Care of EVD During Management of Shunt Infections in Children – Adrian Caceres, M.D.

Ongoing Nursing Care of Patient With an EVD

• Patient assessment: Assess neurological and vital signs every hour for 12 hours postoperatively. If the patient is stable, assessment intervals can be extended to every 2 hours.
• Telemetry: Place patient on cardiac monitor/pulse oximetry for 24 hours or until stable postoperatively.
• Activity: Activity as ordered by physician. Readjust EVD system with patient’s position changes. Notify patients/visitors of the importance of keeping the EVD at the appropriate level. Apply immobilizers as necessary to prevent removal of EVD.
• Dressing: Observe dressings for drainage and intactness.
• Replace fluids lost to EVD: Replace CSF output ml/ml with IV 0.9 normal saline as ordered.
• Monitor lab values: Monitor lab values (e.g., electrolytes) as ordered by the physician.

Assessment of EVD

At shift change, the outgoing and incoming nurse will jointly evaluate the hourly and total output of CSF by the EVD as well as its functionality as manifested by pressure fluctuation in the reading tubing and continued CSF output. Samples of the CSF in the system should be obtained on a routine basis. Each of the points below should be assessed at least on an hourly basis:

• System’s drainage scale is adjusted to patient: The “0” level of the EVD system is level with the patient’s external auditory canal. (Obtain clarification from physician regarding the “0” level of this system and for any other drains, such as chest, abdominal EVD, and lumbar drain.)
• Confirm system set to drain to prescribed value: The EVD pressure scale is in cm H2O. Confirm that the requested drain settings in the orders are also in cm H2O. Then confirm that the system is set to drain to the prescribed pressure (that the drainage chamber is adjusted to the appropriate value on either scale or with regard to the level of the patient’s external auditory meatus).
• Label EVD tubing: This is especially important near the injection port to avoid confusion with IV tubing.
• Record previous hour’s EVD output: Record the amount of fluid in the burette, then empty into the collection bag.
• Record characteristics of drained CSF: Record CSF color, thickness, presence of sediment or blood, and fluctuation in pressure in the system.

Management of EVD

• Clamp EVD for activities: Clamp system for 30 minutes or as tolerated for feedings or other activities. The EVD system may require clamping before EVD specimen collection to build up pressure. Note the patient’s tolerance of EVD clamping.
• Clamp EVD for transportation: Insure that the system and filter tubing is clamped when transporting the patient to tests or surgery. Initiate Management of Patient with Clamped EVD protocol below.
• Clamp EVD by order of surgeon: Initiate Management of Patient with Clamped EVD protocol below.

Management of Patient with Clamped EVD

• Assess patient status at least hourly: Assess neurological and vital signs every hour if the system is clamped for more than 1 hour.
• Notify physician of changes: Notify the physician immediately if there are any changes in neurological or vital signs.

Troubleshooting an EVD

Assess an EVD or lumbar drain system in the following steps when a block is suspected (e.g., when it is without fluctuation for 1 hour).

1. Confirm tubing intact: Check for kinking of the tubing (this may require assessment beneath the head dressing). Unkink the tubing and secure in place. Check for signs of leakage or breakage in the tubing. Contact the surgeon or replace tubing per local protocol.
2. Confirm stopcocks and filter vent slide clamps in proper position: Check the entire length of the patient’s EVD line for stopcocks and, if closed, reopen to allow fluid to drain into the flow chamber. Check the line for any clamps that have closed the line, and reopen to permit drainage of CSF. The clamp on the line just proximal to the system’s buretrol is used to avoid wetting of chamber’s filter vent; clamp only for system set-up and transport.
3. Confirm system is at zero level: EVD system is at “0” level with the patient’s external auditory canal or otherwise ordered for EVDs externalized from the chest/abdomen or lumbar drain.
4. Confirm system’s setup for drainage pressure correct: Drainage pressure level is at pressure setting ordered by physician in cm H2O.
5. Confirm no internal obstruction in tubing or at inlets: If the flow has not been reestablished with the above steps, then look for a plug in the line. If a plug is noted, distal irrigation may be performed per the institution’s protocol. The physician is called for proximal irrigation. If unsuccessful, further assessment of the system is indicated as a block at the proximal catheter may be present.

Reportable Conditions

• Change in patient: Notify the physician of changes in neurological or vital signs.
• New drainage dressing: Notify the physician if fresh drainage is present on the dressing.
• Positive culture or abnormal lab value: Notify the physician of positive CSF culture gram stain and abnormal glucose and protein when reported by microbiology or chemistry department.
• Failure to correct no-output EVD: Notify the physician after completing troubleshooting measures and the patient remains without fluctuation and/or drainage.

Infection Control

• Preoperative shampoo: A preoperative shampoo with antibacterial soap the evening or night before an EVD placement can be considered.
• Maintain contact isolation when indicated: This precaution includes hand washing before and after care procedures, gown for patient and/or system contact when in protective isolation, and utilization of gown, mask, and sterile gloves when opening the EVD system.
• Keep EVD tubing and area neat: Position and/or secure EVD tubing to avoid contact with the floor, entanglement, etc. Maintain a clean patient environment
• Dressing changes on routine schedule: Change EVD dressings using sterile technique every Monday and Thursday. Wait 48 hours after surgery to perform the initial dressing change unless the EVD dressing becomes non-adherent. Observe for signs of infection or skin breakdown Notify physician as needed. (Usual dressing change consists of cleaning the EVD site with betadine, covering with 2 x 2 inch gauze over and under the EVD tubing, and securing the gauze with 1-inch steri-strips. Mastisol may be used to increase the adhesiveness of the steri-strips. Stockinette or elastic dressings may also be used to hold the dressing in place as appropriate.
• Avoid overflow of EVD bag: Change the drainage bag when ¾ full per EVD procedure to avoid fluid buildup in the system with contamination of the filter.

Psychosocial Support

• Inform: Provide support and information about procedures and tests.
• Encourage: Encourage expression of feelings and concerns regarding EVD.
• Support: Reinforce positive body image/self concept.
• Divert: Provide diversional activities to offset environmental isolation.

Patient/Family Education

• Handouts: Provide EVD “information for parents” handout.
• Direct: Offer guidance to other educational resources (books, DVD, YouTube video, etc.).