Prone to Infection after External Ventricular Drainage

“…[11][12][13] This increases ICP and poses a life-threatening condition to the patient. EVD placement is an emergent but life-saving procedure in hydrocephalus patients whose clinical condition is rapidly deteriorating and unconscious, [14] especially in hydrocephalus patients with shunt dysfunction, this procedure decreases rapidly the ICP and prevent the brain herniation. Emergent EVD is also placed in intraventricular hemorrhages (IVH) that have occurred for different reasons besides hydrocephalus.…”