Clinical Guideline

EXTERNAL VENTRICULAR DRAIN (EVD) CARE

AND MANAGEMENT
SETTING Bristol Royal Hospital for Children and St Michaels Hospital Neonatal Intensive
Care unit

FOR STAFF All registered nursing and medical staff

PATIENTS Paediatric neurosurgical patients with an external ventricular drain

_____________________________________________________________________________

Statement / Definition:
An external ventricular drain (EVD) is a temporary method of draining cerebrospinal fluid (CSF)
from the ventricular system of the brain when the normal flow of CSF is altered.

Indications Signs and Symptoms of raised ICP

Common indications include raised - Irritability
intracranial pressure (ICP) associated - Headache
with - Nausea/vomiting
- Head injury - Full/bulging fontanelle in babies
- Intracranial haemorrhage - Decreased Glasgow Coma Score
- Acute hydrocephalus (GCS)
- Cerebral / spinal tumours - Hypertension/bradycardia
- Meningitis/ventriculitis/shunt - Pupil changes (fixed, sluggish, or
infection dilated pupils)

An EVD system involves introducing a catheter into one of the ventricles of the brain (see
Figure 1)
This procedure is undertaken in theatres. An EVD system may be connected to a butterfly
secured into a ventricular access device (Ommaya reservoir). The Medtronic EVD system used
at the Bristol Royal Hospital for Children (see Figure 2) must always be set to the black
ventricular side cmH2O (see Figure 3)

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 External
Ventricular drain
Figure 1

Medtronic EVD system It must always be set on the black

Figure 2 side Ventricular CM H20 Figure 3

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Positioning, Zeroing and Securing Rationale
Check all connections and tubing are secure Ensures there is no accidental disconnection
ensuring that they move with the child of the system or leakage of CSF
If intubated and ventilated maintain head Assists with venous drainage from the head,
elevation at 30O reducing potential for elevated ICP
Establish correct zero reference point using The tragus of the ear is a good reference point
visual landmarks “tragus of the ear”. (see figure 4) for the equivalence of the
Foramen of Munro
Ensure that the chamber is at correct level on This allows CSF to drain when pressure in the
gauge as prescribed by the neurosurgeons. ventricles is above the prescribed level
This should be recorded in the medical notes This should reflect the child’s ICP
(usually set at 10 – 15 cmH20)

Tragus of the ear

Laser beam
leveller. Depress
black button
underneath to
shoot beam.
NOT
DISPOSABLE

The zero (highlighted in red on the system) should be levelled to the tragus of
the ear.
Position one end of the spirit level or medronic lazer beam at the red zero
reference point.

Figure 4

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 Moving/Transferring Patient Rationale
Before moving the child: There is a risk of potential over drainage,
1. The two white 3 way taps should be turned disconnection or dislodgement when
off to the child (see figure 5) moving/transferring a child
a) nearest child
b) nearest the chamber Prevent over drainage should an open drain
2. The EVD chamber should be emptied by be placed at a lower height
opening the yellow 3 way tap immediately
below the chamber and then reclose – this
volume should be charted on the fluid chart.
After these steps have been undertaken the
entire system may now be placed on the
bed/trolley.
Once the patient is settled onto the bed/trolley
and the zero point is re-established both 3 way
taps must be reopened

To the head

Off to head when moving patient.

To the drain

Draining- Remember to re-open white 3 way taps after the move process is Figure
finished and drain is securely back at the correct height 5

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Observations Rationale
Measure, record and empty CSF drainage To keep accurate record of drainage
hourly Increasing or decreasing volumes of drainage
may indicate a neurosurgical concern and the
neurosurgical team should be informed
Inform the neurosurgical team if the amount of Excessive drainage may collapse the
drainage exceeds 10mls more than the ventricles, pulling the brain away from the
previous hour OR if more than 30mls has dura. This may potentially result in a sub-dural
drained in one hour OR if you have any haematoma/collection.
concerns
Signs and symptoms of over drainage
- Headaches
- Irritability
- Decreased GCS
- Vomiting
- Sunken fontanelle in infants

Signs and symptoms of underdrainage

- Headaches
- Irritability
- Decreased GCS
- Vomiting
- Full fontanelle in infants
If no drainage over one hour, check tubing for No drainage may indicate an obstruction in the
kinks, blockages or closed 3 way taps drainage system such as a 3 way tap being
closed, or the ventricular catheter being
If no obvious cause detected lower the blocked.
drainage chamber to the bottom of the EVD
scale (-5) observe for dripping CSF into Tubing may be blocked internally by blood or
chamber. Do not allow more than 3 - 5 drops protein particles. Over drainage may occur if
to drip into chamber when lowering drain to more than a few drops are allowed to drip into
establish patency. Return back to original the chamber when checking for blockages.
height immediately
A blocked drain may cause a rapid
If the EVD does not drain this constitutes a deterioration in the condition of the patient.
neurosurgical emergency

Suspected blockage of tubing (no CSF

dripping into chamber when drain lowered as
above) must be reported immediately to the
Neurosurgical Team and the Outreach Team
for additional support with a clear timescale for
review. DO NOT ATTEMPT TO UNBLOCK
THE EVD

If the Neurosurgical Team have not reviewed

within 30 minutes or there is deterioration in
the child’s condition during this time they must
be contacted again and then have clear
direction for ward staff.

In addition contact the paediatric intensive

care or high dependency (PICU/HDU)

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consultant.
If in doubt call 2222.
Document and report to the Neurosurgical Frank blood in the CSF may indicate a bleed
Team immediately any change in the colour of and is a neurosurgical emergency. Cloudy
the CSF drainage. Normal CSF is clear and CSF may indicate infection.
colourless.
CSF drainage should be replaced hourly ml CSF is rich in sodium so replacement is
for ml with intravenous 0.9% Sodium Chloride needed to prevent hyponatraemia
unless instructed by the neurosurgical team
If the catheter is accidentally cut or there is a There may be a deterioration in the child’s
suspicion that there is a split in the catheter clinical condition.
tubing, IMMEDIATELY clamp the catheter as There is also a risk of infection.
close to the scalp as possible using non
toothed clamps and inform the neurosurgical
team immediately.
Record neurological assessment of the child – Detection of any deterioration in the child’s
minimum of hourly recordings condition secondary to possible raised
intracranial pressure.
The Neurosurgical Team and Outreach Team
should be alerted if you have any concerns or
there are significant changes. Frequency of
neurological assessment and observations
should be increased to every 15 - 30 minutes
or as directed by Neurosurgical Team if;
1. the height of drain is changed
2. drain is clamped for more than 10
minutes
3. the child’s GCS deteriorates
4. drain becomes blocked or blockage
suspected
- check that 3 way taps are open
- check patency by lowering drain as
described above

For patients with longer term EVDs following a

discussion with the Neurosurgical Team and
documentation in the medical notes
observations may be decreased in frequency.
However if there is a change in clinical
condition neurological assessment this needs
to be reassessed

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Infection Rationale
Maintain asepsis at all times to reduce the risk The catheter has direct passage into the brain
of infection therefore increasing the risk of infection i.e.
meningitis / ventriculitis
Entry site should be dressed with a sterile Inform the Neurosurgical Team if dressing
occlusive dressing and changed only if soiled becomes wet, as this may indicate CSF
or becomes loose leakage at the entry site
Changing Bag Rationale
The bag should be changed when ¾ full using An overfull bag may not drain effectively SNTT
a Sterile non touch technique (SNTT) must be used to minimise the risk of ascending
(this includes sterile field and sterile gloves) infection
Drain Removal Rationale
Drain removal is carried out by a member of
the neurosurgical team/medics who have
completed competency. To reduce the chances of ventriculitis.
Intrathecal antibiotics are instilled prior to
removal according to the EVD removal To prevent CSF leakage, if this does occur the
protocol (usually 3 days). child should be nursed upright to facilitate CSF
After the drain has been removed a suture drainage via the normal channels.
may be required and/or pressure bandage
applied for 24 hours.
Measuring ICP Rationale
If ICP measurement is required:
1. Using a sterile non touch technique Any addition to the EVD circuit is a potential
(SNTT) attach a 0.9% sodium chloride source of infection
filled monitoring line to the first three
way tap on the drainage tubing. The monitoring line does not need a flush
2. No flush is required i.e. no 50ml syringe running to maintain patency
3. Connect to a transducer and zero
pressure as per instructions below (see It is imperative that the EVD be on drainage
figure 6) other than the few moments taken to measure
4. The transducer should be placed level the pressure unless the neurosurgical team
with the tragus of the ear at all times have asked for ICP monitoring after clamping
either the drain
- in a transducer holder attached to a drip
stand
- on the bed
- or bandaged to the side of the child’s
head if they are mobile (see figure 7)
5. The tap should be turned off to the
transducer allowing drainage to take
place and only turned off to the drain
briefly each hour to obtain a reading of
the ICP value
6. Remember to open 3 way tap to
drainage after the reading is taken –
unless the drain is clamped continually
Note on the paediatric intensive care unit
(PICU) a Codman ICP wire may be in situ
allowing for continuous ICP monitoring

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 Figure 6

Zeroing ICP – Open red bung to air- Reading ICP – Turn off to drain. Do not
turn 3 way tap off to patient. Press leave turned off for any length of time
Zero button on monitor. Ensure 3 way unless the drain is clamped. Good
tap is opened to the patient after trace and value should read on monitor
zeroing is complete

Figure 7

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MEDICAL/NURSING STAFF

1. Alteration in a child’s neurological status may be an indication of rising intracranial

pressure. Clinical signs to be concerned about include
• Change in level of consciousness
• Focal neurological deficits
• Changes in pupil reaction (reactive to non-reactive, unequal pupil size)
• Systemic changes are a late sign of neurological dysfunction
• Bulging fontanelle in infants
• Check patency of drain by lowering the drain and observing for movement in the
column of fluid
• Ensure the 3 way taps are open

CSF sampling should be performed by the neurosurgical team or appropriately trained and
competency assessed staff only)

2. If the catheter is accidentally cut or there is a suspicion that there is a split in the catheter
tubing, IMMEDIATELY clamp the catheter as close to the scalp as possible using non
toothed clamps and inform the neurosurgical team immediately.

Giving drugs/ sampling. MEDICAL STAFF ONLY. This is only undertaken by appropriately
trained and competency assessed staff. Please call the Advanced Paediatric Nurse Practitioner
team (APNP) or Neurosurgery Registrar for assistance

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Adapted from:
Paediatric Intensive Care, Bristol Royal Hospital for Children. (2011) Care of a Child with an
Extra-Ventricular Drain. Nursing Guideline. University Hospitals Bristol NHS Foundation Trust.

Barbara Russell Children’s Ward, Frenchay Hospital. (2004) Protocol for the Care of External
Ventricular drains. Nursing Guideline. North Bristol Hospital Trust

Bibliography:
Gibson I (1995) Making Sense of External Ventricular Drainage. Nursing Times 91(23)p34-35

Greater Glasgow and Clyde NHS Trust (2012) External Ventricular Device Guideline. Available
at: URL
Http://www.clinicalguidelines.scot.nhs.uk (Accessed 16th April 2015)

Great Ormond Street Hospital (2012) External Ventricular Drainage. Clinical Guideline.
Available at: URL
Http://www.gosh.nhs.uk (Accessed 25th February 2015)

Macqueen S et al (2012) The Great Ormond Street Hospital – Manual of Childrens’ Nursing
Practices. Wiley Blackwell

Medtronic. Intracranial Pressure Monitoring. A Handbook for the Nursing Professional. Available
at: URL
Http://www.Medtronic.com. Accessed 20th March 2015)

The Royal Children’s Hospital Melbourne (2013) External Ventricular Drains and Intracranial
Pressure Monitoring. Clinical guideline. Available at: URL
Http://www.rch.org.au (Accessed 25th February 2015)

Woodward S, Addison C, Shah S, Brennan F, Macleod A, Clements M (2002) Benchmarking

Best Practice for External Ventricular Drainage. British Journal of Nursing Vol 11 (1) p47-53

AUTHORISING Paediatric Surgical governance

BODY

SAFETY It is imperative that the drain remains at the specific height to the patient at
all times to ensure correct drainage

QUERIES Contact
Advanced Practitioners (APNP) via bleep 6714
Nursing staff on Bluebell Ward via ext. 27930/27931
Neurosurgical on call registrar bleep 6730 in hours via radio page out of
hours
Paediatric Outreach/ Clinical Site Team bleep 2968 / 3217

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 External Ventricular Drains (EVD)
A practical guide to looking after an EVD

An EVD is drains cerebrospinal fluid (CSF) from the cerebral ventricles to the drainage system outside the body.

Risks of EVD:
• Infection ventriculitis / meningitis
• Under drainage rise in intracranial pressure (ICP) with possible coning
• Over drainage decrease in ICP and possible subdural collections
• Any of above may cause a change in the neurological function or Glasgow Coma Score
(GCS) of the child

Be alert to any changes in the child’s behaviour – if concerned please call the

Care of EVD
At the start of your shift : Hourly EVD observations :
• Take face to face handover at bedside • Record amount of drainage
• Establish and document surgical request for • Record colour of drainage
height of drain • Set up / give ml/ml replacement intravenously,
• Establish patency of drain if prescribed
• Establish if intrathecal antibiotics are due • Check height of drain is correct
today and discuss with Advanced Paediatric • Check 3 way taps on drain to ensure open to
Nurse Practitioner (APNP) or neurosurgery drainage
registrar on call re timing • If no drainage re-establish patency (see
• Check exit site is covered with clear below)
dressing o If drain is not patent please call

Things to be concerned about : How to check patency of the EVD:

Please discuss urgently with neurosurgical • Look for dripping CSF into chamber
team (see contact list below) • If no dripping -
• No drainage and drain not patent o check tubing for kinks
• Significant increase (> 10mls) in drainage o check 3 way taps to ensure not turned off
compared to the last hour o drop chamber to -5 (on black scale) to see
• Significant increase in bloodstaining of CSF if pressure is too low for drainage at
• Deterioration in GCS by 2 points specified height:
o CSF should then drip into chamber

Who to call if you are concerned:

• Advanced Paediatric Nurse Practitioner (APNP) Monday – Friday 07.30 – 20.00 via bleep 6714
• Neurosurgical Registrar on call via bleep 6730 or radio page out of hours
• Outreach team via bleep 2968
• If no-one is able to review the child (consider if the registrar is in theatre) then please call the
Neurosurgical on call Consultant – via switchboard

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