External Ventricular Drain Management Research Articles

Effectiveness of a multimodal strategy to reduce external ventricular drain–associated infection: A quasi-experimental study

Infection is a serious complication in neurosurgical patients who undergo external ventricular drain (EVD) insertion and is associated with high morbidity and mortality. We conducted a quasi-experimental study in patients who underwent EVD insertion to evaluate the impact of a strategy to reduce the incidence of external ventricular drain associated infections (EVDAIs). The study was divided into 2 periods; (1) the pre-intervention period when techniques for EVD insertion and maintenance were up to the discretion of the neurosurgeons and (2) the post-intervention after implementation of a multi-modal strategy (cefazolin prophylaxis, preoperative chlorhexidine showers, application of postoperative chlorhexidine-impregnated dressing, limited manipulation of the EVD, and meticulous EVD management). The primary outcome was the incidence rate of EVDAIs; secondary outcomes included in-hospital mortality rate and the hospital length of stay. In total, 135 patients were included. The incidence rate of EVDAIs was significantly reduced in the post-intervention period (5.6 cases/1,000 EVD-days) compared with the pre-intervention period (18.2 cases/1,000 EVD-days; P=0.026). There were no differences in all secondary outcomes analyzed. This multi-modal strategy was associated with high satisfaction among healthcare personnel. Implementation of a multi-modal strategy was associated with a reduction in the incidence of EVDAIs. This was in line with our goal of promoting a new culture of safety despite being in a resource-limited setting.

Standardized Criteria to Initiate External Ventricular Drain (EVD) Weaning in a Neurological Intensive Care Unit to Increase the Safety of EVD Discontinuation and Reduce the Need for a Shunt.

Introduction Patients with subarachnoid hemorrhages (SAH) with external ventricular drains (EVD) candevelop chronic hydrocephalus (HCP), requiring permanent cerebrospinal fluid (CSF) diversion via an external shunt. Two different strategies have been used to assess for dependence on EVD: 1) prompt closure, and 2) gradual weaning.Gradual weaning of EVDs is performed by increasing drainage resistance to outflow over days.However, when to start one strategy or the other is up to the physician. No uniform guidelines exist raising a question: Are standardized criteria necessary to initiate the EVD weaning process for SAH patients to increase the safety of EVD discontinuation and reduce the need for a shunt? This study shares criteria used to initiate EVD weaning that displayed increased safety of EVD discontinuation for patients with subarachnoid hemorrhage requiring EVD, particularly with regards to length of hospital stay (LOS), hospital-acquired infection rates, and ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement. Methods One hundred and fifty-one SAHpatients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non-aneurysmal nontraumatic SAH (naSAH) patients required EVD placement.A gradual EVD weaning protocol was initiated if patients met the following criteria: 1. The reason for EVD placement has resolved or is resolving, 2. The quantity of CSF output is <250mL over 24 hours, 3. Quality of CSF is nonbloody, 4. Intracranial Pressure (ICP) must be within normal limits, and 5. The patient must be neurologically stable. It was acceptable to initiate the weaning process when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing the drain (chamber) height by 5 millimeters of mercury every 24 hours if the criteria were met. Charts were reviewed for LOS, infection rates, and rate of VPS/ETV. Gender, age, race, wean failure incidence, Hunt-Hess scores, modified Fisher scores, and syndrome of inappropriate antidiuretic hormone/cerebral salt wasting (SIADH/CSW) rates were obtained. Results The average LOS for aSAH patients with EVD was 20.35 days. The incidence of VPS/ETV was 11%. A chi-square analysis revealed that aSAH patients had higher rates of VPS/ETV placement (p<0.001) and EVD wean failures (p<0.001) than naSAH patients. aSAH patients had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally. Conclusions Standardized criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provided a uniform approach to EVD management. Comparable infection rates and LOS for SAH patients requiring EVDs compared to national averages were found.

The Role of Nursing Care in the Management of External Ventricular Drains on the Neurosurgical Ward: A Quality Improvement Project

The management of external ventricular drains (EVDs) is a critical aspect of patient care in the intensive care setting. However, nurses on the general floor are not commonly exposed to patients with EVD and therefore lack the necessary knowledge and skills to manage and troubleshoot EVDs effectively. The aim of this study was to evaluate the level of knowledge, comfort, and impact of EVD management among nurses on the floor after the implementation of a quality improvement (QI) tool. This is a cross-sectional study conducted among registered nurses working on the neurosurgical floors of the Montreal Neurological Hospital. Data were collected using a questionnaire based on the plan-do-study-act model. A survey assessing the level of knowledge and comfort with EVD management was conducted before and after the implementation of the QI tool. Seventy-six nurses completed the questionnaire regarding their knowledge and comfort level in EVD management. Results showed that only 42% of the nurses reported feeling "comfortable" whereas 37% reported feeling "uncomfortable" in caring for patients with an EVD. In addition, only 6.5% reported being "comfortable" in troubleshooting a malfunctioning EVD. However, the level of comfort significantly improved after using the QI project. The results of this study highlight the need for continued training and education to support the care of patients with EVDs in the ward setting. The implementation of a QI tool can significantly improve nurses' knowledge and comfort level in EVD management, leading to improved patient outcomes and overall quality of care.

Letter to the Editor Regarding “Differences in Health Care Resource Utilization After Surgery for Metastatic Spinal Column Tumors in Patients with a Concurrent Affective Disorder in the United States”

The management of external ventricular drains (EVDs) is a critical aspect of patient care in the intensive care setting. However, nurses on the general floor are not commonly exposed to patients with EVD and therefore lack the necessary knowledge and skills to manage and troubleshoot EVDs effectively. The aim of this study was to evaluate the level of knowledge, comfort, and impact of EVD management among nurses on the floor after the implementation of a quality improvement (QI) tool.This is a cross-sectional study conducted among registered nurses working on the neurosurgical floors of the Montreal Neurological Hospital. Data were collected using a questionnaire based on the plan-do-study-act model. A survey assessing the level of knowledge and comfort with EVD management was conducted before and after the implementation of the QI tool.Seventy-six nurses completed the questionnaire regarding their knowledge and comfort level in EVD management. Results showed that only 42% of the nurses reported feeling “comfortable” whereas 37% reported feeling “uncomfortable” in caring for patients with an EVD. In addition, only 6.5% reported being “comfortable” in troubleshooting a malfunctioning EVD. However, the level of comfort significantly improved after using the QI project.The results of this study highlight the need for continued training and education to support the care of patients with EVDs in the ward setting. The implementation of a QI tool can significantly improve nurses' knowledge and comfort level in EVD management, leading to improved patient outcomes and overall quality of care.

Neuroendoscopic Evacuation Improves Outcomes Compared with External Ventricular Drainage in Patients with Spontaneous Intraventricular Hemorrhage: A Systematic Review with Meta-Analyses

Spontaneous intraventricular hemorrhage (IVH) is a cause of significant morbidity and mortality. Treatment for resulting obstructive hydrocephalus has traditionally been via an external ventricular drain (EVD). We aimed to compare patient outcomes after neuroendoscopic surgery (NES) evacuation of IVH versus EVD management. MEDLINE, Embase, and Cochrane Library databases were searched on October 8, 2022. Of the 252 records remaining after removal of duplicates, 12 met study inclusion criteria. After extraction of outcomes data, fixed-effect and random-effects models were used to establish odds ratios (ORs) with 95% confidence intervals (CIs) for intensive care unit length of stay, rate of permanent cerebrospinal fluid diversion, Glasgow Outcome Scale score, and mortality rate. The results of the pooled analysis showed that intensive care unit length of stay was shorter (OR-2.61 [95% CI-5.02,-0.19]; I2= 97.76%; P= 0.034), permanent cerebrospinal fluid diversion was less likely (OR-0.79, 95% CI [-1.17,-0.41], I2= 46.96%, P < 0.001), higher Glasgow Outcome Scale score was more likely (OR 0.48, 95% CI [0.04, 0.93], I2= 60.12%, P= 0.032), and all-cause mortality was less likely (OR-1.11, 95% CI [-1.79,-0.44], I2= 0%, P= 0.001) in the NES evacuation group compared with the EVD group. NES for evacuation of spontaneous IVH results in reduced intensive care unit length of stay, reduced permanent cerebrospinal fluid diversion rates, improved Glasgow Outcome Scale score, and reduced mortality when compared with EVD. More robust prospective, randomized studies are necessary to help inform the safety and utility of NES for IVH.

Reducing external ventricular drain associated ventriculitis: An improvement project in a level 1 trauma center

External ventricular drain (EVD)-associated infections have a negative impact on healthcare cost and patient outcomes. Practice variation in EVD management may place patients at increased risk for EVD-associated infection. This project aimed to evaluate the impact of implementing an interprofessional evidence-based EVD bundle of care on reduction of EVD-related ventriculitis rates. An interprofessional team developed an evidence based EVD care bundle and order set to eliminate practice inconsistencies. Standardization of EVD equipment and optimization of the electronic health record occurred. Education and competency validation were completed with neurosurgical providers and nurses. Interprofessional rounds occur weekly for observation, recognition, and in-the-moment education. A pre/post intervention design was used to show that the rate of EVD-associated ventriculitis decreased from 8.8 per reported EVD days in 2019 to 0 per reported EVD days in 2021 after implementation of the EVD care bundle. Through an interprofessional team approach, reduction in EVD-associated infection rates is feasible with implementation of an evidence based EVD care bundle.

Management of External Ventricular Drains and Related Complications: a Narrative Review

Management of External Ventricular Drains and Related Complications: a Narrative Review

Abstract 1122‐000094: EVD Weaning Criteria Decreases VPS/ETV Placement and Hospital Stay in Subarachnoid Hemorrhage Patients

Introduction : The Neurocritical Care Society encourages an external ventricular drain (EVD) wean “as quickly as is clinically feasible” but guidelines on achieving it are limited (1). This study aims to improve quality of care by sharing a protocol to initiate EVD weaning. These criteria were developed over 7 years and showed a reduction in ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement and length of stay (LOS) at our institute compared to national averages. Methods : 151 subarachnoid hemorrhage (SAH) patients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non‐aneurysmal nontraumatic SAH (naSAH) patients required EVD placement. A gradual EVD weaning protocol was initiated if patients met the following criteria: the reason for EVD placement has resolved or is resolving, quantity of CSF output must be &lt;250mL over 24 hours, quality of CSF must be nonbloody, ICP must be within normal limits, and the patient must be neurologically stable. It was acceptable to wean when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing drain height by 5 millimeters of mercury every 24 hours if criteria were met. Charts were reviewed for LOS and rate of VPS/ETV. Gender, age, race, wean failure incidence, infection rates, and SIADH/CSW rates were obtained. Results : Average LOS for aSAH patients with EVD at our institute was 20.35 days. Incidence of VPS/ETV was 11%. Chi‐square analysis was performed, and aSAH patients were found to have higher rates of VPS/ETV placement (p&lt;0.001) and EVD wean failures (p&lt;0.001) than naSAH patients. Conclusions : Our criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provides a standardized approach to EVD management. aSAH patients at our institute had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally (2). aSAH patients at our institute also had a lower LOS at 20.35 days compared to 21.5 days nationally (3).

Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study.

Survivors of aneurysmal subarachnoid hemorrhage (SAH) face a protracted intensive care unit (ICU) course and are at risk for developing refractory hydrocephalus with the need for a permanent ventriculoperitoneal shunt (VPS). Management of the external ventricular drain (EVD) used to provide temporary cerebrospinal fluid diversion may influence the need for a VPS, ICU length of stay (LOS), and drain complications, but the optimal EVD management approach is unknown. Therefore, we sought to determine the effect of EVD discontinuation strategy on VPS rate. This was a prospective multicenter observational study at six neurocritical care units in the United States. The target population included adults with suspected aneurysmal SAH who required an EVD. Patients were preassigned to rapid or gradual EVD weans based on their treating center. The primary outcome was the rate of VPS placement. Secondary outcomes were EVD duration, ICU LOS, hospital LOS, and drain complications. A rapid EVD wean protocol was associated with a lower rate of VPS placement, including a delayed posthospitalization shunt, in an adjusted Cox proportional analysis (hazard ratio 0.52 [p = 0.041]) and adjusted logistic regression model (odds ratio 0.43 [95% confidence interval 0.18-1.03], p = 0.057). A rapid wean was also associated with 2.1 fewer EVD days (p = 0.007) and saved an estimated 2.5 ICU days (p = 0.049), as compared with a gradual wean protocol. There were fewer nonfunctioning EVDs in the rapid group (odds ratio 0.32 [95% confidence interval 0.11-0.92]). Furthermore, we found that the time to first wean and the number of weaning attempts were important independent covariates that affected the likelihood of receiving a VPS and the duration of ICU admission. A rapid EVD wean was associated with decreased rates of VPS placement, decreased ICU LOS, and decreased drain complications in survivors of aneurysmal SAH. These findings suggest that a randomized multicentered controlled study comparingrapid vs. gradual EVDweaning protocols is justified.

Perioperative Management of Aneurysmal Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.

A Narrative Review of the Published Literature, Hospital Practices, and Policies Related to External Ventricular Drains in the United States: The External Ventricular Drain Publications, Practices, and Policies (EVDPoP) Study.

External ventricular drain (EVD) placement and management pose risks to neurocritically ill patients. Yet, little is known about EVD management or hospital EVD management practices and policies in US hospitals. A narrative review was conducted to describe EVD-related publications reported in PubMed and Embase between 1953 and 2019, and a survey was used to examine US hospital EVD practices and policies, including adherence to EVD guideline recommendations. Overall, 912 relevant articles were published between 1953 and 2019 (average 21; range, 0 to 102 articles, per year), primarily related to indications for EVD placement (n=275, 30.2%), EVD-associated complications (n=206, 22.6%), and EVD care (n=200, 21.9%). The number of EVD publications increased over time (R2=0.7), and most publications addressed EVD-associated infection (n=296, 73.4%) and EVD insertion (n=195, 45.2%). Survey responses were received from 30 hospitals (37.5% response rate), and reported use of antimicrobial-impregnated catheters in 80% of hospitals, preinsertion antibiotic administration in 70%, collection of cerebrospinal fluid samples for suspicion of ventriculitis in 73.3%, tracking of EVD-associated infection in 86.7%, routine EVD clamping during transport in 66.7%, and monitoring of intracranial pressure during transport in 33.3%. Adherence to hospital policies was high for recommendations related to flushing an EVD and changing cerebrospinal fluid drainage systems (100% [range, 0% to 100%] each), but low for intrahospital transportation (16.7% [0% to 83.3%]), EVD removal (0% [0% to 66.7%]), patient and family education (0% [0% to 100%]), and administration of intraventricular medication (0% [0% to 100%]). In summary, the published literature related to EVD insertion and maintenance, and reported EVD hospital practices and policies, primarily focus on reducing EVD-associated infections. Still, overall adherence of hospital EVD policies to guideline recommendations is modest. To promote a culture of EVD safety, clinicians should focus on reducing all EVD-associated adverse events.

Evidence-Based Management of External Ventricular Drains

The optimal management of external ventricular drains (EVD) in the setting of acute brain injury remains controversial. Therefore, we sought to determine whether there are optimal management approaches based on the current evidence. We identified 2 recent retrospective studies on the management of EVDs after subarachnoid hemorrhage (SAH) which showed conflicting results. A multicenter survey revealed discordance between existing evidence from randomized trials and actual practice. A prospective study in a post-traumatic brain injury (TBI) population demonstrated the benefit of EVDs but did not determine the optimal management of the EVD itself. The recent CLEAR trials have suggested that specific positioning of the EVD in the setting of intracerebral hemorrhage with intraventricular hemorrhage may be a promising approach to improve blood clearance. Evidence on the optimal management of EVDs remains limited. Additional multicenter prospective studies are critically needed to guide approaches to the management of the EVD.

The National Neuroscience Institute External Ventricular Drain Study: A Pragmatic Multisite Risk-Stratification Pathway to Reduce Ventriculostomy-Related Infection

Ventriculostomy-related infection (VRI) is associated with potential serious morbidity, extended hospitalization duration, increased health care costs, and mortality. We assessed the effectiveness of a pragmatic risk-stratification pathway for external ventricular drain (EVD) management, allowing for surgical decision making, in reducing the rate of VRIs. Two studies were performed concurrently. A retrospective audit of EVD infection rates and outcomes in our unit across 3 hospitals was conducted from January to December 2014. The second prospective study compared the same variables during the implementation of the EVD pathway across the 3 sites from January 2015 to December2016. The number of patients requiring EVDs increased from 2014 to 2016 (165 vs. 189 vs. 197 patients, respectively), with a significant increase in patients with intraventricular hemorrhage (P= 0.009). Despite increasing risk, overall EVD infections decreased during the implementation period, from 4.8% (8/165) in 2014 to 3.7% in 2015 (7/189) and 2.0% in 2016 (4/197, P= 0.33). In 2 sites (site 1, 2.0% vs. 2.1% vs. 1.9%, and site 2, 4.7% vs. 5.0% vs. 5.3%), transition to the EVD risk-stratification pathway maintained already low infection rates; in site 3, EVD infections decreased from 6.8% (5/73) to 3.9% (4/102) and 0% (0/86, P= 0.06). The introduction of a pragmatic evidence-based risk-stratification pathway, in which different options for EVD management are incorporated, results in low EVD infection rates across a multisite institutional practice. Our results are comparable to published protocols involving the implementation of standard care bundles and/or antibacterial EVDs alone, in reducing VRIs.

Intermittent CSF drainage and rapid EVD weaning approach after subarachnoid hemorrhage: association with fewer VP shunts and shorter length of stay.

There is variability and uncertainty about the optimal approach to the management and discontinuation of an external ventricular drain (EVD) after subarachnoid hemorrhage (SAH). Evidence from single-center randomized trials suggests that intermittent CSF drainage and rapid EVD weans are safe and associated with shorter ICU length of stay (LOS) and fewer EVD complications. However, a recent survey revealed that most neurocritical care units across the United States employ continuous CSF drainage with a gradual wean strategy. Therefore, the authors sought to determine the optimal EVD management approach at their institution. The authors reviewed records of 200 patients admitted to their institution from 2010 to 2016 with aneurysmal SAH requiring an EVD. In 2014, the neurocritical care unit of the authors' institution revised the internal EVD management guidelines from a continuous CSF drainage with gradual wean approach (continuous/gradual) to an intermittent CSF drainage with rapid EVD wean approach (intermittent/rapid). The authors performed a retrospective multivariable analysis to compare outcomes before and after the guideline change. The authors observed a significant reduction in ventriculoperitoneal (VP) shunt rates after changing to an intermittent CSF drainage with rapid EVD wean approach (13% intermittent/rapid vs 35% continuous/gradual, OR 0.21, p = 0.001). There was no increase in delayed VP shunt placement at 3 months (9.3% vs 8.6%, univariate p = 0.41). The intermittent/rapid EVD approach was also associated with a shorter mean EVD duration (10.2 vs 15.6 days, p < 0.001), shorter ICU LOS (14.2 vs 16.9 days, p = 0.001), shorter hospital LOS (18.2 vs 23.7 days, p < 0.0001), and lower incidence of a nonfunctioning EVD (15% vs 30%, OR 0.29, p = 0.006). The authors found no significant differences in the rates of symptomatic vasospasm (24.6% vs 20.2%, p = 0.52) or ventriculostomy-associated infections (1.3% vs 8.8%, OR 0.30, p = 0.315) between the 2 groups. An intermittent CSF drainage with rapid EVD wean approach is associated with fewer VP shunt placements, fewer complications, and shorter LOS compared to a continuous CSF drainage with gradual EVD wean approach. There is a critical need for prospective multicenter studies to determine if the authors' experience is generalizable to other centers.

External Ventricular Drain Management Practices in Thailand: Results of the EPRACT Study

We explored the external ventricular drain (EVD) practices in Thailand. We performed a survey-based study to describe EVD insertion, maintenance, quality improvement (QI) practices, and incidence of EVD infection. The study included 58 of 101 hospitals contacted (57.4% response rate), with ≥600 beds (44.8%) and dedicated neurocritical care units (53%). The reasons for EVD placement included aneurysmal subarachnoid hemorrhage, traumatic brain injury, and ventriculoperitoneal shunt malfunction or infection; 75.9% of the hospitals cared for ≤100 EVDs annually. In Thailand, nonantimicrobial EVD catheters (98.3%) were used most often. Most hospitals (56.9%) did not routinely sample the cerebrospinal fluid. Prophylactic daily antibiotic use was prevalent (62.1%). Most hospitals (77.6%) did not measure the intracranial pressure during intrahospital transport. EVD infection was a commonly (69%) tracked QI measure; however, up to one third of the hospitals did not track any EVD QI measure. Most hospitals (94.8%) had no written EVD insertion and maintenance protocols. Most hospitals (79.3%) reported an EVD infection rate of ≤5% in the previous year. The low EVD infection rate, high cost, and/or the lack of equipment could account for the low usage of antimicrobial catheters and intracranial pressure monitoring. The results of the present study have identified QI opportunities in EVD management in Thailand. The development of an EVD-related QI process, reliable tracking of EVD infection rates, adaptation of U.S. guidelines to create standardized EVD protocols, and examination of the association between EVD practices and clinical outcomes in low-to middle-income countries are urgently needed.

Simulation workshops as an adjunct to perioperative care bundles in the management of external ventricular drains: improving surgical technique and reducing infection.

Temporary CSF diversion through an external ventricular drain (EVD) comes with the risk of EVD-related infections (ERIs). The incidence of ERIs varies from 0.8% to 22%. ERIs increase mortality, morbidity, length of stay, and costs; require prolonged courses of antibiotics; and increase the need for subsequent permanent CSF diversion. The authors report the results of a quality improvement project designed to improve infection rates and EVD placement using simulation training in addition to a standardized perioperative care bundle. This project resulted not only in a decrease in ERIs, but also a significant improvement in surgical outcomes. A best-practice standardized perioperative approach and care bundle was approved by consensus among the senior neurosurgeons at the authors' institution, and a standardized operative note was designed to encourage adherence to policy and improve documentation. This approach was adapted from the bundle previously described by Kubilay et al. Simulation workshops were introduced to teach safe sampling technique, administration of intrathecal drugs, and a standardized operative technique using the Rowena head surgical model. Effects of the interventions on placement, infection rates, and displacement were measured at two distinct time points over a 2-year period. Baseline audits demonstrated satisfactory EVD placement in 74%, an infection rate of 8.5%, and displacement occurring in 20%. In the 2 years following the interventions, satisfactory placement improved to 96%, infection rate fell to 4.8%, and inadvertent displacement occurred in only 1.7%. Simulation training and standardizing the perioperative care of patients requiring EVDs dramatically improved placement accuracy, reduced infection rates, and reduced EVD displacement rate.

Strategies to reduce external ventricular drain-related infections: a multicenter retrospective study.

OBJECTIVEVarious strategies have been proposed to reduce the incidence of external ventricular drain (EVD)-related infections. The authors retrospectively studied the impact of EVD care management on EVD-related infections at 3 French university hospital intensive care units.METHODSBetween 2010 and 2014, 462 consecutive adult patients with no evidence of a preexisting CSF infection received EVDs as part of their care at one of the following sites: Grenoble (221 patients), Saint-Etienne (130 patients), and Marseille (111 patients). Written protocols describing the EVD placement procedure, management, and removal were implemented at the 3 sites. Daily CSF sampling and intraventricular administration of antibiotics prior to EVD removal were performed at the Grenoble site only. EVD-related infection was considered for any confirmed ventriculostomy-related infection (VRI) and ventriculitis. VRI was defined as one or more positive CSF cultures or Gram stain with CSF pleocytosis and biochemical abnormalities. Ventriculitis was defined as CSF pleocytosis and biochemical abnormalities with degradation of neurological status and fever.RESULTSA total of 6945 EVD days were observed in the entire population. In the Grenoble cohort, the mean cumulative incidence of EVD-related infections was significantly lower than that in the 2 other cohorts: 1.4% (95% CI 0.0%-2.9%) versus 9.2% (95% CI 4.2%-14.2%) and 7.2% (95% CI 2.4%-12.0%) at Saint-Etienne and Marseille, respectively (p < 0.01). Accounting for the duration of external ventricular drainage at each site, the risk for EVD-related CSF infections was significantly higher at Saint-Etienne and Marseille than at Grenoble, with ORs of 15.9 (95% CI 3.6-71.4, p < 0.001) and 10.0 (95% CI 2.2-45.5, p = 0.003), respectively.CONCLUSIONSThese findings indicate that it is possible to attain a low incidence of EVD-related infections, provided that an EVD care bundle, which can include routine daily CSF sampling, is implemented and strongly adhered to.

External Ventricular Drains After Subarachnoid Hemorrhage: Is Less More?

External ventricular drains (EVD) are essential in the early management of hydrocephalus and elevated intracranial pressure after subarachnoid hemorrhage (SAH). Once in place, management of the EVD is thought to influence long-term patient outcomes, rates of ventriculitis, incidence of delayed cerebral ischemia, need for a ventriculoperitoneal shunt, and intensive care unit (ICU) and hospital length of stay. The available evidence supports adopting early clamp trials and intermittent cerebrospinal fluid (CSF) drainage. However, a recent survey demonstrated that most neurological ICUs employ the opposite approach of continuously open EVDs and gradual weaning. In this article, we review the literature and arguments for and against the different EVD approaches. We conclude that an early clamp trial and intermittent CSF drainage can be safe and result in fewer EVD complications and shorter length of stay. Given the discrepancy between the available evidence and current practice, more studies on the optimal management of EVDs are warranted with the greatest need for multicenter prospective studies.

Management of External Ventricular Drains After Subarachnoid Hemorrhage: A Multi-Institutional Survey.

Patients with aneurysmal subarachnoid hemorrhage (SAH) often develop hydrocephalus requiring an external ventricular drain (EVD). The best available evidence suggests that a rapid EVD wean and intermittent CSF drainage is safe, reduces complications, and shortens ICU and hospital length of stay as compared to a gradual wean and continuous drainage. However, optimal EVD management remains controversial and the baseline practice among neurological ICUs is unclear. Therefore, we sought to determine current institutional practices of EVD management for patients with aneurysmal SAH. An e-mail survey was sent to attending intensivists and neurosurgeons from 72 neurocritical care units that are registered with the Neurocritical Care Research Network or have been previously associated with the existing literature on the management of EVDs in critically ill patients. Only one response was counted per institution. There were 45 out of 72 institutional responses (63%). The majority of responding institutions (80%) had a single predominant EVD management approach. Of these, 78% favored a gradual EVD weaning strategy. For unsecured aneurysms, 81% kept the EVD continuously open and 19% used intermittent drainage. For secured aneurysms, 94% kept the EVD continuously open and 6% used intermittent drainage. Among continuously drained patients, the EVD was leveled at 18 (unsecured) and 11cm H2O (secured) (p<0.0001). When accounting for whether the EVD strategy was to enhance or minimize CSF drainage, there was a significant difference in the management of unsecured versus secured aneurysms with 42% using an enhance drainage approach in unsecured patients and 92% using an enhance drainage approach in secured patients (p<0.0001). Most institutions utilize a single predominant EVD management approach, with a consensus toward a continuously open EVD to enhance CSF drainage in secured aneurysm patients coupled with a gradual weaning strategy. This finding is surprising given that the best available evidence suggests that the opposite approach is safe and can reduce ICU and hospital length of stay. We recommend a critical reassessment of the approach to the management of EVDs. Given the potential impact on patient outcomes and length of stay, more research needs to be done to reach a threshold for practice change, ideally via multicenter and randomized trials.

Abstract WMP86: Evaluation of Cerebrospinal Fluid Dynamics and External Ventricular Drain Management in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial (CLEAR III)

Background: Acute obstructive hydrocephalus secondary to spontaneous intracerebral/intraventricular hemorrhage (ICH/IVH) requires early cerebrospinal fluid (CSF) drainage to reduce intracranial pressure (ICP). Extensive CSF drainage may reduce IVH clot burden. We characterize CSF dynamics, strategies and impact on end of treatment (EOT) IVH volume (72 hours post randomization [Rand]) in the CLEAR III trial. Methods: Prospective analysis of CSF output in all 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing EVD + intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume &lt;30cc. CSF output was recorded every 4 hours until 7 days post Rand, and compared by clinical and radiological variables. Results: Daily median CSF output in the first week was 188cc (IQR: 125, 252). Maximum daily EVD drip settings were &lt;10mmHg in 27.8%, =10 in 44.1% and &gt;10 in 28.1%. Independent predictors of higher daily CSF output after adjustment for initial IVH volume (p=0.04) were lower drip setting (p&lt;0.001), lower age (p&lt;0.001), male sex (p=0.03), dual EVD (p=0.005), CSF protein (p&lt;0.001) and ICP&gt;20mmHg (P=0.007). Both EOT IVH volume and change in IVH volume (ChgIVH) (over 1 st week) were independently associated with total CSF output (P=0.004/&lt;0.001, respectively), and initial IVH volume (P&lt;0.001/&lt;0.001)). Early opening of 3 rd and 4 th ventricle (P=0.03) was associated with lower EOT volumes, while CSF protein (P=0.02), and side of EVD ipsilateral to largest IVH (P=0.04) were associated with ChgIVH. Shunting for hydrocephalus was performed in 18.6% over 1 year follow-up and was associated with higher total CSF output over first week (P&lt;0.001). Conclusions: CSF circulation in severe IVH can be assessed by CSF output which is associated with EVD drip management and other clinical variables. EOT IVH volume and IVH volume reduction are important surrogate endpoints which are related to CSF dynamics. VP shunt requirement in spontaneous IVH is associated with early CSF output levels. These results permit future correlation of CSF output with treatment rendered (thrombolysis versus placebo) with upcoming unblinding of the trial.