Clinical Guidelines (Nursing)

External ventricular drains and intracranial pressure monitoring


  • Introduction

    The cranial vault contains brain tissue, blood and cerebrospinal fluid (CSF). The cranial vault is similar to a rigid box. As the volume of the three components within the skull (brain matter, blood and CSF) must remain equal, an increase in one component there must be accompanied by a decrease in another component. If there is not, an increase in intracranial pressure (ICP) will occur. 


    ICP can be monitored via a fibre optic monitor (Codman monitor) which is placed on the surface of the brain or in the brain or an external ventricular drain (EVD) system which is a closed sterile system allowing drainage of CSF via a silastic catheter tip which rests in the anterior horn of a lateral ventricle.


    The ventricular system produces CSF at approximately 25ml/hr (estimated at 0.35mls/kg/hr in children) by the choroid plexus in the lateral ventricles. The CSF circulates around the brain and spinal cord and is then reabsorbed via the arachnoid villi. The normal range of ICP is 0-15mmHg with the upper limit being 20mmHg.


    Aim

    This guideline is aimed at RCH staff involved in the use and management of EVD and ICP monitoring.


    Definition of terms

    • External ventricular drain (EVD): A temporary system that allows drainage of cerebral spinal fluid (CSF) from the ventricles to an external closed system
    • Intracranial pressure (ICP) monitoring: A temporary device allowing measurement and recording of intracranial pressur
    • Intracranial Pressure (ICP): Pressure within the skull. Contributed to by volume of brain tissue, CSF and blood
    • Cerebral Perfusion Pressure (CPP): Pressure of blood perfusing the brain. CPP= Mean Arterial Pressure (MAP) – ICP. Normal range is age dependant: see later in guideline for details
    • Lumbar drainage devices: A temporary device allowing drainage of cerebral spinal fluid (CSF) from the subarachnoid space to an external closed syste
    • Hydrocephalus: An abnormal accumulation of cerebral spinal fluid in the ventricles within the brain
    • Meningitis: An inflammation of the protective membranes that surround the brain
    • Standard Aseptic:


    Indications

    Indications for an EVD or ICP monitor can include hydrocephalus, haemorrhage, tumour, meningitis or traumatic brain injury.


    Contraindications

    An EVD / ICP monitor is contraindicated in the following circumstances:

    • The patient is receiving anticoagulation therapy or who is known to have coagulation problems 
    • The patient has a scalp infection
    • The patient has a brain abscess 


    Assessment

    Physical assessment including completing ABCD and neurological assessment on the paediatric patient with an EVD/ICP monitor and documenting is required at the beginning of each shift and PRN in relation to the patient’s condition. See Nursing Assessment Clinical Practice Guideline for more information. 


    Increased ICP is usually referred to as above 15mmHg. Common clinical signs of early intracranial hypertension include: vomiting, irritability, headache, seizures, photophobia, lethargy, nystagmus, and diplopia.


    With severe intracranial hypertension, consciousness is depressed, tone and reflexes of the limbs are altered, pupils enlarge, papillary reaction to light is sluggish and spontaneous movement of the limbs is decreased. Signs may be unilateral or bilateral depending on the cause of the intracranial hypertension. At a pre-morbid high level of ICP, spontaneous respiration is depressed, hypertension occurs and heart rate is slowed, this is known as Cushing’s triad. Infants who have non-fused suture lines with open fontanel’s have a degree of compensation before signs of increased ICP are evident.


    Management

    Management of raised ICP may include drainage of CSF if an EVD is in place. Other management may include urgent surgical decompression, administration of an osmotic agent (e.g., mannitol), diuretic, temporary mechanical hyperventilation (which lowers CO2 tension in blood and causes cerebral vasoconstriction), serum sodium maintained at 140-145, sedation and muscle relaxation (PICU/NICU only), and therapeutic hypothermia.

    When an ICP monitor has been inserted in the operating theatre, upon admission to the recovery room or return to the PICU, NICU or Cockatoo ward, it is imperative that the patient be monitored closely with routine post anaesthetic observations as per operation notes and neurological assessment. See Routine Post Anesthetic Observations Clinical Practice Guideline.


    External ventricular drains

    Setting Up

    Patients will usually arrive on the unit from the operating theatre with the EVD insitu, if the EVD is not set up; seek advice from the AUM, CNF or CNS.


    Mandatory Checks (Treatment Orders)

    At the beginning of each shift it is the responsibility of the nurse RN caring for a patient with an EVD to complete the following mandatory safety checks:

    • Patient has a valid EVD treatment order;
    • Reportable limits are noted and adhered which is patient specific 
    • EVD drainage point is set at the prescribed level (as per Neurosurgeon documentation in postoperative orders) 
    • EVD transducer is leveled to the patient’s external auditory meatus (Tragus)
    • EVD column is oscillating and patent
    • ICP waveform is pulsatile on monitor
    • Head dressing is dry and intact 
    • Observe and record volume level of CSF in burette 
    • Report any signs of changes in patient’s neurological condition to medical staff. 


    Documentation

    It is imperative that the management of the drain is documented hourly.
    Hourly documentation must include:

    • Level of CSF in burette
    • Hourly Drainage
    • Progressive total for 24 hour period
    • Is the drain oscillating?
    • Is the dressing dry and intact?
    • Height of EVD in cm’s of H2O
    • Has the EVD been leveled to the Foramen of Monro (FOM)


    Levelling the EVD system

    Introduction

    The pressure transducer of the EVD must be maintained at the same horizontal level as the ventricles to ensure reliable interpretation of its value. The laser level device should be in line with the patient's Foramen of Monro (FOM). If the patient is supine, level the EVD system to the tragus of the ear. If the patient is lateral, level the EVD to the mid sagittal line (between the eyebrows). Every time the patient moves the EVD must be releveled.


    Errors in positioning the transducer

    • Too far above the FOM will lead to a falsely low ICP measurement and insufficient drainage of CSF - in this case intracranial hypertension would go undetected and untreated.
    • Too far below the FOM will lead to a falsely high ICP measurement and excessive drainage of CSF - with subsequent collapsing of the ventricles with perhaps blockage of the system and unnecessary other treatment.


    Procedure

    1. Explain to the patient/family what is about to occur
    2. Turn on the laser (protect the child’s eyes from the laser) 
    3. Ensure the spirit level is horizontal 
    4. Alter the height of the entire EVD system to bring the transducer laser horizontal with the patient’s FOM (supine = tragus of the ear, lateral = mid sagittal line, between the eyebrows)
    5. This procedure needs to be followed at the beginning of the shift, hourly and every time the patient moves or is moved **Parents and untrained staff are NOT to alter EVD including clamping or unclamping


    CSF Sampling from the EVD

    Introduction

    CSF sampling must be conducted using standard aseptic technique every 24 hours (preferably in the AM) unless otherwise indicated by the Neurosurgeon. The procedure will require 1 – 2 registered nurses who are competent and confident with this procedure, having previously completed their EVD and CVAD competencies.


    N.B. If patient has minimal drainage: consider clamping EVD 10 – 15 minutes prior to sampling to assist with collection of CSF as the patients ICP will increase enabling a sample to be obtained more easily. To maintain patient safety ensure this is discussed with AUM. 

    Under no circumstances is a sample to be obtained via aspiration, as the risk of aspirating brain parenchyma exists.


    Equipment 

    • Key parts: Sterile Dressing Pack, 10ml Syringe,1 Red Cap, Extra Gauze
      If emptying CSF collection bag – require, collection jug and one extra red cap
    • Key Site Disinfectants: Chlorhexidine 0.5% in Alcohol 70%, Betadine Solution 
    • Personal protective equipment (PPE): Sterile Gloves, goggles
      Sterile CSF tubes

    See: RCH Aseptic Technique Policy (RCH access only)


    Procedure

    1. Explain to the patient/family what is about to occur 
    2. Perform Hand Hygiene
    3. Clean trolley/work surface with detergent and water or impregnated wipe
    4. Identify and collect all equipment for procedure
    5. Perform Hand Hygiene
    6. Open procedure pack/tray by using corners
    7. Peel open sterile equipment and drop onto sterile field using non touch technique
    8. Perform Clinical / Procedural Handwash with antimicrobial soap and don Sterile Gloves
       - Perform procedure ensuring all key parts are protected
       - Sterile items are used once and disposed of into waste bag
       - Only sterile key parts should contact disinfected or sterile key sites
       - Sterile items should not come into contact with non-sterile items 
    9. Ensure the EVD is off to the patient 
      - Assistant RN to clamp the EVD and remove old Integra Stopcock Protection Box furthest from the patient and hold line in air 
      - Assistant RN to ensure 3 way tap at base of CSF collection chamber is closed to the collection bag 
      - Assistant RN to lift line and Operator RN to place sterile towel under line 
      N.B If collection bag needs to be emptied after CSF specimen is taken, also clean the access hub at the base of the bag with Chlorhexidine 0.5% in Alcohol 70% solution and allow antiseptic solution time to dry completely, (this can take up to 2 minutes), AFTER you have collected the specimens then remove red cap and drain CSF into collection jug and replace with new sterile red cap.  Ensure CSF is discarded into pan flusher.
    10. Operator RN to disinfect key part of Medtronic Exacta EVD kit 3 way tap with Chlorhexidine 0.5 % in Alcohol 70% solution and allow antiseptic solution time to dry completely, (this can take up to 2 minutes)
    11. Cover with dry sterile gauze the key part cap from side access hub (usually red cap) to be removed and discard
    12. Check the 3 way tap is off to the EVD system, therefore open to the patient (to collect to freshest CSF)
    13. Collect minimum of 1.0 mL (around 10 drops) CSF in sterile CSF tube. Never aspirate CSF from an EVD, allow drops to drip out
    14. Turn 3 way tap off to side access hub
    15. Place new red cap on side access hub
    16. Open 3 way tap from the patient to the drain
    17. Assistant to open both Integra Stopcock Protection Boxes and fill with Betadine Solution using syringe, close boxes 
    18. Ensure the EVD transducer is at a horizontal level to the Foramen of Monro 
    19. Turn the EVD on and ensure drain is oscillating / draining 
    20. Remove gloves and perform hand hygeine
    21. Clean trolley, dispose of waste and perform Hand hygiene
    22. Label and Send specimens
    23. Document procedure


    Dressing changes

    Dressings of the EVD site need to be observed hourly and this documented to ensure a leak has not occurred. If a leak is identified, place pressure combine/dressing and notify the AUM and Neurosurgical team. Dressings should be changed using sterile technique when soiled or otherwise directed by Neurosurgical team.


    Changing the EVD system set 

    The entire system needs to be changed using sterile technique every 7 days. The procedure will require 2 registered nurses who are competent and confident with this procedure.


    Equipment

    Sterile Dressing Pack and extra Gauze, Chlorhexadine 0.5 % in Alcohol 70%, Sterile Gloves, 2 Sterile Integra Stopcock Protection Boxes (External reference number 901400), Medtronic Exacta EVD Kit (Stores Number 309634), 0.9 % Normal Saline, 10ml and 20ml Syringes, Drawing Up Needle, Betadine Solution, Forceps


    Procedure

    Link: Aseptic Technique Policy & Procedure (RCH access only) 

    1. Explain to the patient/family what is about to occur 
    2. Perform Hand Hygiene
    3. Clean trolley/work surface with detergent and water or detergent wipe
    4. Identify and collect all equipment for procedure
    5. Perform Hand Hygiene
    6. Open procedure pack/tray by using corners
    7. Peel open sterile equipment and drop onto sterile field using non touch technique
    8. Perform Clinical / Procedural Hand wash with antimicrobial soap and don Sterile Gloves
        - Perform procedure ensuring all key parts are protected
        - Sterile items are used once and disposed of into waste bag
        - Only sterile key parts should contact disinfected or sterile key sites
        - Sterile items should not come into contact with non-sterile items 
    9. Operator RN Prime Medtronic Exacta EVD kit with 0.9% Normal Saline (ensuring all 3 way taps are primed and the system has no air in it)
    10. Fill Integra Stopcock Protection Boxes with Betadine Solution using syringes 
    11. Assistant RN clamp/turn off the EVD and remove old Integra Stopcock Protection Box closest to the patient and hold line in air
    12. Assistant RN to use forceps and gauze to clamp Silastic tubing as close to the patient’s head as possible and remove old Medtronic Exacta EVD kit from laser level device
    13. Assistant to raise line and Operator to place sterile towel under line 
    14. Operator RN to clean the connection between Medtronic Exacta EVD set and silastic tubing with Chlorhexidine 0.5 % in Alcohol 70% solution and allow antiseptic solution time to dry completely (this can take up to 2 minutes)
    15. Disconnect old line (discard in infectious waste at end of procedure) 
    16. Connect new Medtronic Exacta EVD kit to the patient 
    17. Ensure connection is secure 
    18. Apply new Integra Stopcock protection boxes to both sections of the Medtronic Exacta EVD kit 
    19. Fill both Stopcock boxes with Betadine solution and close both boxes
    20. Ensure line is open to the patient (draining to the burette) 
    21. Load new Medtronic Exacta EVD kit into laser level device at appropriate H20 level / height as per Neurosurgeon’s instructions 
    22. Remove forceps from silastic tubing at patient’s head 
    23. Ensure Medtronic Exacta EVD kit is leveled to the patient’s FOM 
    24. Turn on EVD and ensure it is oscillating or draining 
    25. Remove gloves and perform HH
    26. Clean trolley, dispose of waste and perform HH


    Complications of EVD’S

    • Infection: As with any foreign body, potential for infection is possible, however, prophylactic antibiotics are recommended; generally Cephazolin 10-15mg/kg 8 hourly is prescribed until the EVD is removed. If any of the signs of infection are observed (fever, redness or exudate at the site), inform the AUM and Neurosurgical team. A CSF sample may need to be obtained. 
    • Blocked Drain: If CSF output is less than documented reportable limits, the EVD is not oscillating, or the ICP waveform is flat, the Neurosurgeon must be contacted immediately. Inadequate drainage of CSF may lead to an increased ICP. This can be due to a variety of reasons: a blockage in the system; accidentally clamped EVD; dislodgement from within the ventricles; CSF leak or rising pressure.  Ensure the AUM and Neurosurgeon are notified (and PICU consultant if patient in PICU), and the patient is observed for signs of increased ICP.
    • Excess Drainage: If drainage exceeds reportable limits the Neurosurgeon must be contacted as the risk of excessive drainage can lead to collapsed ventricles or a subdural haemorrhage.  This can be prevented in some instances by intermittently clamping the EVD if the patient has a transient increase in ICP e.g. crying, vomiting, coughing, sudden change in position or straining. This is only a very short-term management and must be done in consultation with the AUM/ PICU consultant (if in PICU).
    • Fluid and Electrolyte Imbalance:
      • Patients with an EVD are losing CSF, which the body would normally reabsorb. With Neurosurgeon direction, CSF losses may be replaced ml for ml with 0.9% Normal Saline. Patients with an EVD may require daily full blood count and urea and electrolyte measurements to ensure electrolyte stability.
      • For neonates on Butterfly Ward, if the CSF volume drained reaches 20ml/kg within a 24 hour period, then it must be replaced ml for ml. The previous 4 hours of losses, and subsequent losses should be replaced ml for ml with 0.9% normal saline IV over the following 4 hours until the CSF loss is less than 20ml/kg within a 24 hour period. The 24 hour measurement period is midday to midday, and volumes are measured 4 hourly.
    • CSF Leak: If the patient has visible clear fluid on or around the entry site, this must be reported to the AUM and Neurosurgeon. 
    • Accidental Removal of EVD: If the EVD is accidentally dislodged from the patient’s head, obtain sterile gauze and apply pressure to the wound site.  Consider a pressure bandage. The Neurosurgery team must be contacted immediately to review the patient and implement the appropriate management.

    Removal of EVD

    1. Clamping EVD- Prior to removal of the EVD the Neurosurgery team may ask for the drain level to be altered or clamped, this needs to be clearly documented.
    2. Once the patient has the EVD clamped, observe for signs and symptoms of increased ICP, CSF leak at dressing site and ensure the dressing is dry and intact.
    3. Removal of EVD- When it is determined that the patient can have the EVD removed; this is completed by a member of the Neurosurgery team on the unit. The procedure is completed in the treatment room, under sterile conditions with appropriate pain relief, distraction and staff assistance.  Post removal of the EVD ensure the patient and wound site are observed and the dressing remains dry and intact.


    ICP monitoring via the EVD

    If the patient with a Medtronic Exacta EVD requires ICP monitoring, attach and prime with 0.9% Normal Saline, via sterile procedure, attach the ICP transducer (Stores Number 7291) to the Medtronic Exacta EVD system at the three way tap parallel to the burette.


    ICP monitoring

    Codman Monitor (ICP Express) – is a device which enables measurement of pressure via a pressure transducer and fibre optic cable but it does not have the ability to drain CSF as an EVD does. The monitor is usually placed in an extra-axial position (surface of the brain, eg subdural space) but it may be placed within the brain (parenchymal position) or within the CSF.


    Mandatory checks (treatment orders)

    At the beginning of each shift it is the responsibility of the RN caring for a patient with an ICP monitor to complete the following mandatory safety checks:

    • Ensure the patient has a completed valid and correct treatment order
    • Zero the ICP monitor (ensure this is strictly completed at the beginning of a shift – press the “0” function button on the ICP monitor to do this) 
    • Ensure head dressing is dry and intact 
    • Ensure reportable limits are set on monitor and adhered to 
    • Report any signs of changes in patient condition to medical staff 


    Documentation of ICP

    • Record ICP level hourly and document patients state e.g. asleep, crying, c/o headache
    • For a Codman monitor, the reading is taken directly from the Codman monitor (this should also correlate with the Phillips monitor– if not recalibrate/zero the machine, may need to enter the 3 digit reference code
    • If the ICP is being printed, document on the printout every hour the patient’s ICP and patient’s position 
    • If the patient ICP has a spike(s) (increased ICP reading), ensure this is documented at the time and add a description of the patient’s activity, inform the AUM and/or Neurosurgical team where required. 


    Setting up the ICP monitor

    There are two types of ICP monitoring, Codman and via an EVD. A Codman is utilized when ICP monitoring is needed without the need to drain CSF, e.g. investigation of headache. ICP monitoring can also be conducted via an EVD with the benefit of being able to drain excess CSF when necessary.


    To enable printing with an ICP monitor, the ICP needs to be displayed on a large Phillips Screen.


    ICP paper set up

    1. Turn the monitor on ensure appropriate ICP cords and transducer box are available 
    2. Set appropriate alarm limits (including ICP limits) 
    3. To load paper for printing of ICP, locate the printer at the left hand side of the monitor 
    4. Turn the printer on, open paper door, load ICP paper into paper slot 


    ICP Printing

    1. Connect ICP cable (either Codman or EVD) to transducer pack on Phillips monitor 
    2. On the main screen on the Phillips monitor press the recordings touch screen button
    3. Then press High Res ICP touch screen button
    4. Printing should commence at this point


    Zeroing

    It is essential when monitoring ICP that the transducer is calibrated to the monitor at a minimum of once a shift (preferably the commencement of a shift). If this is not performed strictly, the variation in ICP reading can be up to +/- 2mmHg outside of the true ICP.


    Codman ICP zeroing


    Codman monitor should be connected to Phillips  monitor via ICP monitor cable into transducer 

    1. Turn the Codman monitor on and press ‘0’ 
    2. On the Phillips monitor, press the ‘Zero’ button 
    3. Press ‘Menu’ on the Codman monitor once zero has been displayed on the Codman and Phillips monitor- follow the automatic instructions on the screen
    4. Press the ‘20’ on the Codman monitor and wait until 20 is displayed on the Codman and Phillips monitor- follow the automatic instructions on the screen
    5. To manually zero the Codman, enter the 3 digit reference code (found on post operative notes) 
    6. On completion press the ‘Menu’ key 
    7. The ICP must be zeroed at the commencement of each shift
    8. Check alarm is turned on via main menu 
    9. Ensure appropriate alarm ICP limits are set, in accordance with postoperative orders/treatment orders


    * NB the reference range will be documented on the inpatient notes or in the patient’s post-operative orders.


    EVD / ICP zeroing

    1. ICP transducer must be connected to the monitor via an ICP cable to the Phillips monitor
    2. Wash your hands and ensure a non-touch technique 
    3. Turn the 3 way tap on the EVD system off to the rest of the system (leaving the system open to the transducer only) 
    4. Remove a cap (white or yellow) to open the transducer to the atmosphere 
    5. There are 2 ways to zero the ICP Monitor:
    6. Press the ‘Zero’ button on the monitor transducer twice, you should hear a beep/ press the ICP scale on the monito
    7. Press zero while the EVD transducer is still open to the atmosphere. Press the button twice and the machine will beep once completed 
    8. The screen should say ICP zeroed and have the time and date
    9. The ICP must strictly be zeroed at the commencement of shift
    10. Ensure appropriate alarm ICP limits are set


    Reading ICP

    Reading with an EVD

    • When measuring and documenting ICP in a patient with an open EVD, it is crucial that the drainage to the burette system be clamped, enabling a true ICP reading to be obtained from the patient (otherwise the drainage pressure will be recorded).  
    • Wait for the waveform to stabilize prior to documenting the reading (approximately 1 minute).
    • Continuous CSF drainage and ICP measurements cannot be measured simultaneously  (ICP cannot be measured if the EVD is on continuous drainage) 
    • Ensure the EVD is then reopened to allow continuous drainage 


    Normal ranges/reportable limits


    Intracranial Pressure is the pressure exerted by the CSF, which circulates from the ventricles around the brain and spinal cord. The normal range of ICP is 0-15mmHg; increased ICP is usually referred to as above 15mmHg (refer to assessment section for clinical signs). 
     It is essential to refer to the reportable limits specific to the patient and notify the AUM / Neurosurgery team if a patient has a sustained increase in ICP or changes are noted during their regular observations.
    Cerebral perfusion pressure (CPP=Mean arterial pressure-ICP) is also measured in patients whilst admitted to PICU with an ICP monitor. Adequate CPP is required to ensure the brain is being well perfused therefore receiving oxygen and important substrates. Inadequate CPP should be reported to the PICU consultant and AUM. Inadequate CPP may be due to elevated ICP, low BP or a combination of both and should be managed according to the underlying problem.


    Normal range for CPP is age dependant:

    • Neonate:>30mmHg
    • 1 month-6 month: >35mmHg
    • 6 month-11 month: >40mmHg
    • 1 year-4 year: >45mmHg
    • 5 years-9 years: > 50mmHg


    Ensuring a true ICP reading with an EVD

    • Continuous CSF drainage and ICP measurements cannot be measured simultaneously. Therefore when documenting the ICP level in a patient with an open EVD it is crucial that the EVD be clamped to the burette system, enabling a true ICP reading to be obtained from the patient.  Wait for the waveform to stabilize prior to documenting the reading (approximately 1 minute).
    • Ensure the EVD is then reopened to allow continuous drainage.


    Dressing changes

    Dressings of the ICP site need to be observed hourly and this documented to enable early detection of any leak. If a leak is identified, place pressure combine/dressing and notify the AUM and Neurosurgical team. Dressings should be changed sterilely as per Neurosurgeon or when soiled.


    Complications

    • Dislodgement: The fiber optic catheter may become dislodged from its correct position and cause an inaccurate ICP reading or a CSF leak.
    • Infection: As with any foreign body potential for infection is possible. The literature suggests that infection rate is very low however prophylactic antibiotics, generally Cephazolin 10-15mg/kg 8 hourly is prescribed with ICP monitoring until the catheter is removed.


    Removal of ICP monitor line

    When it is determined that the patient can have the ICP catheter or device removed, this is performed by a member of the Neurosurgery team on the unit. The procedure is performed in the treatment room, under sterile conditions with appropriate pain relief, distraction and staff assistance. Ensure the site remains dry and no sign of CSF leak is evident.


    NB. Please clean and return all equipment (EVD measuring set, pole and Codman devices) to theatre upon finishing with patient monitoring.   


    Lumbar drainage devices

    Lumbar drains can be indicated for insertion to assist with CSF leaks, evaluate the effect of reduced CSF pressure or as a temporary external shunt. As lumbar drains use the same circuits as EVD’s the management remains consistent with that of an EVD. However, the zero-point of lumbar drains is the insertion site, the drain will be most often at mattress level/ bed height therefore level with insertion site, and the patient is required to lay supine (flat on their back) to ensure accurate measuring.  The Neurosurgical team will document parameters, drainage height or drainage volume.


    Transportation 

    When patient with an EVD is being transported off the ward, the patient MUST be accompanied by an accredited RN. This RN must stay with patient at all times until handed over to another accredited person. 


    ** Parents are not to be taught how to clamp the EVD, an accredited RN or doctor are only to handle the EVD.  


    References

    • Adelson. P., et al. (2003). Intracranial pressure monitoring. Paediatric Critical Care, 4(3) (suppl.):S28–S3
    • Bisnaire D, Robinson L. (1997). Accuracy of Levelling Intraventricular Collection Drainage Systems. Journal of Neuroscience Nurses 29(4):261–26
    • Iacono L. (2000). Exploring the guidelines for the management of severe head injury.Journal of Neuroscience Nurses 32(1): 54–60
    • Medtronic. (2011). Medtronic, exacta TM external drainage and monitoring system quick reference guide. Medtronic Inc.
    • Pope W. (2007). External Ventriculostomy: a practical application for the acute care nurse.  American Association of Neurosciences Nurses 30(3):185–19
    • Richardson. J., et al.(2012) External ventricular device guideline (EVD). Royal Hospital for Sick Children PICU-Neurosurgery: 1-16
    • Royal Children’s Hospital. (2008). Central venous access device insertion and management. Royal Children’s Hospital, Hospital Clinical Guidelines: 1-
    • Shann F. et al (2008). Paediatric Intensive Care Guidelines. Intensive Care Unit, Royal Children’s Hospital. Collective Pty Ltd
    • Slazinski. T., et al. (2011) Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage. American Association of Neuroscience Nurses: 1-3
    • Tippett. N. (2006). Intracranial pressure (ICP) monitoring and extraventricular drains (EVD). Bayside Health, Alfred ICU: 1-1
    • Western Health Sydney. (2003). Collection of CSF from a ventricular drain: Intensive care, evidence based practice guideline
    • Williams. DG, Hayes. J, McCool S. (1996). Shunt infections in children; presentation and management. Journal of Neuroscience Nursing 28(3):155–16
    • Yanko.J, Mitcho. K. (2001). Acute management of severe traumatic brain injuries. Critical Care Nurses 23(4):1–23


    Evidence table

    External Ventricular Drains and Intracranial Pressure Monitoring evidence table.


    Links

    Nursing Competency Workbook- External Ventricular Drains and Intracranial Pressure Monitoring

    Medtronic: Exacta- external drainage and monitoring system- quick reference guide

    Aseptic Technique Procedure

    RCH Clinical Practice Nursing Guideline: Nursing Assessment

    RCH Clinical Practice Nursing Guideline: Routine Post Anesthetic Observations 


    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Sinead O'Flaherty, RN, Michelle Taverna, ANUM & Jess Ellis, Clinical Nurse Facilitator, all of Cockatoo Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2016.