A Retrospective Quality Analysis of External Ventricular Drain Infection Rates Following Stroke Diagnoses and Other Brain Injuries: Comparison of Emergency Room and ICU/OR Setting.

David Altschul,Rony Thomas,Jinyuan Liu,Rose Fluss,Andre E Boyke,Christopher Lin,Andrew Kobets,Santiago R Unda,Mousa K Hamad

doi:10.7759/cureus.7173

Abstract

ObjectiveThe purpose of this study was to analyze the incidence of infections in patients following placement of External Ventricular Drain (EVD) in either the Emergency Room (ER) or the Intensive Care Unit (ICU)/ Operating Room (OR) at a single Comprehensive Stroke Center.MethodsRetrospective analysis of post-procedure infection rates in 710 patients with EVDs placed on site between 2010 and 2018 was performed. We analyzed cases between sex, age, stroke and non-stroke related and further requirement of conversion of the EVD to a ventriculoperitoneal (VP) shunt.ResultsSignificant decrease in EVD related infection (ERIs) rates following the shift in EVD placement from ER to ICU/OR (from 13% to 7.7%, p=.03) among all ages, sex and type of brain injury was observed. Furthermore, our data also shows that the rate of conversion of EVDs to VP shunts is independent of the setting where EVD was placed, but increases in patients who develop ERIs. 23.1% of stroke patients that developed an ERI required a conversion to VP shunt while 67.3% of non-stroke patients that developed an ERI required further VP shunt (p<.001) showing that non-stroke EVD patients with infections are more likely to require VP shunt.ConclusionThis is one of the larger retrospective studies conducted on EVD related infections. ERIs were significantly higher when EVDs were placed in the ER. Moreover, our results highlight the relation between ERIs and further requirement of conversion EVD to VP shunt. These figures highlight the importance of focusing on infection rates, and the implications CSF infection has on the long-term care of patients.

Highlights

External ventricular drain (EVD), otherwise known as external ventriculostomy, is a neurosurgical procedure that is used for monitoring and treatment of elevated intracranial pressure (ICP) after traumatic brain injury (TBI) as well as primary hydrocephalus or secondary to subarachnoid hemorrhage (SAH), intra-parenchymal hemorrhage (IPH), intra-ventricular hemorrhage (IVH), malignancies and cerebrospinal fluid (CSF) leak [1,2]
Significant decrease in External ventricular drainage (EVD) related infection (ERIs) rates following the shift in EVD placement from Emergency Room (ER) to Intensive Care Unit (ICU)/Operating Room (OR) among all ages, sex and type of brain injury was observed
Our data shows that the rate of conversion of EVDs to VP shunts is independent of the setting where EVD was placed, but increases in patients who develop EVD-related infections (ERI). 23.1% of stroke patients that developed an ERI required a conversion to VP shunt while 67.3% of non-stroke patients that developed an ERI required further VP shunt (p

Summary

Introduction

External ventricular drain (EVD), otherwise known as external ventriculostomy, is a neurosurgical procedure that is used for monitoring and treatment of elevated intracranial pressure (ICP) after traumatic brain injury (TBI) as well as primary hydrocephalus or secondary to subarachnoid hemorrhage (SAH), intra-parenchymal hemorrhage (IPH), intra-ventricular hemorrhage (IVH), malignancies and cerebrospinal fluid (CSF) leak [1,2]. EVD placement is considered a low-risk procedure, it can carry complications such as hemorrhage, obstruction of the drainage system, and the most common EVD-related infections (ERI) [3,4,5]. ERI’s rates have been reported to be as high as up to 45% and the consequent meningitis or ventriculitis are associated with increased morbidity, mortality, hospital stay, prolonged treatment time with antibiotics and costs [2,6]. Several studies have focused on the prevention of these high infection rates using specialized instruments, including antibiotic-impregnated catheters, and increasing antibiotic prophylactic treatments preoperatively [7,8]. Other authors have suggested possible epidemiological and clinical risk factors for ERIs [6,9,10,11].

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