Note: This guideline is currently under review.

Introduction

Aim

Definition of Terms

Indications

Assessment

Contraindications

Complications

Procedure

Equipment

Preparation

Procedure

Potential complications

Evidence table

References

Introduction

Hydrocephalus is a condition characterised by excessive accumulation of cerebrospinal fluid (CSF) within the ventricular system of the brain causing increased pressure within the skull. Hydrocephalus can be present at birth (congenital) or occur as a result of injury (acquired). 

The most common cause of hydrocephalus is post-haemorrhagic hydrocephalus which may result in poor outcomes including cognitive defects, disability and mortality. A ventricular shunt is often required to decompress the ventricular system to alleviate symptoms of raised intracranial pressure. The procedure involves the surgical placement of a catheter into one of the lateral ventricles which is connected to a reservoir implanted under the scalp. The reservoir can then tapped and controlled serial aspiration of CSF attended whilst the need for a more permanent ventriculoperitoneal shunt is evaluated. 

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.

Definition of Terms

• Cerebrospinal Fluid: clear, colourless liquid that fills and surrounds the brain and the spinal cord.
  
• Hydrocephalus: a condition characterised by excessive accumulation of cerebrospinal fluid within the ventricular system of the brain causing increased pressure within the skull.
  
• Ventricular Reservoir: a device that can be implanted into the brain which is used to administer medications and/or to retrieve cerebrospinal fluid.
  

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

Assessment

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

Contraindications 

• Clinical instability of vital signs
  
• Coagulopathy
  
• Electrolyte imbalance
  
• Local signs of infection or skin breakdown related to reservoir
  
• Concerns of CSF over-drainage clinically or on ultrasound imaging
  

Complications

Parents should be informed and consented, prepare the patient ensuring that they have been advised of the benefits and potential complications associated with the ventricular reservoir tap:

• Infection 
  
• Apnoea, bradycardia or hypotension associated with hypotension
  
• Skin break down over reservoir site
  
• Bradycardia, pallor and hypotension: The Doctor/NNP should immediately stop aspiration and order 10-15 mL/kg of normal saline IV to be infused rapidly
  
• Hyponatremia: Monitor serum and urinary electrolytes regularly (every second day to once a week as required) and supplement as necessary
  
• Hypoproteinemia: Monitor protein intake weekly and provide adequate protein intake
  

Procedure

Analgesia

• Non-pharmacological techniques such as positioning, containment holding and non-nutritive sucking
• Oral sucrose should be used for infants < 18 months (see Nursing guideline: oral sucrose for infants guideline)
  

Monitoring 

• Maintain continuous cardiorespiratory monitoring (see: Nursing Clinical guideline: Observations and Continuous Monitoring) during the procedure and for four hours post procedure
• Observe for signs of raised intracranial pressure post procedure
  

Position

• Provide developmental swaddling and positional support to the infant, ensuring that the head remains in a neutral position Precautions
  
• Avoiding puncturing the bottom of the reservoir 
  
• Always use a fresh site for insertion of every tap
  

Using Surgical aseptic technique (see Aseptic technique policy and procedures (RCH access only))

Equipment

• One person to hold patient’s head in place
  
• Operator (Doctor/NNP) to wear 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 gauge butterfly needle
  
• 20 mL syringe
  

Preparation

• Perform hand hygiene 
  
• Clean trolley/work surface and prepare waste bag
  
• Perform hand hygiene 
  
• Identify and collect all equipment for procedure
  
• Perform hand hygiene
  
• Aseptically peel open sterile equipment and drop onto critical aseptic field
  
• Perform hand hygiene, apply sterile gloves, set up aseptic key parts.
  
• Prepare skin key site using dual agent skin disinfectant such as chlorhexidine 0.5% in isopropyl alcohol 70%. Apply skin preparation over the reservoir site in a 5cm radius x3 times and allow skin disinfectant to dry.
  
• Perform procedure protecting all key parts
  
• Take the tops of the CSF tubes whilst maintaining sterility
  

Technique

To be performed by Doctors/NNP’s only

• Insert butterfly needle (with syringe attached) at an angle of 45 degrees through the skin into the bladder of the reservoir and then move into a 90 degree position
  
• Remove 10 mLs/kg unless otherwise specified by neurosurgery and slowly aspirate over 20 minutes
  
• Remove needle and apply pressure over insertion site for 2-5 minutes until homeostasis is achieved
  
• Remove gloves and perform hand hygiene
• Clean trolley/work surface, dispose of waste and perform hand hygiene
  
• Send CSF samples for microscopy, protein, glucose and culture (See CSF interpretation guideline), order laboratory test. 
  
• Document the procedure within emr
  

The neurosurgeons may leave a butterfly needle insitu with the line end and three way tap secured in an Integra^tm Stopcock Protection Box. To perform a tap prepared 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 disinfectant cleaning of 3-way tap with example skin disinfectant 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 and 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^TM Protection Box used, observe dressing and system hourly for signs of dislodgement and notify Doctor immediately if dislodgement occurs
  

Evidence table

Complete evidence table for this guideline is found here. 

References

• Bembich S., Cont G., Bua J., Paviotti G., and Demarini S. (2019).  Cerebral Hemodynamics During Neonatal Cerebrospinal Fluid Removal. Pediatric Neurology. 94:70-73.
  
• Pettorini, B., Keh, R., Ellenbogen, J., Williams, D. and Zebian, B. (2014). Intraventricular haemorrhage in prematurity. Infant. 10(6): 186-190.
  
• 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 Sally Jeston, NP, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2020.