External Ventricular Drain (EVD) in Nursing HUDA (2).pptx

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1. External Ventricular Drain (EVD) in Nursing Care Student: Huda al Owais Raad al Abadi

2. Outline: Introduction Indications Anatomy. Physiology. Pathophysiology for EVD Insertion of external ventricular drainage Drain management Pitfalls Complication Rules and facts Conclusion

3. objective 1-to understand the definition for EVD and function 2-To identify indication for EVD placement 3-To describe the procedure for EVD insertion 4-To recognize potential complication and intervention 5-To apply critical nursing intervention

4. Introduction What is an EVD? An External Ventricular Drain (EVD) is a device used to drain excess cerebrospinal fluid (CSF) from the brain's ventricles to relieve increased intracranial pressure (ICP).It is commonly used in cases of hydrocephalus, traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), and brain tumors (Checketts.2012)

5. Anatomy of the Brain's Ventricular System Ventricles of the Brain: Lateral ventricles : Largest and contain the choroid plexus that produces CSF. Third and Fourth ventricles : Pathways for CSF flow . Subarachnoid space : CSF surrounds the brain and spinal cord. Arachnoid Villi : Absorb CSF into the venous system

6. Physiology of CSF Circulation Functions of CSF: Provides cushioning and protection to the brain Removes waste products Maintains homeostasis (balance of ions and pH) CSF is absorbed into the bloodstream via arachnoid villi Normal CSF pressure ranges from 5-15 mmHg

7. Pathophysiology Conditions Requiring EVD: Hydrocephalus : Excess CSF accumulation due to blockage, overproduction, or impaired absorption Traumatic Brain Injury (TBI ): Swelling or bleeding obstructing CSF flow. Subarachnoid Hemorrhage (SAH): Bleeding disrupting normal CSF pathways. Brain Tumors: Tumors blocking CSF flow and increasing ICP. ICP Management: EVD is used to drain CSF and reduce ICP to prevent brain herniation and further injury.

8. Indications 1-To relieve raised intracranial pressure (ICP) 2-To divert infected CSF 3- To divert bloodstained CSF following neurosurgery /hemorrhage 4=To divert the flow of CSF 5-For ICP monitoring 6- For Irrigation? Causes of Increased Intracranial Pressure… Aneurysm rupture Encephalitis Head injury Intraventricular hemorrhage Status epilepticus Subdural hematoma Cerebral edema Epidural hematoma Hydrocephalus Meningitis Stroke/Intracerebral hemorrhage

9. EVD PLACEMENT PROCEDURE … 1- PATIENT POSITIONED WITH HEAD 30. 2- STERILE TEQNIQUE IS USED. 3- CATHETER INSERTED INTO THE LATERAL VENTRICLE. 4- EXTERNAL DRAINAGE SYSTEM CONNECTED. 5- DRESSING APPLIED TO PREVENT INFECTION.

10. Positioning, Zeroing and Securing the EVD … .1.check all connections and tubing's are secure ensuring that move with the head. 2. If intubated & ventilated means maintain head end elevation >30 degree. 3. Establish correct zero reference point using visual landmarking's "tragus of the ear. 4. Ensure that the chamber is at correct level on gauze as prescribed by the neurosurgeon. This should be recorded in the physician notes as well as documented in the Nurses notes ( usually set at the 10-15cmH20).

11. Equipment

12. SUBJECTIVE Symptoms (PATIENT REPORTED) HEADACHE. Nausea and Vomiting Altered Mental Status Visual Changes Dizziness or loss of photophobia Objective Signs (Clinically Observed or Measured) •Increased Intracranial Pressure (ICP) •Pupil changes (Unequal or Dilated Pupils) •Bradycardia or irregular heart rate •Hypertension •Neck stiffness •Seizure •Hemiparesis or paralysis •Changes in behavior or response to stimuli

13. Diagnostic Procedure for EVD Placement Neurological Examination : Assessment of consciousness (e.g., using the Glasgow Coma Scale), pupillary response, motor function, and overall neurological status… (Checketts.2012)

14. Imaging Studies 1. Computed Tomography (CT) Scan: CT brain scan is typically the first step for diagnosing conditions like hydrocephalus, TBI, brain hemorrhage, and brain tumors. 2. Magnetic Resonance Imaging (MRI): An MRI may be used for more detailed imaging of the brain and spinal cord, particularly in the case of tumors or abnormal brain anatomy.

15. 3. X-rays (Post-Procedure): X-rays of the skull are often used after EVD insertion to confirm the position of the catheter and ensure it is correctly placed in the ventricles.

16. Normal and abnormal condition for (EVD): CONDITION NORMAL ABNORMAL CSF APPEARANCE CLEAR AND COLORLESS CLOUDY.. BLOODY CSF INDICATE FOR INFECTION ICP LEVELS 5_15MMHG ICP>15MMHG NEUROLOGICAL STATUS IMPROVED OR STABLE MENTAL STATUS DECREASED CONSCIOUSNESS ALERT MRNAL STATUS CSF DRAINAGE STEADY AS PER SETTING NO DRAINAGE OR IRREGULAR DRAINAGE(INDICATING OF OBSTRUCTION) SIGNS OF INFECTION NO FEVER. REDNESS. SWELLING AT INSERTION SITE. FEVER. CHILLS. REDNESS. SWELLING AT THE INSERTION SITE (INFECTION) CATHETER POSITION PROPER PLACEMENT WITHOUT DISPLASMENT DISLODGMENT OR MISPLACEMENT CAUSING INEFECTIVE DRAINAGE SIGNS OF OVERDRAINAGE NO SIGNS OF DEHYDRATION OR COLLAPS OF VENTRICLES SUDDEN WORSENING OF SYMPTOMS LIKE HEADACHE. DIZZINESS. OR SUBDURAL HEMATOMA (OVERDRAINAGE). SIGNS OF UNDERDRAINAGE STEADY DRAINAGE. NORMAL ICP MANAGMENT INCREASED ICP. HEADACH. VOMITING. CSF COLORE AND CONSISTENCY CLEAR. NORMAL CONSISTENCY. CLOUDY. BLOOD_STREAKED CSF (INFECTION OR BLEEDING) GENERAL CONDITION PATIENT IMPROVEMENT OR STABLE SUDDEN WORSENING OF HEADACHE. NAUSEA. OR NEUROLOGICAL STATUS.

17. Complications of EVD..... 1.infection (fever, redness or exudate at the site) 2.blocked Drain-. inadequate drainage, tube block or accidentally clamped 3. Excess Drainage :- excessive drainage can lead tocollapsed ventricles, subdural haemorrhage or in some cases upward herniation.. 4. Fluid & electrolyte loss - sodium potassium loss5.CSF leak6.accidental removal of EVD. ( dey M, Jaffe J, Stadnik A, Awad IA. External ventricular drainage for intraventricular hemorrhage. Curr Neurol Neurosci Rep. 2012;12:24–33. doi : 10.1007/s11910-011-0231-x)

18. NURSING INTERVENTIONS..... INTERVENTIONS TO LOWER OR STABILIZE ICP INCLUDE "ELEVATING THE HEAD OF THE BED TO THIRTY DEGREES, KEEPING THE NECK IN A NEUTRAL POSITION, MAINTAINING A NORMAL BODY TEMPERATURE, AND PREVENTING VOLUME OVERLOAD“ 1.Monitor vital signs, GCS, Intake out chart & CSF drainage output chart hourly, watch for signs of ICP or LOC 2.frequently check EVD tube for any kink, blockage, if identified inform immediately to Intensivist or Neurosurgeon 3. DURING TRANSPORTATION, CHANGING THE POSITION, WHILE MAKING PATIENT SUPINE please make sure EVD in CLAMPED status.

19. Nursing care of the drain NURSING INTERVENTIONS..... Maintain the integrity and sterility of the closed system by keeping all connections tight If system becomes disconnected at catheter site, clamp catheter with a sterile clamp and notify physician or nurse practitioner Assure tubing is not kinked NEVER INJECT ANALYTHING INTO THE SYSTEM

20. NURSING INTERVENTIONS..... 4.while handling with EVD CIRCUIT Prefer aseptic precautions like Hand hygiene, Hand washing 5.EVD Sampling should be done by NEUROSURGEON (as per policy) 6.Never inject anything 7.Hourly CSF drain output monitoring, suppose there is no output in 1 hour please check interring & inform immediately to neurosurgery team, watch closely for patient GGS.. 8.level of EVD should be adjusted by the Neurosurgeon, please make sure for clear documentation 9. Follow TBI chart 10. Patient & family education

21. NURSING DIAGNOSIS..... ALTERED CONSIOUS LEVEL LOC, RELATED TO OBSTRUCTED CSF FLOW OR BRAIN DAMAGE. INEFFECTIVE BREATHING PATTERN DYSPNEA RELATED TO ALTERED SENSORIUM. RISK FOR INFECTION OPEN DRAIN RELATED TO LACK OF KNOWLEDGE. ALTERED NUTRITIONAL STATUS RELATED TO DECREASED INTAKE. RISK FOR HYPERTHERMIA OR HYPOTHERMIA RELATED TO ALTERED THERMOREGULATION OR INFECTION.

22. Documentation… It is imperative that the management of the drain is documented hourly. Follow TBI chart...Hourly documentation must include: Drain status (e.g. clamped/unclamped).,, Drain levelled (e.g. tragus/ mid sagittal line). Drain height (cmH2O). Hourly output (mL)., CSF appearance (e.g. rosé, clear, cloudy), the drain oscillating?, Patient position (e.g. supine, lateral, sitting up in chair). Patient state (e.g. alert, crying, settled, c/o headache).Dressing status (e.g. dry and intact, old ooze)., Dressing Intervention.

23. In conclusion… Conclusion Maintain sterility when handling EVD Accurate charting of amount and pattern of drainage To convert to internal CSF diversion system as early as possible Single broad-spectrum antibiotics as prophylaxis is useful to prevent CSF infection Regular change EVD does not change CSF infection rate Antibiotic-impregnated shunt catheters may lower CSF infection rate

24. REFERECE…. 1-Bisnaire D, Robinson L. Accuracy of levelling intraventricular collection drainage systems. J Neurosis Nur's. 1997;29:261–8. Doi: 10.1097/01376517-199708000-00008. [DOI] [PubMed] 2-.Brown PD, Davies SL, Speake T, Millar ID. Molecular mechanisms of cerebrospinal fluid production. Neuroscience. 2004;129:957–70. Doi: 10.1016/j.neuroscience.2004.07.003. [DOI] [PMC free article] [PubMed] 3-Czosnyka M, Pickard JD. Monitoring and interpretation of intracranial pressure. J Neurol Neurosurgeon Psychiatry. 2004;75:813–21. Doi: 10.1136/jnnp.2003.033126. [DOI] [PMC free article] [PubMed] 4.Dey M, Jaffe J, Stadnik A, Awad IA. External ventricular drainage for intraventricular hemorrhage. Curr Neurol Neurosis Rep. 2012;12:24–33. Doi: 10.1007/s11910-011-0231-x. [DOI] [PMC free article] [PubMed] 5-(Checketts.2012) 6-(dye M, Jaffe J, Stadnik A, Awad IA. External ventricular drainage for intraventricular hemorrhage. Curr Neurol Neurosis Rep. 2012;12:24–33. Doi: 10.1007/s11910-011-0231-x)..