Care of the Patient with an EVD or Lumbar Drain - PowerPoint Presentation

Slide1

Care of the Patient with an EVD or Lumbar Drain

Lauren Walker RN, BSN, CCRN

Slide2

Objectives

Review prerequisite nursing knowledge necessary for competent care of a Lumbar or EVD drain.

Review EVD and Lumbar equipment, monitors, patient positioning, and management.

Discuss neurologic assessment with a Lumbar Drain or EVD.

Analyze possible complications of specific drains and pressure monitoring.

Discuss procedure for sending CSF for testing.

Return-demonstration of management and care of the Lumbar drain and EVD.

Slide3

CSF and Ventricular System

CSF is a colorless, clear fluid produced by choroid plexus in third and fourth ventricles.

Functions as a cushion for brain and spinal cord

500-600 ml CSF produced daily

125-150 ml circulates in the ventricular

system and subarachnoid space at one time (remainder is reabsorbed)Brain has four CSF filled and interconnected ventricles

Slide4

Intracranial Pressure

Intracranial Pressure (ICP) is the pressure exerted by the brain content:

Brain Tissue (85%)

Cerebral Spinal Fluid (CSF) (10%)

Intravascular blood (2-11%)

Cerebral Autoregulation: The ability of the cerebral vessels to constrict and dilate as needed to maintain adequate cerebral perfusionImpaired with brain injury and the cerebral blood flow becomes passively dependent on blood pressureMonro-Kellie Hypothesis: an increase in one component must be offset by an equal decrease in one or more components otherwise an increase in ICP will result

Slide5

ICP Pressures

Normal ICP 0-10 mmHg

Increased ICP occurs when the intracranial volume exceeds the brain’s ability to compensate for increased volume

Sustained ICP above 20 mmHg is considered a neurologic emergency

When the brain suffers an insult or injury, changes occur that affect cerebral hemodynamics, including changes in ICP, cerebral blood flow, and oxygen delivery

Slide6

Cerebral Perfusion Pressure

Cerebral Perfusion Pressure (CPP):

Pressure at which the brain is

perfused

About 15-20% of cardiac outputCPP = Mean Arterial Pressure (MAP) – ICP. Normal CPP 60-80 mmHGCPP less than 50mmHg will result in cerebral ischemia and tissue death

Slide7

Causes of Increased ICP

Contusions

Hematomas

Tumors

Infarcts

Fluid overloadMechanical ventilation (PEEP)Valsalva maneuver

Coughing

Endotrachial suctioning

Hypercarbia

Hypoxia

Increased CSF Production

Metabolic disturbances

Slide8

Indications for Measuring ICP

TBI with GCS of less than or equal to 8

with an abnormal CT scan results

Normal CT scan results with hypotension, posturing, and older than 40.

ICH

SAHCerebral EdemaMassFulminant hepatic failure with encephalopathyIschemic Stroke with massive edemaMeninigitisCystsHydrocephalus

Congenital anomalies

Craniosynostisis

Slide9

ICP Monitoring and the EVDIntraventricular catheters are the

gold standard

for measuring ICP

Placed directly in the ventricle

(typically in the anterior horn of the lateral ventricle through a burr hole in the skull)Attached to a pressure transducerAn external ventricular device (EVD) Has ICP monitoring capabilities Can also assist with controlling increased ICP by CSF drainageThe main disadvantage to an EVD is that it is the most invasive device because it penetrates the meninges and brain

Slide10

ICP Monitoring and Lumbar Drains

Lumbar drainage devices (LD) are closed sterile systems that allow the

drainage of CSF

from the subarachnoid space.

LD are inserted via a specialized spinal needle into the lumbar subarachnoid space at the L2–L3 level or below

avoids injury to the spinal cordIn the lumbar CSF space, the spinal catheter will be alongside the cauda equinaConsists of the ventral and dorsal spinal nerve roots that descend from the spinal cord and exit the spinal canal at lumbosacral levels

Slide11

Lumbar Space

L1 pedicle

→

Sacrum

→L2 pedicle

→

←

Dural Tube

LD is inserted in lumbar subarachnoid space: L2 to L3 space avoiding injury to spinal cord

Spinal Cord ends at L1-L2 at Conus Medularis

←

Conus Medularis

←

Cauda Equnia

Slide12

Indications for a Lumbar Device

Postoperative or traumatic

dural

fistula (CSF leak)

Treatment of shunt infections

Diagnostic evaluation of idiopathic normal pressure hydrocephalus Reduce ICP during a craniotomy Adjuvant therapy in the management of TBI Thoracoabdominal AAA to improve spinal cord perfusion Manage

nontraumatic

subarachnoid hemorrhage to prevent vasospasm

Manage increased ICP associated with

cryptococcal

meningitis

Slide13

Patient Care with LDPatient positioning is crucial to prevent complications

The head of the bed, height of drainage chamber, and changes in patient positioning must be monitored closely to prevent sudden

overdrainage

.

Patients may turn from side to side without significant impact on drainage unless the catheter is found to be positional.

Nursing staff should monitor which positions result in variances in drainage rate from the LD and plan patient carePerform a complete motor and sensory exam with neuro examAssess for s/s of meningeal irritation Photophobia, neck stiffness, N/V, HA, bowel and bladder function

Slide14

Expected Outcomes of ICP Monitoring and CSF Drainage

Avoid secondary injury

Patient will maintain CPP of approximately 60-70 mmHG

WBC will be within expected limits

CSF cell count, protein, glucose and culture will be within expected limits

Patient/family will receive information and reinforcement regarding ICP monitoring and CSF drainageVisitors will verbalize understanding of limiting movement of patient

Slide15

Patients who require an EVD or LD should be closely monitored by nurses trained and competent in assessment and management of both the drain and the neuroscience patient population

Slide16

Nursing Management and Assessment

Maintain optimal cerebral tissue perfusion

Perform and document neuro assessment every hour and PRN and note trends.

Notify physician for changes in neuro status and CPP less than 60mm Hg for more than 5 minutes.

Monitor Hourly:Vital Signs: BP, pulse, respiration and temperature. Pupil size and reactionGlasgow coma scaleICP MAP CPP = MAP – ICP

Slide17

Nursing Management and Assessment

Monitor the patient

every hour

and as necessary for symptoms of increasing ICP

Change in level of consciousness:

HeadacheRestlessness/agitationNausea/VomitingSeizure activityVisual changesChanges in LOCChanges in pupillary responsesLabored respirations and/or patternChanges in motor strength

Cushing’s Triad: Increasing BP with a widening pulse pressure, decreased HR, irregular respirations

Slide18

Nursing Management and Assessment

Assessment of the EVD/Lumbar Drain hourly

Inspecting EVD from insertion site along the entire drainage system

Check for cracks in the system or fluid leaking from the insertion site

Dressing is intact

Hourly assessment of CSF drainage amount, color, and clarity.Ensure the system is appropriately clamped or open depending on order. Check patient position to ensure transducer is at the ordered reference level. If the patient is very active and moving around in bed, it is imperative to frequently assess that the drain is leveled appropriately to prevent over- or under-drainage.

Slide19

Nursing Management and Assessment

Facilitate venous return:

Patient’s head may be elevated according to the discretion of the attending and neurosurgeon.

The head position must remain neutral, may use soft cervical collar or sandbags, if necessary.

Prevent hip flexion greater than 90 degrees.

Instruct family members regarding the plan of care and the need to limit stimulation of patient r/t head injury.

Slide20

Nursing Management and Assessment

Identify activities that alter intracranial pressure

lights, noise, repositioning

Arrange nursing care to minimize elevation in ICP (cluster care)

Assess ICP waveform continuously

Body temperature should remain below 38 C. Assure prescribed seizure prophylaxis is instituted if indicated.

Slide21

Nursing Management and Assessment

Monitor labs, as ordered.

Maintain HCT greater than 25%.

If patient is receiving

Mannitol

, obtain Serum Osmolarity every 6 hours. (Notify MD prior to administering if serum osmo > than 310).Record I/O every hour. If urine output is greater than 200 mL for 2 hours and specific gravity is less than 1.005, not associated with Mannitol dosing, notify neurosurgeon

Slide22

Managing ComplicationsIf the ICP is greater than 15 mmHg, rises abruptly or is greater than parameters determined by the MD and/or the CPP is less than 60 mmHg for more than 5 minutes and notify MD:

Remove any stimulus from the patient.

Reposition head to neutral position.

Confirm adequate volume status (CVP 7-13). If low, obtain order for volume replacement or follow Traumatic Brain Injury Protocol as ordered.

Medicate with medications as ordered after assessing patient LOC.

Slide23

EVD ComplicationsAn absence of an ICP waveform

May be the result of air bubbles, clots, or debris within the drainage tubing or across the transducer.

A malfunctioning pressure cable, module, or transducer may also result in the loss of the ICP waveform

Infections

Manipulation and accessing of drainage tubing can be a source of contaminationDrainage tubing accidentally becomes disconnected: every effort should be made to maintain the sterility of the ventricular catheter. New sterile EVD tubing should be obtained and connectedAn occlusive dressing is placed to cover both incisions

Slide24

EVD Complications

CSF Overdrainage

EVD: Maintain the drip chamber at the prescribed zero reference and pressure levels

Family and Pt education!!

changing the bed position is to be

performed only with assistance. Raising the level of the bed with an can result in a large increase in CSF drainage.Clamp the device any time there is a patient response or procedure that may cause CSF OverdrainageClamp for coughing, vomiting, suctioning, or repositioning.

Slide25

Lumbar Drain Complications

Overdrainage

Movement and repositioning of the patient

Not frequently observing the amount draining

Infection at insertion site

Manipulation of catheter and tube could be a source of contaminationNon-occlusive dressingTube DislodgementLower extremity weaknessChanges in bowel and bladder patternsCould indicate a nicked nerve

Tracking in tubing

Bleeding in spinal cord

Slide26

Management of the EVD and Lumbar Drain

Slide27

Zeroing the TransducerEVD

Raise or lower the system measured to the tragus of the ear

Lower the

Buretrol

to the “zero point” on the system by pinching the tabs together above the

buretrol and lowering into alignment with zero on the deviceTurn the stopcock “off” to the patient (open to the Buretrol/transducer)Do Not open the transducer to air (the transducer will be opened to air automatically through the vent on top of the

Buretrol

).

Highlight the ICP box on the GE monitor screen and select “zero ICP” on the drop down menu choices. Wait for a “0” to appear on the monitor for the ICP reading.

Replace the

Buretrol

to the position on the pole mount that has been ordered by the physician.

Zero the ICP every 12 hours

Slide28

Leveling EVD

The transducer on the set-up is leveled to the patient’s external auditory meatus.

The “pressure level” indicator (located on the drip chamber of the collection system) is aligned to the ordered cm H2O above the external auditory meatus.

If continuously draining CSF, turn the drain off to the patient momentarily to obtain the ICP reading.

Slide29

Level to Tragus of Ear for EVD

Slide30

Leveling EVD

Slide31

Obtaining an ICP Tracing

Turn stopcock “off” to the drain and “open” to the transducer to obtain an accurate ICP numerical value and waveform.

The ICP numerical value and waveform should be obtained every hour.

If there is an increase in intracranial pressure, then the value should be obtained more often (i.e., Q15 minutes).

Slide32

Draining CSF

For Continuous ICP Measurements:

Keep the EVD stopcock “off” to drain and “open” to the transducer for continuous ICP monitoring.

If ordered by MD, when the ICP reaches a specified pressure, “open” the stopcock to drain CSF for a short time period.

Continuous CSF Drainage/Intermittent ICP Monitoring

The EVD stopcock is “off” to transducerThe amount of CSF drainage is controlled by raising the pressure level on the graduated burette above the Foramen of Monro, which is the zero reference level.The EVD device does not allow practitioner’s to drain CSF and monitor ICP simultaneously.

Slide33

Lumbar DrainZeroing

There is no such thing



We are not measuring ICP with a Lumbar Drain

No transducer on system

No need for zeroing!(One less thing for you to do!)

Slide34

LD Leveling

The transducer on the set-up is leveled to the patient’s shoulder or iliac crest (per MD order)

The “pressure level” indicator (located on the drip chamber of the collection system) is aligned to the level at which it drains the order volume

Iliac Crest

↓

Slide35

LD Drainage

1.

Draining to a specific volume:

MD orders a specific amount of CSF to be drained at a particular time period

Manipulation of the drain to achieve specific amount

2. Draining at a specific level: MD orders level of the pt’s bodyContinuous drainage (ICU monitoring)3. Draining at a specific pressure: MD orders a specific pressure for draining System drains only when the pressure exceeds the pressure pressureUsually for shunt infections/malfunctionICU Monitoring

Slide36

Emptying the BuretrolMeasure and record amount of drainage in the Buretrol every hour.

Turn the stopcock at the transducer “off” to patient.

Open the stopcock between Buretrol and the collection bag, fluid should flow from Buretrol into collection bag.

Turn the stopcock between the Buretrol and the collection bag “off” toward Buretrol.

Open the transducer stopcock to patient to obtain readings.

Slide37

Changing the Drainage Bag

The collection bag is changed when about three quarters full.

Wear sterile gloves and a mask.

Cleanse the stopcock below Buretrol with Betadine (Scrub connection for 30 seconds).

Assure the stopcock between the Buretrol and the collection bag is “off” toward Buretrol.

Using sterile handling technique, disconnect the drainage collection bag from the Buretrol stopcock and detach bag from the system panel. (Handing the full bag off to a second person is recommended.)Connect a sterile replacement collection bag to Buretrol stopcock and attach to system panel.Cap off the open port of the full collection bag and dispose in red trash bag.

Slide38

Obtain CSF Sample

MD: will obtain CSF cultures from the

distal stopcock

and is required to use a lab label to label the specimen prior to leaving the patient’s room.

RN is requested to obtain the CSF culture: will be obtained from the specimen collection port on the Buretrol drainage collection chamber.

Equipment:Non-sterile glovesBetadine solution/swab/applicatorSterile glovesSterile 10 mL luer-lock syringeSterile container (e.g., urine C&S container)Lab label

Slide39

CSF Collection Cont.

A mask and sterile gloves are required during all CSF specimen collections.

Don non-sterile gloves.

Specimen port is scrubbed with Betadine for 30 seconds. Allow to air dry.

Remove nonsterile gloves and wash hands.

Set up for sterile specimen collection (open and maintain sterility of syringes, specimen container and gloves).Don sterile gloves.Attach luer-lock syringe to cleansed and dry needleless access port.

CAUTION

: DO NOT insert a needle into the needleless sampling port.

Slide40

CSF Collection Cont.

Turn stopcock OFF to the drainage collection bag and withdraw equal to or greater than 1 mL

(absolute minimal sample for microbiology laboratory specimen of 0.5 mL).

NOTE: The hand used to turn the stopcock is no longer sterile; do not touch syringe or specimen container with the contaminated hand.

Maintain sterile technique, remove syringe from the stopcock and expel the CSF sample into the sterile container.

Close container and assure labeling.Discard syringe in sharps receptacle, discard used supplies.Send specimen to the laboratory.

Slide41

Dressing Changes

Dressings at the ventriculostomy insertion site must remain dry.

Dressings are changed routinely every 72 hours and prn if the dressing becomes damp or otherwise ordered by the physician.

Wearing a mask, cap and gloves, use sterile technique to change the dressing. Use betadine swabs to cleanse the catheter insertion site.

Re-dress the insertion site of the transduced ventricular catheter with a sterile 2x2 dressing and secure with an occlusive dressing.

Slide42

Patient Transport

Clamp the EVD during transport, when repositioning or with any patient movement that would cause the zero point of the EVD/LD to be lower than the reference point.

Re-zero, level and re-open the EVD/LD after patient transport or movement is completed.

Slide43

WaveformsICP waveform analysis identify patients who are at risk for increases in ICP and decreases in CPP

The ICP waveform has three components: pulse, respiratory, and “slow waves”

Pulse: consists of three peaks, decreasing in height

Pulse waves represent arterial pulsations in large cerebral vessels as they produce a fluctuation in the volume within the ventricles

P1, the first and sharpest peak, “percussive wave” and results from arterial pressure being transmitted from the choroid plexus.

P2, the second peak, referred to as the“tidal wave,” varies in amplitude with brain compliance P3 represents the “dicrotic wave” and is caused by closure of the aortic valve

Slide44

Waveforms Cont.As the ICP increases the amplitude of P1, P2, and P3 all increase

If ICP continues to rise, P2 becomes more elevated than P1 until eventually P1 may disappear within the waveform

Constriction of cerebral blood vessels (Seen with hypocapnia or vasospasm) will exhibit a decrease in the amplitude of the waveform

Patients who have undergone a craniectomy (bone flap removal) will have a dampened waveform

Slide45

Waveforms

Slide46

Waveforms

Rounding of ICP waveform due to aneurysmal vasospasm

Slide47

References

American Association of Neurosciences Nurses. (2011).

Care of the patient undergoing intracranial pressure Monitoring/External ventricular drainage or lumbar drainage. AAN clinical practice guideline series

. Glenview, IL: Codman and Shurleff. http://www.aann.org/pubs/content/guidelines.html.

Barker, E. (Ed.). (2008).

Neuroscience nursing, A spectrum of care (3rd ed.). St Louis, MO.: Mosby Elsevier. Buchbinder, D. (2012). AO Surgical Reference. Retrieved April 18, 2012, from https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwML1yBXAyMvYz8zEwNPQwN3A_2CbEdFAEfu4iM!/?showPage=rehabilitation&bone=CMF&segment=Cranium&classification=93-Skull+base,+Temporal+bone+(lateral+skull+base)&treatment=&method=Delayed+management+of+hearing+loss&implantstype=&approach=&redfix_url=1289912913263. Inova Health System. (2011). Critical care standard 2.400 intracranial pressure monitoring- procedure and protocol.

Unpublished manuscript.

Wiegand, D. (Ed.). (2011).

AANC procedure manual for critical care

(6th ed.). St. Louis, MI: Elseview Saunders.