Clinical Guidelines (Nursing)

Ventricular Reservoir Management in Neonates

  • Introduction

    Intraventricular haemorrhage (IVH) secondary to bleeding from the fragile blood vessels of the germinal matrix is associated with serious morbidity including post-hemorrhagic hydrocephalus, which can result in poor outcomes including cognitive deficits, disability and mortality. Controlled serial aspiration of cerebrospinal fluid (CSF) by tapping a surgically placed ventricular reservoir can successfully decompress the ventricular system of a preterm infant while awaiting placement of a ventriculo-peritoneal shunt. 
    The tap is to be performed by a Doctor or Neonatal Nurse Practioner (NNP).

    Aim

    • To provide a guide for nursing staff on what to prepare for a Rickhams tap and the management of an infant undergoing a tap.
    • To provide a guide for Doctors on how to perform a tap on a ventricular reservoir.

    Assessment

    • Head circumference prior to procedure
    • Follow Neurosurgery recommendations regarding frequency of reservoir tap based on assessment and recent cranial ultrasound
    • Perform a clinical nursing assessment on the infant: (link to Clinical guideline nursing assessment)

    Indications

    • Rapidly increasing head circumference, more than 1cm/week
    • Clinical indication of raised intracranial pressure such as full or tense anterior fontanelle, split sutures, lethargy, poor feeding, vomiting or apnoea/bradycardia
    • Ultrasound evidence of progressive ventriculomegaly

    Complications

    No consent is required but parents should be advised of the benefits and potential complications associated with the procedure:

    • Infection 
    • Apnoea, bradycardia or hypotension associated with low circulating blood volume
    • Skin break down over reservoir site

    Management

    Analgesia

    Monitoring 

    Position

    • Infant should be swaddled/restrained comfortably with the head in a neutral position

    Precautions

    Equipment

    • One person to hold patient’s head in place
    • Mask, cap, sterile gloves
    • Sterile drapes and procedure tray
    • Skin preparation: chlorhexidine 0.5% in isopropyl alcohol 70% 
    • CSF tubes (number will depend on volume collected) 
    • 25 or 27 gauge butterfly needle
    • 20 ml syringe 

    Preparation

    • Wash hands
    • Aseptically put on gown and sterile gloves
    • Prepare skin using chlorhexidine 0.5% in isopropyl alcohol 70% clean skin over the reservoir site in a 5cm radius and allow cleaning solution to dry prior to inserting needle
    • Take the tops of the CSF tubes whilst maintaining sterility

    Procedure

    To be performed by Doctors/NNP’s only

    • Insert butterfly needle (with syringe attached) at an angle of 30-45 degrees through the skin into the bladder of the reservoir.
    • Remove 10 mls/kg unless otherwise specified by neurosurgery. Slowly aspirate over 20 minutes.
    • Remove needle and hold pressure for 2 minutes over insertion site
    • Send CSF samples for microscopy, protein, glucose and culture. See CSF interpretation guideline
    • Document the procedure in the patient’s chart.  

    The neurosurgeons may leave a butterfly needle insitu with the line end and three way tap secured in an Integra Stopcock Protection Box. To perform a tap prepare as above:

    • Assistant to open the Integra Stopcock Protection Box and hold the line in the air.
    • Doctor to place sterile towel under the line and clean the 3 way tap
    • Perform sterile cleaning of 3 way tap with Chlorhexidine 0.5% in Alcohol 70% solution and allow antiseptic solution time to dry completely (this can take up to two minutes).
    • Remove cap from 3 way tap and attach syringe.
    • Open 3 way tap to patient.
    • Remove 10mLs/kg unless specified by neurosurgery. Slowly aspirate over 20 minutes.
    • Turn 3 way tap off to patient.
    • Place new red cap onto 3 Way tap.
    • Assistant to fill Integra Stopcock Protection Cox with Betadine using a syringe.
    • Doctor to place 3 way tap and line into Integra Stopcock box and assistant to close box.

    Post procedure

    • Monitor for signs of raised intracranial pressure.
    • Observe site for signs of bleeding or infection.
    • Observe site for signs of CSF leaking – visible clear fluid on or around needle entry site, report to AUM/Doctor if this is seen
    • If Integra Stopcock Protection Box used – observe dressing and system hourly for signs of dislodgement. Notify Doctor immediately if dislodgement occurs.

    Potential complications

    • Bradycardia, pallor and hypotension: Stop aspiration. Infuse 10-15 ml/kg of normal saline IV rapidly. At the next tap consider removing a smaller volume at a slower rate.
    • Hyponatremia: Monitor serum and urinary electrolytes regularly (every second day to once a week as required) and supplement as necessar
    • Hypoproteinemia: Monitor protein intake weekly and provide adequate protein intake

    Evidence table

    Complete evidence table for this guideline is found here

    References

    • Kormanik, K., Praca, J., Garton, H.J.L and Sarkar, S. (2010). Repeated tapping of ventricular reservoir in preterm infants with post hemorrhagic ventricular dilatation in preterm infants with post-hemorrhagic ventricular dilatation does not increase with the risk of reservoir infection. Journal of Perinatology 30, 218-22
    • MacDonald, M.G. and Ramasethu, J. (2007). Tapping ventricular reservoirs. Atlas of Procedures in Neonatology 4th edition, pp 366-368
    • Western Neonatal Network Guideline group (2012). Guidelines for the assessment and management of post-haemorrhagic ventricular dilatation neonates and infants. http://nestteam.org/attachments/File/Guidelines

    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Joanne Scott, NP, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2016.