The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement

Abstract

External ventricular drains (EVDs) are commonly placed to monitor intracranial pressure and manage acute hydrocephalus in patients with a variety of intracranial pathologies. The indications for EVD insertion and their efficacy in the management of these various conditions have been previously addressed in guidelines published by the Brain Trauma Foundation, American Heart Association and combined committees of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. While it is well recognized that placement of an EVD may be a lifesaving intervention, the benefits can be offset by procedural and catheter-related complications, such as hemorrhage along the catheter tract, catheter malposition, and CSF infection. Despite their widespread use, there are a lack of high-quality data regarding the best methods for placement and management of EVDs to minimize these risks. Existing recommendations are frequently based on observational data from a single center and may be biased to the authors' view. To address the need for a comprehensive set of evidence-based guidelines for EVD management, the Neurocritical Care Society organized a committee of experts in the fields of neurosurgery, neurology, neuroinfectious disease, critical care, pharmacotherapy, and nursing. The Committee generated clinical questions relevant to EVD placement and management. They developed recommendations based on a thorough literature review using the Grading of Recommendations Assessment, Development, and Evaluation system, with emphasis placed not only on the quality of the evidence, but also on the balance of benefits versus risks, patient values and preferences, and resource considerations.

What Do We Mean by Poor-Grade Aneurysmal Subarachnoid Hemorrhage and What Can We Do?

“…There is emphasis on initially reducing intracranial pressure including ventriculostomy in acute obstructing hydrocephalus [4], managing potential seizures, managing pulmonary edema, and neurogenic cardiac failure in addition to proceeding with early aneurysm repair. Later, care is directed at avoiding major additional medical complications that would set back achieved gains.…”

Real-time ultrasound-guided external ventricular drain placement: technical note

“…12 The recent Neurocritical Care Society evidence-based consensus statement on EVD insertion and management now advises clinicians to consider image guidance for difficult cases (that is, those with small ventricles or distorted anatomy). 4 Ultrasound has a clear advantage over stereotactic neuronavigation in terms of speed of setup and avoidance of the additional imaging sequences typically required for registration. For VP shunts, to which our technique is equally applicable, accurate positioning of the proximal catheter has been found to be among the most important variables predicting shunt longevity.…”

Complications of invasive intracranial pressure monitoring devices in neurocritical care

“…To this end, the 2016 Neurocritical Care Society consensus statement on neuromonitoring recommended the use of AI-EVDs, and the Brain Trauma Foundation 4th edition guidelines provided a Level III recommendation for the use of AI-EVDs to prevent VAIs. 9,19 Specific protocols designed to decrease infection rates for EVDs and ICPMs are being used more frequently in institutions and critical care settings around the world. In a prospective study, Chatzi et al introduced a protocol that included education of surrounding personnel regarding infection control, meticulous handling of the EVD, minimization of CSF sampling from the EVD, and routine replacement of the catheter on Day 7.…”