Nursing Management of the Patient with an External Ventricular Drain

Jamie M. Sicard, RN, BA, BSN, PCCN,CCRN-CMC-CSCSurgical Trauma Intensive Care UnitMedical university of South Carolina

andVAMC Charleston Surgical Intensive Care Unit

Why an entire module on external ventricular drains?

Epidural hemorrhages have 5-50% mortality rateSubarachnoid hemorrhages occur 11-12/100,00025,000 ruptured aneurysms per year in United States25% will be disabled or die from the initial hemorrhageMortality rate of 60% during first month following injuryIntracerebral hemorrhages occur 12-25/100,000 and account for 8-13% of all strokes in the United States350/100,000 hypertensive hemorrhages annually in elderly20,000 deaths per year attributed to intracerebral hemorrhages30 day mortality rate of 44% for intracerebral hemorrhages62,000 external ventricular drains placed in 2002..yet no outcomes research has shown that external ventricular drains effect patient outcome more than parenchymal monitors.

Review of Basic Anatomy

Bones of the SkullOccipitalParietalFrontalTemporalEthmoidSphenoid

Regions of the BrainDiencephalonFrontal LobeLimbic Lobe Parietal LobeOccipital LobeTemporal LobeCerebellar HemisphereBrainstem

Cerebral Blood Flow: Circle of Willis

Incidence: 30% Anterior Communicating Artery25% Posterior Communicating Arteries20% Middle Cerebral Arteries10% Basilar Artery5% Vertebral Arteries

*Incidence is really unknown* Why?

Blood in the Brain

Subarachnoid Epidural Subdural Intraventricular

Brain Physiology: Just the Facts Please…

Approximate weight of brain is 2-3% of total body weight (1.4 Kilograms)80% brain volume composed of water, 10% cerebrospinal fluid, and 10% bloodReceives 13.9% of body’s cardiac outputCerebral blood flow is approximately 750 milliliters per minute 54 milliliters of blood/100 grams brain tissue/minute (75% to gray 25% to white matter)Tissue death at less than 8-10 milliliters/100 grams brain tissue/minuteConsumes 80 milligrams of glucose per minute (25% of body’s glucose)Cerebral extraction of oxygen ranges between 24-40%Brain temperature is usually 0.5-1 degree Celsius>than core temperatureInjured brain temperature is 1-5 degrees Celsius>than core temperatureBrain temperature decreases 0.5-0.9 degrees Celsius per hourBrain cannot store glucose or oxygenAcidosis results in vasodilation while alkalosis yields vasoconstrictionNormal intracranial pressure between 0-15 millimeters of mercuryNormal cerebral perfusion pressure between 70-90 millimeters of mercury

Flow of Cerebrospinal Fluid

How it flows:Lateral VentriclesForamina of MonroThird VentricleSylvian AqueductFourth VentricleForamina of LuschkaForamina of MegendeSubarachnoid Spaces

CSF: Supports and Protects Brain and Spinal Cord

40-70% of CSF formed in choroid plexuswhile 30-60% formed in ependyma and piaat rate of 0.357 ml/min, 22 ml/hr, or 500 ml/day150ml bathing brain/spinal cord at any time25ml in each lateral ventricle4 times/day total volume of CSF is replaced85-90% CSF reabsorbed by superior saggital sinus while remaining 10-15% by dural sinusoids on dorsal nerve roots

Signs of Increased Intracerebral Pressure

Headache BradycardiaNausea Widened Pulse PressureVomiting IrritabilityVisual Field Disturbance SomnolencePapilledema Ocular Palsies Loss of Consciousness Respiratory Abnormalities Systolic Blood Pressure Increase

*These all directly relate to the Munro-Kellie Doctrine*

Factors that Increase Intracranial Pressure

Tumor MeningitisAbscess EncephalitisVenous Obstruction Abdominal Compartment SyndromeArteriovenous Malformations Increased Intrathoracic PressureCerebral Edema Toxin ExposureHydrocephalus Hypoxic InjurySAH, SDH, ICH/IVH Hepatic Encephalopathy Eclampsia

Intracranial Pressure Monitoring Devices (Variety is the spice of life)

External Ventricular Drain...ie, the good ‘ole ventric.Parenchymal Catheter....the not so good ‘ole CodmanSubdural bolt placed between arachnoid membrane and cerebral cortexSubdural sensor between arachnoid membrane and cerebral cortexEpidural sensor placed into the epidural space

Indications for Placement of an EVD: Monitor and Drain

1. Glascow Coma Score of 3-8 with abnormal CT scan of brain (mid-line shift)OR

2. Normal CT Scan of brain with 2 or more of the following:

Uni/bilateral Motor Posturing Traumatic Brain InjurySBP<90mmHg Postoperative CraniotomySubarachnoid Hemorrhage CSF InfectionsAcute Hydrocephalus Over 40 Years of AgeBrain Tumor Reye’s SyndromeStroke Cerebral Infarctions

Midline Shift and Correlation to Level of Consciousness

(Normal Brain) (Midline Shift)

Degree of Shift Level of Consciousness• 0-3mm Shift Alert• 3-4mm Shift Drowsy• 6-8.5mm Shift Stupor• 9-13mm Shift Comatose

Contraindications for EVD Placement

• Platelet Count less than 100,000• Prothrombin Time greater than 16• INR greater than 1.3• Severe Infection• Hemodynamically Unstable• Immunosuppression• Open Wounds to Scalp/Skull• But…there are ways to deal with each

Supplies Required for Ventriculostomy

Hair clippers, surgical prep razors, and plastic bag for hairBoat of 4X4 gauze spongesMultiple syringes, filter needle, fill needles, and subcutaneous needlesBottle of BetadyneTowels beneath patient’s head...could save you a messPreservative free saline (Pink top...not Green)Pressure cableMedtronic cranial access kitMedtronic external drainage systemArgon pressure transducer from single transducer kit (A-Line)Blue capLevel (remember from transducer to ear hole)...there are laser levelsnow tooExtra occlusive dressing

Nursing Responsibilities During Ventriculostomy

Position patient with head of bed in semi-Fowler’s positionOptimize patient’s body position to ensure maximal ICP reduction duringprocedure

Place towel beneath patient’s head and possibly premedicateVerify maximum barrier protection during procedureDisconnect pressure tubing from former a-line set up and flush with preservativefree saline and leave 10CC syringe leured into port that would normally housesaline flush tubing and 500CC bag. Ensure sterility .

Flush preservative free saline through former a-line set-up by pushing buttonand allow preservative free saline to flow out distal end of former a-line set up.

Level stop-cock of former a-line to external auditory meatus (ear hole)Hold patient’s head while neurosurgeon twist drills site and places drainOpen sterile kits and pass to neurosurgeon so he/she can connect patient to drain.Connect to drainage system and allow CSF to backflow through thesystem.Document opening pressure, color, and quantity of CSFReview neurosurgeon’s orders for height of drain and call parameters

*The nice part is the neurosurgeon walks you through this...and it really takes afew times to get the hang of it. If it is your first ventric, the twist drill is yours tokeep as a mark of completing this Rite of Passage*

Insertion of the External Ventricular Drain

The neurosurgeon will position the patient’s head and make several measurements on the skull to ensure proper placementof the drain into the patient’s non-dominant anterior horn of thelateral ventricle. If ICPs remain high for protracted periods thiscould lead to a decompressive craniotomy.

Multiple anatomical landmarks are used for drain placement:• Inner canthus of ipsilateral eye• Midpupillary line• Tragus of the ear• Coronal suture• Nasium

Primary+Secondary Brain Injury: The Bottom Line

Primary Brain Injury: Injury that occurs at the time of the actual injury resulting in nervecell, fiber tract, or blood vessel injury.

Secondary Brain Injury: Brain injury resulting from physiological events occurring between hours to days after the primary brain injury which further complicates the injury. Goal is to prevent hypoxia, hypoperfusion (ie, hypotension), elevated intracranial pressures,hyperthermia, hyperglycemia, and hypoglycemia. This is what we can prevent and should strive to prevent.

Nursing Management of the External Ventricular Drain

The neurosurgeon will write orders for drain level (example “Set drain at 0mmHg”), drain hourly, call parameters (usually zero CSF output for an hour or greater than 30CC in an hour), and for ICP readings greater than 20mmHg for more than 5 minutes...don’t be nervous about calling.Stopcock remains open to drain except when measuring ICP at which time amount of CSF isgathered from drip chamber and stopcock is left closed to monitor.Once ICP is obtained, MAP from arterial line should be used to calculate CPP (MAP-ICP).When going on road trips, the stopcock should be turned to the closed position to avoid excessive drainage of CSF.ICP waveform strip should be mounted on chart every shift.The nurse performs neurological exam hourly with sedation lifted unless patient is therapeuticallyparalyzed, in which case pupils will only be checked.The neurosurgeon will want to perform a neurological examination every morning. Prior to thatexam, sedation should be held so that an accurate exam can be solicited.AM Labs usually consist of CBC, COAGS, Chem-10, and ABG. When the drainage bag to the EVD is full, the nurse can change it using strict aseptic technique.There is a stopcock close to the exit of the EVD from the patient’s head. This is routinely used bythe neurosurgeon to gather CSF samples and for flushing. Be sure it is clearly marked to avoid infusion into this port.The EVD dressing is changed using normal sterile technique every seven days or earlier if itbecomes non-occlusive. Remember to go slow so the EVD does not get displaced.The neurosurgeon will frequently draw samples of CSF from the EVD to check for infection

Intracranial Pressure Waveform Analysis

Three distinct waves of intracranial pressure waveform:• P1 (Percussion Wave): Ejection of blood from heart transmitted

through choroid plexus into the ventricles• P2 (Tidal Wave): Reflective of brain compliance and venous

compartment• P3 (Dicrotic Wave): Closure of aortic valve

Three trend waves of the intracranial pressure waveform:• A-Waves: Elevation of ICP to 50-100mmHG for 5-20 minutes.• B-Waves: Elevations in ICP to 20-25mmHG related to CBF• C-Waves: Normal. Seen when ICP rises to 20mmHG

Nursing Considerations• Conduct accurate hourly neurological

assessment• Documentation of CSF output (quantity, color)• Calculate CPP and document (MAP-ICP)-Goal

usually >70• Post ICP waveform strip for day to day

comparison• Head of bed elevated to at least 30 degrees• Avoid “gatched” knees• Head in neutral position• Preoxygenate prior to suctioning• Report hypo/hypertension and act quickly with

vasoactive drugs• Avoid PCO2>40 (Goal is usually 30-35)• Goal PaO2 >100• Avoid Chronic Hyperventilation• Prevent Hypo/Hyperglycemia• Provide thermoregulation, maintain euvolemia• Be aware of need for pain control, sedation, use

of stool softeners, seizure prophylaxis, GI prophylaxis, SCDS/TEDS

Neurological Assessment: Glascow Coma Score

I. Motor Response 6 - Obeys commands fully: Self explanatory 5 - Localizes to noxious stimuli : Attempts to remove source of noxious stimuli. Comes up and down…4 - Withdraws from noxious stimuli: Moves arms away from noxious stimuli 3 - Abnormal flexion (decorticate posturing): Flexion and adduction of arms and wrists with

extension of lower extremities and plantar flexion 2 - Extensor response (decerebrate posturing): Adduction, extension, and pronation of upper

extremities and extension of lower extremities with plantar flexion 1 - No response: Flaccid to noxious stimuliII. Verbal Response 5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and jumbled phrases consisting of words 2 - Incomprehensible sounds 1 - No soundsIII. Eye Opening4 - Spontaneous eye opening 3 - Eyes open to speech 2 - Eyes open to pain 1 - No eye

* Pupil Response Assessment must be assessed bilaterally for size, shape, and reactivity to light.

• Prevent Secondary Brain Injury...this is what leads to long term disability.• Keep ICP below 20, but when it rises above 20 for greater than 5 minutes

take immediate, definitive, and aggressive action. Absolute normal is between 0-15.• Report all neurological changes...and refine your assessment technique…do RN-RN

confirmation of neurological status and presence of ICP waveform at change of shift.• If you see lots of blood clots or brain particulate matter (high school memories)...EVD may

need to be flushed by the neurosurgeon. Clotted or obstructed drains lead to new EVDs.• Know your drugs for these patients: nimodipine, vasoactive drugs,

sedatives, paralytics, antiseizure medications, osmotic diuretics, hypertonicsaline, and pain medications....and be ready to insert a Swan-Ganz Catheter quickly.

• Learn goals for lab values...magnesium 2.0, phosphorus 3.0, potassium 4.0,serum OSM <320, increases in UOP, and goal coags.

• Treat hyperthermia (greater than 38.0) aggressively...no matter what the cause may be.• Set the right environment for neurological healing....TV off, lights dim,

low tone of voice, don’t cluster activities, educate family membersand visitors…and learn when Lifepoint needs a call.

• Turn and reposition• By convention, the tubing from the EVD should not have anything overlaying it...and the

stopcock closest to the patient should be marked to prevent erroneous infusion.• Know how to use the Train of Four (wrist is preferred site…then ankle…then face).• If you have never put a ventric in or managed one…find someone who has experience with it• Trust your little voice that tells you something is wrong…and act on it …you are usually right

A few tips from me to you….so consider the source

The Future of Neurological Monitoring…and Some of It is Already Here

1. Licox Monitoring System for ICP monitoring, brain temperature monitoring, and brain tissue oxygenation.

2. Transcranial Doppler to assess for vasospasm3. Intravascular Jugular Bulb Venous Oxygen Saturation to measure

oxygen saturation of blood leaving cerebral circulation4. INVOS or In-Vivo Optical Spectroscopy measures regional oxygen

saturation in the brain parenchyma5. Cerebral Microdialysis for measuring extracellular metabolites6. Bedside continuous Electroencephalogram (EEG)7. BIS Monitoring or Bispectral Index Monitoring for appropriateness of

sedation.8. Pupillometer for assessing the difficult pupils and to obtain a ballpark ICP.9. At some point we may see continuous cardiac output monitors via A-line.

When in doubt…

Pull Your Head Out

A Few Words of Thanks

• Marlo S. Anderson, BSN, RN CCRN (MUSC)• Amelia Dahdah, RN CCRN, CNRN (Formerly of MUSC)• Malverne O. Inniss, BSN, RN PCCN, CCRN (MUSC and

VAMC Charleston)• Tim Monroe, MD (Dept of Neurosurgery)

• Tanya Jones, MD (Dept of Neurosurgery )• The men and women of the United States Armed Forces

A Bigger Word of Thanks

AANN Core curriculum for neuroscience nursing (2004). (4th ed, p. 30-42, 87-92) St Louis, MO: Saunders

American College of Surgeons Committee on Trauma. (2004). Advanced trauma life support for doctors (Student Course Manual),(7th ed, p.151-167),Chicago IL

Codman Package insert for external drainage system (2006) (p.1-6) Raynham, MA

Clinical Neuroanesthesia. (1998). (2nd ed, p. 19- 100) Churchill Livingston Inc.

Emergency Nurses Association.(2000). Trauma nursing core course. ( 5th ed p.85-111).Des Plaines, IL

Emergency Nurses Association. (2003).Course in advanced trauma nursing-II: A conceptual approach to injury and illness (Student Manual), (2nd ed, p. 149-184), Des Plaines, IL

Ganong, WF.(2001). Review of medical physiology (20th ed., p ). New York, NY: McGraw Hill Medical Publishing Division.

Guide to the care of the patient withintracranial pressure monitoringHttp://www.aann.org/pubs/pdf/icp.pdf

Http://USCNeurosurgery.com/infonet/5036/ventriculo stomy%20new.htm#incision

Illustrated manual of nursing practice (2002).(3rd ed, p. 455-511)Philadelphia, PA: Lippincott Williams&Wilkins

Kapit, W., & Elson, LM.(2003). Anatomy coloring book, (2nd ed, p.134-138). New York, NY:HarperCollins Publishers.

Kapit, W., Macey, RI., Meisami, E.(2000). Physiology coloring book, (2nd ed, p. 82-98).New York, NY:HarperCollins Publishers.

Neuroscience nurse review: Preparing for certification (2007). (September 2007 Lecture I p.1-6, Lecture III p.1-5, Day II Lecture I p.1-3, Lecture II p. 1-6) Integra Clinical Education Institute, Inc.