Nursing Management of the Patient with an External Ventricular Drain

Jamie M. Sicard, RN, BA, BSN, PCCN,CCRN-CMC-CSC Surgical Trauma Intensive Care Unit Medical university of South Carolina and VAMC Charleston Surgical Intensive Care Unit

Why an entire module on external ventricular drains?

Epidural hemorrhages have 5-50% mortality rate Subarachnoid hemorrhages occur 11-12/100,000 25,000 ruptured aneurysms per year in United States 25% will be disabled or die from the initial hemorrhage Mortality rate of 60% during first month following injury Intracerebral hemorrhages occur 12-25/100,000 and account for 8-13% of all strokes in the United States 350/100,000 hypertensive hemorrhages annually in elderly 20,000 deaths per year attributed to intracerebral hemorrhages 30 day mortality rate of 44% for intracerebral hemorrhages 62,000 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 Skull Occipital Parietal Frontal Temporal Ethmoid Sphenoid

Regions of the Brain Diencephalon Frontal Lobe Limbic Lobe Parietal Lobe Occipital Lobe Temporal Lobe Cerebellar Hemisphere Brainstem

Cerebral Blood Flow: Circle of Willis

Incidence: 30% Anterior Communicating Artery 25% Posterior Communicating Arteries 20% Middle Cerebral Arteries 10% Basilar Artery 5% 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% blood Receives 13.9% of bodys cardiac output Cerebral 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/minute Consumes 80 milligrams of glucose per minute (25% of bodys glucose) Cerebral extraction of oxygen ranges between 24-40% Brain temperature is usually 0.5-1 degree Celsius>than core temperature Injured brain temperature is 1-5 degrees Celsius>than core temperature Brain temperature decreases 0.5-0.9 degrees Celsius per hour Brain cannot store glucose or oxygen Acidosis results in vasodilation while alkalosis yields vasoconstriction Normal intracranial pressure between 0-15 millimeters of mercury Normal cerebral perfusion pressure between 70-90 millimeters of mercury

Flow of Cerebrospinal Fluid

How it flows: Lateral Ventricles Foramina of Monro Third Ventricle Sylvian Aqueduct Fourth Ventricle Foramina of Luschka Foramina of Megende Subarachnoid Spaces

CSF: Supports and Protects Brain and Spinal Cord

40-70% of CSF formed in choroid plexus while 30-60% formed in ependyma and pia at rate of 0.357 ml/min, 22 ml/hr, or 500 ml/day 150ml bathing brain/spinal cord at any time 25ml in each lateral ventricle 4 times/day total volume of CSF is replaced 85-90% CSF reabsorbed by superior saggital sinus while remaining 10-15% by dural sinusoids on dorsal nerve roots

Signs of Increased Intracerebral Pressure

Headache Nausea Vomiting Visual Field Disturbance Papilledema Loss of Consciousness Systolic Blood Pressure Increase

Bradycardia Widened Pulse Pressure Irritability Somnolence Ocular Palsies Respiratory Abnormalities

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

Factors that Increase Intracranial Pressure

Tumor Abscess Venous Obstruction Arteriovenous Malformations Cerebral Edema Hydrocephalus SAH, SDH, ICH/IVH Eclampsia

Meningitis Encephalitis Abdominal Compartment Syndrome Increased Intrathoracic Pressure Toxin Exposure Hypoxic Injury Hepatic Encephalopathy

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 Codman Subdural bolt placed between arachnoid membrane and cerebral cortex Subdural sensor between arachnoid membrane and cerebral cortex Epidural 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 SBP<90mmHg Subarachnoid Hemorrhage Acute Hydrocephalus Brain Tumor Stroke Traumatic Brain Injury Postoperative Craniotomy CSF Infections Over 40 Years of Age Reyes Syndrome Cerebral Infarctions

Midline Shift and Correlation to Level of Consciousness

(Normal Brain) Degree of Shift 0-3mm Shift 3-4mm Shift 6-8.5mm Shift 9-13mm Shift Level of Consciousness Alert Drowsy Stupor Comatose

(Midline Shift)

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 Butthere are ways to deal with each

Supplies Required for Ventriculostomy

Hair clippers, surgical prep razors, and plastic bag for hair Boat of 4X4 gauze sponges Multiple syringes, filter needle, fill needles, and subcutaneous needles Bottle of Betadyne Towels beneath patients head...could save you a mess Preservative free saline (Pink top...not Green) Pressure cable Medtronic cranial access kit Medtronic external drainage system Argon pressure transducer from single transducer kit (A-Line) Blue cap Level (remember from transducer to ear hole)...there are laser levels now too Extra occlusive dressing

Nursing Responsibilities During Ventriculostomy

Position patient with head of bed in semi-Fowlers position Optimize patients body position to ensure maximal ICP reduction during procedure Place towel beneath patients head and possibly premedicate Verify maximum barrier protection during procedure Disconnect pressure tubing from former a-line set up and flush with preservative free saline and leave 10CC syringe leured into port that would normally house saline flush tubing and 500CC bag. Ensure sterility . Flush preservative free saline through former a-line set-up by pushing button and 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 patients head while neurosurgeon twist drills site and places drain Open sterile kits and pass to neurosurgeon so he/she can connect patient to drain. Connect to drainage system and allow CSF to backflow through the system. Document opening pressure, color, and quantity of CSF Review neurosurgeons orders for height of drain and call parameters *The nice part is the neurosurgeon walks you through this...and it really takes a few times to get the hang of it. If it is your first ventric, the twist drill is yours to keep as a mark of completing this Rite of Passage*

Insertion of the External Ventricular Drain

The neurosurgeon will position the patients head and make several measurements on the skull to ensure proper placement of the drain into the patients non-dominant anterior horn of the lateral ventricle. If ICPs remain high for protracted periods this could 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 nerve cell, 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...dont be nervous about calling. Stopcock remains open to drain except when measuring ICP at which time amount of CSF is gathered 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 therapeutically paralyzed, in which case pupils will only be checked. The neurosurgeon will want to perform a neurological examination every morning. Prior to that exam, 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 patients head. This is routinely used by the 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 it becomes 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 stimuli II. 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 sounds III. Eye Opening 4 - 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.

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

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 techniquedo 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, hypertonic saline, 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, dont cluster activities, educate family members and visitorsand 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 sitethen anklethen face). If you have never put a ventric in or managed onefind someone who has experience with it Trust your little voice that tells you something is wrongand act on it you are usually right

The Future of Neurological Monitoringand 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 vasospasm 3. Intravascular Jugular Bulb Venous Oxygen Saturation to measure oxygen saturation of blood leaving cerebral circulation 4. INVOS or In-Vivo Optical Spectroscopy measures regional oxygen saturation in the brain parenchyma 5. Cerebral Microdialysis for measuring extracellular metabolites 6. 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. 19100) 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 with intracranial pressure monitoring Http://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.