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Clinical Practice Keywords Cerebrospinal fluid/Brain

ventricles/Drainage/Haemorrhage
Review
Neurology This article has been
double-blind peer reviewed

In this article...
● C
 erebrospinal fluid production and circulation, and causes of hydrocephalus
● Indications for external ventricular drains, components and complications
● Practical points for safe nursing care of patients with external ventricular drains

Caring for neurosurgical patients

with external ventricular drains
Key points
Author Emily Humphrey is staff nurse (mental health), neurosciences department,
Hydrocephalus, surgical division, Nottingham University Hospitals Trust.
an excess of
cerebrospinal fluid, Abstract External ventricular drains are life-saving devices used in neurosurgical
is a medical patients with hydrocephalus (excessive amounts of cerebrospinal fluid). The fluid is
emergency as it produced in the brain ventricles and circulates around the brain and spinal cord,
raises intracranial protecting them from injury and supplying brain cells with nutrients. Hydrocephalus
pressure can occur due to impaired circulation or malabsorption and is a medical emergency,
which can lead to raised intracranial pressure. Nurses are responsible for the care of
Excess fluid can be patients who have external ventricular drains. This article explains how the drains
removed from the work and discusses key nursing considerations for their management.
brain by an external
ventricular drain Citation Humphrey E (2018) Caring for neurosurgical patients with external
ventricular drains. Nursing Times [online]; 114: 4, 52-56.
Patients with

H
EVDs need to
have cerebrospinal ydrocephalus is a medical Before entering the subarachnoid
output monitored emergency and its treatment space, CSF travels through the ventricles
hourly involves inserting an external (Waugh and Grant, 2014), four specialised
ventricular drain (EVD) into cavities in the brain: one in each of the two
EVDs carry a high one of the lateral ventricles of the brain to cerebral hemispheres (left and right lateral
risk of infection, remove excess cerebrospinal fluid (CSF). ventricles) plus two additional ones. The
so nurses need to This article discusses the essentials of fluid is constantly produced and reab-
maintain asepsis nursing care for patients with EVDs. sorbed, so while 500ml is produced daily,
and regularly assess only around 150ml is in circulation at any
patients CSF circulation one time in healthy patients (Hickey,
Cerebrospinal fluid is a clear, odourless 2009). On average, 125ml of CSF is present
Assessing patients’ liquid containing substances that bathes in the subarachnoid space and 25ml in the
consciousness is the brain and spinal cord, providing ventricles of the brain (Sakka et al, 2011).
crucial to identify energy to the working brain cells (neu- The route of CSF circulation is as fol-
neurological rons), such as glucose, oxygen and electro- lows: most is produced in the blood vessels
deterioration early lytes (Hickey, 2009). It travels around the lining the two lateral ventricles (choroid
brain and spinal cord within the subarach- plexus) (Sakka et al, 2011). The fluid passes
noid space, an enclosed area that sits from the lateral ventricles into the intra-
between two of the three outer protective ventricular foramina, a narrow descending
layers (meninges) that envelop the brain passageway, before entering the third ven-
and spinal cord (Fig 1). tricle. It then passes into the cerebral aque-
From outer to inner layers, the order of duct, a longer and narrower descending
the meninges and subarachnoid space is: passageway, to reach the fourth ventricle,
l D
 ura mater; from where it enters the subarachnoid
l A
 rachnoid mater; space through the median aperture (Sakka
l S
 ubarachnoid space; et al, 2011). While CSF moves in one direc-
l P
 ia mater. tion when passing through the ventricles,

Nursing Times [online] April 2018 / Vol 114 Issue 4 52 www.nursingtimes.net


Clinical Practice
Review
Fig 1. Subarachnoid space, ventricles and meninges
Choroid plexus
(produces CSF)
Left lateral
ventricle (hiding
right lateral
ventricle)
Front anterior
horn of lateral
ventricle
Third
ventricle
CSF = cerebrospinal fluid
it moves in several different directions
within the subarachnoid space (Sakka et
al, 2011). It is eventually absorbed by the
arachnoid villi (protruding structures that
line the subarachnoid space) and leaves the
subarachnoid space to enter the venous
bloodstream (Waugh and Grant, 2014).
CSF functions
The CSF cushions the brain and spinal cord,
acting as a shock absorber and reducing the
impact of outside knocks and jolts. It also
keeps the brain buoyant by reducing its den-
sity, thereby preventing its circulation being
cut off by the impact of its weight (Wood-
ward and Mestecky, 2011). In addition, CSF
enables homoeostasis by delivering impor-
tant substances – such as hormones, oxygen
and nutrients – to brain cells and removing
waste (Waugh and Grant, 2014).
These functions rely on a constant flow
of CSF being produced and absorbed in the
correct amounts. However, sometimes
there is excessive CSF in circulation: this is
known as hydrocephalus.
Causes of hydrocephalus
Hydrocephalus is a broad term for any
situation where there is too much CSF in
circulation, for example because the cho-
roid plexus secretes too much, there is an
PETER LAMB
obstruction somewhere on its route, or
there are problems with its absorption by
Nursing Times [online] April 2018 / Vol 114 Issue 4
Skull
Scalp
Fourth
ventricle
the arachnoid villi. Secretion is not in
equilibrium with absorption, and CSF
builds up.
Hydrocephalus can have many causes:
l F
 ollowing subarachnoid haemorrhage,
blood in the subarachnoid space makes
it harder for the CSF to reach the
arachnoid villi and slows down or
prevents its absorption (Bowles, 2014);
l F
 ollowing intraventricular
haemorrhage, blood in the ventricles
can enter the subarachnoid space and
impair CSF absorption (Muralidharan,
2015);
l T
 umours near the third and fourth
ventricles can obstruct CSF flow
(Woodward and Waterhouse, 2009);
l E
 xudate from infection (such as
meningitis or encephalitis) can block
the cerebral aqueduct and therefore
obstruct CSF flow (Woodward and
Waterhouse, 2009);
l G
 enetic disorders, such as: aqueduct
stenosis (abnormally narrow cerebral
aqueduct); Dandy-Walker
malformation (several abnormal brain
structures including a dilated fourth
ventricle); and Arnold Chiari
malformation (where the base of the
brain pushes through the opening of
the skull and protrudes into the spinal
canal) can impair CSF circulation
(Woodward and Waterhouse, 2009);
53
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Pia mater
Meninges of
Arachnoid the brain
mater (which also
envelop the
Dura mater spinal cord)
Subarachnoid space
(contains CSF)
Light blue = CSF circulation
Red = CSF production
l T
 umours of the choroid plexus, which
are rare, can cause overproduction of
CSF (Woodward and Mestecky, 2011).
A medical emergency
Hydrocephalus, from any cause, needs to
be treated urgently as it can cause
increased pressure in the ventricles (either
by build-up of CSF around an obstruction
or by blood increasing the overall circu-
lating volume in the ventricles and suba-
rachnoid space). Increased ventricular
pressure equates to increased intracranial
pressure (ICP) in the skull overall (Sakka et
al, 2011).
Raised ICP is critical because it reduces
blood flow to the brain, starving it of
oxygen, glucose and other vital sub-
stances. Due to the limited space in the
skull, untreated ICP will eventually lead to
brain herniation, a medical emergency in
which the brain shifts into any available
space – usually downwards. It descends
into the opening at the base of the skull,
crushing the structures of the brain stem
and impeding the vital functions they con-
trol, such as respiration and heart rate
(Woodward and Mestecky, 2011).
EVD insertion
Hydrocephalus is temporarily treated by
insertion of an EVD. Also known as an
external ventriculostomy (Hammer et al,
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Clinical Practice
Review
Fig 2. External ventricular drain
Pressure setting for
drainage of CSF
Lateral ventricle
Drainage bag for CSF
CSF = cerebrospinal fluid
2016), the EVD is a small soft catheter
inserted directly into one of the lateral ven-
tricles (Hickey, 2009), usually of the right
hemisphere, to drain excess CSF (Fig 2).
The right hemisphere is the non-dominant
hemisphere for language (Grandhi et al,
2015), so insertion into the right lateral
ventricle reduces the risk of language dys-
function. Box 1 lists the clinical indications
for EVD insertion
To reduce the risk of infection, the cath-
eter is initially tunnelled a few centimetres
under the scalp before entering the skull. It
is then inserted into the anterior horn of
the ventricle (the large C-shaped structure
at the front) by drilling a small hole in the
skull (burr hole) and incising the
meninges. The skin incision is then
sutured, the catheter is sutured to the
scalp and the wound covered with a sterile
occlusive dressing (Woodward et al, 2002).
Patients requiring ongoing CSF
drainage will have a cerebral shunt surgi-
cally inserted. Shunts are thin tubes that
drain CSF to other parts of the body such
as the abdomen, heart or lung for absorp-
tion. A valve can be set at the desired pres-
PETER LAMB
sure to allow CSF to escape whenever the
pressure level is exceeded.
Nursing Times [online] April 2018 / Vol 114 Issue 4
Collection
chamber
Zero on
pressure scale
must be
horizontally level
with tragus of
the ear
Monitoring CSF drainage
Outside the skull, the catheter is connected
to a drainage system consisting of a collec-
tion chamber hanging from an intrave-
nous (IV) pole attached to the bed, a pres-
sure scale (also hanging from the IV pole)
and a drainage bag (Fig 2). Stopcocks
between the collection chamber and
drainage bag allow control of the entry of
CSF and its drainage (Fig 3).
Box 1. Indicators for external
ventricular drain insertion
l Monitoring intracranial pressure
l Treating hydrocephalus, including
negative-pressure hydrocephalus,
where pressure level is set below zero,
correcting intracranial hypertension
l Administering medication for
intraventricular haemorrhage or
ventriculitis
l Diverting infected or bloodstained
cerebrospinal fluid, preventing its
absorption by the arachnoid villi
l Treating hydrocephalus secondary
to aneurysmal subarachnoid
haemorrhage or a tumour
54
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The collection chamber and pressure
scale hang side by side. Pressure is measured
in millimetres of water pressure (cmH20).
The scale includes both positive and nega-
tive measurements; zero corresponds to the
pressure where the catheter enters the ven-
tricle, and should always be horizontally
level with the tragus of the patient’s ear (Fig
4) (Woodward and Waterhouse, 2009).
When the patient is lying on one side,
this anatomical reference point becomes
the bridge of the nose (Woodward and
Mestecky, 2011). It is a key nursing respon-
sibility to ensure that zero on the pressure
scale is level with the patient’s tragus at all
times (Woodward et al, 2002).
The number above (or below) the zero
point is the prescribed pressure level of the
EVD determined by the neurosurgical
team (Woodward et al, 2002). In the
patient’s brain, this pressure level corre-
sponds to the amount of pressure that
must be inside the ventricles before the
CSF drains into the catheter. In the
external drainage system, it corresponds
to the height at which the collection
chamber hangs.
If the collection chamber hangs from a
higher point, it will drain CSF from a
higher pressure in the ventricles than one
hanging from a lower point. The pre-
scribed pressure level must be docu-
mented, and the collection chamber must
be checked frequently to ensure it is nei-
ther too high (which would cause under-
drainage of CSF) nor too low (which would
cause over-drainage) (Woodward and
Waterhouse, 2009).
“External ventricular
drains can appear
daunting, but they are
a rewarding aspect of
patient care”
Problems associated with EVDs
Infection
The insertion of an EVD is a highly invasive
procedure and carries a significant risk of
infection (Muralidharan, 2015; Chatzi et al,
2014; Wong, 2011); this risk increases the
more frequently it is accessed by health
professionals to obtain CSF samples (Jam-
joom et al, 2017), and the longer the EVD is
kept in situ (Camacho et al, 2010). Touching
EVD components, such as the stopcock or
drainage bag, must be an aseptic proce-
dure and handling must be kept to a min-
imum (Woodward and Waterhouse, 2009).
A sterile, closed drainage system should
be maintained and the entry site dressing
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Clinical Practice
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Fig 3. Stopcock positioning
Stopcock pointing north
(turned upwards)
indicates EVD is ‘off’
CSF will remain in
collection chamber and
not enter drainage bag
Turn stopcock to this
position before nursing
intervention involving
movement
CSF = cerebrospinal fluid; EVD = external
CSF = cerebrospinal ventricular
fluid; EVD
Fig 4. Ear pierced at the
tragus
should only be changed if it becomes
soiled or loose. The neurosurgical team
should be informed as soon as possible if
the dressing may be wet from CSF leakage
(Woodward et al, 2002) as this poses an
infection risk. The drainage bag should be
changed when it is three-quarters full, as
too much weight could disrupt drainage
(Woodward et al, 2002).
The integrity of the entire EVD system
must be checked at a minimum of every
four hours, and damage or disconnection
of any of the components reported as an
emergency. Patients must also be checked
PETER LAMB
every four hours for early signs of infection
such as an increase in temperature, pulse
Nursing Times [online] April 2018 / Vol 114 Issue 4
Collection chamber
Stopcock Stopcock
Drainage bag
drain
= external ventricular drain
and respirations; cloudiness or debris in
previously clear CSF indicates infection and
should be reported to the neurosurgical
team (Woodward and Waterhouse, 2009).
Patients might need to be monitored more
frequently depending on the stability and
status of their neurological and vital obser-
vations, so this requires clinical judgement.
Over- and under-drainage
It is crucial to monitor EVDs meticulously,
ensuring the zero point on the scale is hor-
izontally level with the patient’s tragus and
that the prescribed pressure level is cor-
rect. If CSF drains at a higher pressure it
will cause under-drainage and lead to
raised ICP, signs of which include:
l R educed level of consciousness
indicated by a decline in Glasgow
Coma Scale score;
l N ew weakness in any of the limbs;
l H eadache;
l C hanges in pupil size and equality;
l V ision changes (including double or
blurred vision);
l O edema of the optic disc (papilloedema);
l C hanges in vital signs (Woodward and
Mestecky, 2011).
Neurological and vital signs should be
observed at least every four hours as above
and CSF output documented hourly on a
fluid balance chart (Woodward et al, 2002).
Signs of under-drainage should be reported
immediately to the neurosurgical team.
Equally damaging for the patient is
over-drainage, which can collapse the
55
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Stopcock pointing west
indicates EVD is ‘on’
CSF will drain from
collection chamber into
drainage bag
Turn stopcock back to
this position after
intervention is finished
ventricle, pulling the brain tissue away
from the dura, tearing cortical veins and
leading to subdural haematoma (Wood-
ward and Waterhouse, 2009). Over-
drainage can be prevented by ensuring
that the CSF is not draining at a lower pres-
sure than that set by the neurosurgeon.
Over-drainage of CSF can be caused by
increased pressure inside the ventricles.
Straining to pass faeces can increase intra-
ventricular pressure, so it is important to
ensure patients with EVDs maintain reg-
ular bowel habits using stool softeners.
Drainage should be turned off at the col-
lection chamber before any intervention
involving patient movement, such as suc-
tioning, walking, physiotherapy and repo-
sitioning in bed – all of which can increase
intraventricular pressure.
Drainage at the collection chamber is
turned off by turning the stopcock so that
it points ‘north’ (upwards). It can be
helpful to visualise the stopcock as
obstructing CSF flow into the drainage bag
when it is pointing north and associate
‘off ’ with the stopcock pointing north. As
soon as the intervention is finished, the
stopcock should be turned to point ‘west’,
turning the drainage system back on again
(Fig 3). Drainage should not be turned off
for longer than needed, as this can cause
the catheter to block.
Early signs of over-drainage include
headaches, and the neurosurgical team
should be notified urgently if the rate of
drainage exceeds 10ml per hour or a total
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Clinical Practice
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Box 2. Monitoring and
documentation
l On pressure scale, check prescribed
pressure level is correct and zero is in
line with tragus
l Document amount of cerebrospinal
fluid (CSF) drained per hour on fluid
balance chart
l Check catheter is oscillating and
not kinked
l Monitor colour of CSF and alert
the neurosurgical team immediately
if it changes
l Monitor clarity of CSF and alert the
neurosurgical team immediately if
cloudiness and/or debris appear
l Check dressing is intact, clean and dry
of more than 30ml drains in one hour
(Woodward et al, 2002).
When the patient is being transferred,
the EVD system must remain in an upright
position and not be left lying flat on the
bed, as this will impair drainage (Wood-
ward and Waterhouse, 2009).
Trauma and haemorrhage
Although they are life-saving devices,
EVDs are not without risk. Lewis et al
(2015) suggest there is a link between EVDs
and delayed hydrocephalus in patients
with subarachnoid haemorrhage, arguing
that the drain may interrupt CSF flow and
slow down clearance of debris from
bleeding, which can impair CSF absorp-
tion by the arachnoid villi.
EVDs themselves can cause trauma and
therefore lead to haemorrhage in the ven-
tricles (intraventricular haemorrhage), or
in functioning brain tissue (parenchymal
haemorrhage) (Dash et al, 2016), as well as
to aneurysm rupture (when a weakened
part of a cerebral blood vessel bursts)
(Muralidharan, 2015).
Placement of the drain can cause the
dura mater to pull away from the
overlapping skull bones and Dash et al
(2016) report the case of a patient devel-
oping a haematoma above the dura (epi-
dural haematoma) after EVD placement.
Grandhi et al (2015) report a case of EVD
placement causing a pseudoaneurysm
(where blood collects between the two
outer layers of an artery) of a major cere-
bral artery; they also cite evidence that
EVDs can cause arteriovenous malforma-
tions (AVMs), which are abnormal connec-
tions between arteries and veins. Aneu-
rysms and AVMs carry a major risk of
rupture and bleeding.
Nursing Times [online] April 2018 / Vol 114 Issue 4
Nurses need to be vigilant for signs of
trauma, which is another reason why neu-
rological and vital observations should be
performed frequently. They also need to:
l A
 lert the neurosurgical team
immediately if previously clear CSF
is blood-stained;
l C
 ohort or provide one-to-one care to
confused or agitated patients to prevent
accidental removal of the EVD;
l R
 egularly check that the catheter is
swinging: a patent catheter will gently
swing but a catheter that is not swinging
at all could indicate that it is blocked by
clotted blood or tissue debris;
l R
 egularly check that the catheter is not
kinked: this can cause a blockage.
A blocked catheter needs immediate
medical attention; the neurosurgical team
may need to irrigate it, remove any haema-
toma or remove the EVD altogether.
Due to the risks of intracranial haemor-
rhage (haemorrhage anywhere in the brain),
prophylactic anticoagulants prescribed for
deep vein thrombosis may be contraindi-
cated in patients with an EVD in situ. Nurses
must check the local policy and raise any
concerns with the neurosurgical team.
Conclusion
Box 2 lists what to monitor and document,
while Box 3 features a range of competen-
cies relating to the safe care and manage-
ment of patients with an EVD in situ.
Although these drains can appear
daunting, with an understanding of their
key elements and functioning they are a
rewarding aspect of patient care. NT
Box 3. Competencies for
managing patients with
external ventricular drains
l Know infection control policies
about handling, monitoring and
cleaning medical devices
l Know how to assess patients
for infection
l Be able to apply principles of asepsis
l Understand how external ventricular
drains (EVDs) work and appreciate
importance of maintaining alignment
with tragus
l Know the ‘on’ and ‘off’ positions of
stopcock
l Be able to identify indications for
and complications of EVDs
l Know how to manage complications
l Be able to use the Glasgow Coma
Scale to detect early neurological
deterioration
56
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