Applies To: UNMH Component(s): Responsible Department: Pediatric ICU
Title:
External Ventricular Drainage, Pediatric
Patient Age Group:
( ) N/A
( ) All Ages
Clinical Practice Guideline
( ) Newborns
(X ) Pediatric
( ) Adult
DESCRIPTION/OVERVIEW The purpose of this clinical practice guideline is to outline the procedure for the safe continuous or intermittent drainage of ventricular fluid, and to provide a way to monitor intracranial pressure (ICP) through this device in pediatric patients. External ventricular drains are cared for in PICU or PSCU only. NOTE: for Codman use and insertion, see Intracranial Pressure Monitoring Guideline. Guidelines do not represent a standard of care. They are guidelines for consideration and may be modified with appropriate documentation according to the individual patient’s need. POLICY/GUIDELINE CROSS REFERENCES ! Patient Care Guideline: Intracranial Pressure Monitoring and Care of Child with Increased ICP ! Patient Care Guideline: Routine Care of the PICU Patient ! Patient Care Guideline: Care of the Peds Specialty Care Patient AREAS OF RESPONSIBILITY The medical director of PICU, in consultation with the neurosurgical team, has approving authority for these guidelines, and his/her approval is required for any changes to these standards. Pediatric ICU, or Pediatric Specialty Care unit staff nurses are responsible for implementing these guidelines, and may modify portions of this guideline based on professional judgment, after consultation with patient’s physician. GUIDELINE PROCEDURES 1. Ventricular drainage and intracranial pressure (ICP) monitoring involves a catheter inserted into the ventricle of the brain. 2. *The ventricular catheter is inserted by a resident and/or attending physician either in the Operating Room or at the bedside in PICU, under sterile conditions. 3. Externalizing a shunt may be done in either pediatric area. 4. *Never aspirate or irrigate a ventricular catheter. This is only done by the physician, as it may introduce bacteria or cause intracranial bleeding to occur: use only non-bacteriostatic NS (without preservatives) for line set up or irrigation. The preservatives in alcohol can have a detrimental effect on the central nervous system if introduced into the CSF. Entering the ventricular drainage or monitoring system is a sterile procedure. Have sterile gloves and chlorohexadine available if the MD will be manipulating the line in any way. 5. *A physician may draw a daily CSF specimen for culture from the ventricular catheter. 6. * Only by a physician may injected medications into the cerebrospinal fluid (CSF) via the ventricular drainage system. 7. RNs who have been trained and demonstrated competence in this skill may perform ventricular drainage set-up and/or intracranial monitoring. Intracranial pressure and amount of fluid drained are recorded on the nursing flowsheet at least every two hours. _________________________________________________________________________________________________________________ Title: External Ventricular Drainage, Pediatric Owner: Pediatric ICU Effective Date: July 2006
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8.
Do not change the monitoring system (transducer and drip chamber with tubing) once it is in place. Change the drainage bag on the drainage system when it is approximately three-fourths full, using sterile technique. Discard the full bag in the BioHazard waste. 9. *Dressing changes are done by physicians only, however, the RN may need to reinforce the dressing to maintain catheter placement and insertion site sterility. Notify the neurosurgery house officer if dressing needs to be changed. 10. Inspect insertion site daily for s/s infection: redness, drainage, increased WBC count, fever, etc. 11. *When the ICP is being transduced, a transducer set up is used. Discard the drip chamber tubing that is proximal to the transducer. Flush the transducer and monitor tubing with nonbacteriostatic normal saline (see procedure below). Do not connect the transducer to any infusion device; cap it off with the occlusive cap provided in the transducer set up. 12. **Notify the neurosurgery on-call resident for CSF drainage of over 50cc in 1 hour, or 250cc in 24 hours. 13. Normal CSF flow is usually: infants- 3-5cc/hr toddler-child- 5-10cc/hr adolescent- 10-15cc/hr EQUIPMENT (essential) 1. Ventricular drainage system (Becker or other brand) 2. Non-bacteriostatic normal saline (the 10cc vials)- 20cc 3. 20 or 30cc syringe with a 25 gauge needle 4. Disposable transducer with pressure tubing if monitoring ICP 5. Transducer cable for Marquette monitor 6. Chlorohexadine swabs 7. Sterile gloves 8. IV pole 9. Insertion kit (supplied by neurosurgical resident doing the procedure) PROCEDURE: 1. Set up ventricular drainage system 1.1. Hang system from IV pole, aligning main system stopcock (zero level mark) with patient’s foramen of Monro (approximately at tragus of the ear). 1.2. *If monitoring intracranial pressure also, attach pressure transducer to the main system stopcock of the Ventricular External Drainage and Monitoring System. 1.3. Pre-fill the system to the flow chamber drip former with non-bacteriostatic normal saline before connecting system to the patient. 1.3.1. Use a 20-30 cc syringe with a 25 gauge needle to backfill the patient line- Inject saline at patient line stopcock injection site until all air has been flushed, from the patient line stopcock back to the drip chamber. 1.3.2. If monitoring, ensure the main system stopcock has been flushed also. 1.3.3. Check the system for any leaks or air bubbles. 1.4. *Set pressure head by sliding the drip chamber arrow to desired pressure setting per MD order- note whether it is ordered in mmHg or (usual) cmH2O. Zero the Marquette monitor in the usual manner. 1.5. Maintain sterility of the end of patient line- attach to ventriculostomy catheter. 1.6. Open main system stopcock to monitor, drain, or both. 1.7. Open patient line stopcock. CSF should be clear and colorless or light yellow. 1.8. If patient is in an electric bed, engage the patient lockouts for HOB and UP/DOWN. _________________________________________________________________________________________________________________ Title: External Ventricular Drainage, Pediatric Owner: Pediatric ICU Effective Date: July 2006
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1.9. To drain CSF from flow chamber to drainage bag. 1.9.1. Open both drainage slide clamps. 1.9.2. Small filter vent slide clamp must be open on top of flow chamber to permit drainage of fluid into drainage bag. Trouble-shooting 1. Waveform dampened: 1.1 Check stopcock on patient line, or main system stopcock 1.2 Check that Marquette monitor scale has not been changed. 1.3 Relevel and zero Marquette monitor. 1.4 Check patient side of tubing for blood (do NOT flush) 1.5 Call Neurosurgery resident on-call. 2. Draining too much or too little CSF 2.1 Check level of main system stopcock and ‘pressure head’ level (arrow on the drip chamber) for correct position. 2.2 Check that bed has not been moved up or down (engage patient lockouts) 2.3 Check for blood clots in patient tubing- call neurosurg. resident. 3. Remember to instruct patient / caregivers not to move the bed up or down; infants should not be taken in or out of the crib without assistance to prevent dumping of CSF. 4. When moving position, or traveling, turn stopcock off to patient drain momentarily until level is reestablished to prevent dumping of CSF. KEY DOCUMENTATION: 1. Plan of care/patient outcomes must address the implementation of this guideline. 2. Documentation of patient/family teaching on the multidisciplinary teaching form. 3. Documentation should include the name of the physician who placed the catheter and how the patient tolerated the insertion procedure if it was done at the bedside. The color and amount of drainage, the appearance of the insertion site and dressing and the ICP, if monitored, should be charted at regular intervals. Example: Ventriculostomy catheter placed by Dr. Neuro in PICU. Patient tolerated procedure without any change in vital signs or neuro status. Immediate drainage of clear light yellow CSF noted. Catheter sutured into in place. Occlusive dressing placed over insertion site by Dr. Neuro, dressing dry and intact with a small amount of bloody drainage at site. ICP reading initially 30, before draining 20 cc of fluid. DEFINITIONS Ventriculostomy: for the purposes of this guideline, this refers only to an external ventriculostomy drain, to include externalized ventricular shunts. Professional Literature: (Indicate if reference is R = Research; NS - National Standard or L = Literature) ! EDMS II drainage system information. ! (L) Hazinski, Mary F., Nursing Care of the Critically Ill Child (1992) pp. 1017 - 1021. SUMMARY OF CHANGES: Change to meet new format requirements KEY WORDS: EVD, Ventriculostomy, Pediatric
_________________________________________________________________________________________________________________ Title: External Ventricular Drainage, Pediatric Owner: Pediatric ICU Effective Date: July 2006
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RESOURCES/TRAINING Resource/Dept
Internet/Link
Pediatric ICU Staff DOCUMENT APPROVAL & TRACKING Item Owner Consultant(s) Committee(s) Nursing Officer Medical Director/Officer Human Resources Finance Legal Official Approver
Contact Date Yvonne Gabaldon, RN / Nurse Manager PICU Lisa Corso, RN / Specialty RN, PICU Policy and Procedure Subcommittee Nursing Clinical Operations Committee Judy L. Spinella, RN, MSN, MBA, CHE / Chief Nursing Officer Mark Crowley, MD / Medical Director PICU
Approval
Y Y
[Day/Mo/Year]
Official Signature nd
2 Approver (Optional) Signature
[Day/Mo/Year]
Effective Date Origination Date Issue Date
July, 2006 Clinical Operations Policy Coordinator
_________________________________________________________________________________________________________________ Title: External Ventricular Drainage, Pediatric Owner: Pediatric ICU Effective Date: July 2006
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