Episode #220 Enhancing Patient Safety with External Ventricular Drains: Launching the EVD Safety Campaign – Part 1 of 3

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are headed into the APSF Resources today to learn more about External Ventricular Drains. This is an important area where anesthesia professionals need to be prepared to help keep patients safe.

Before we dive into the episode today, we’d like to recognize ICU Medical, a major corporate supporter of APSF. ICU Medical has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, ICU Medical – we wouldn’t be able to do all that we do without you!”

Our featured topic today is the External Ventricular Drain Safety Campaign: A Global Patient Safety Initiative which represents a collaboration between the APSF and The Society for Neuroscience in Anesthesiology and Critical Care. To follow along with us, head over to APSF.org and click on the Patient Safety Resources heading. Then, the 7^th one down is External Ventricular Drain Safety Campaign. I will include a link in the show notes as well.

Let’s start by talking about what is an external ventricular drain. You can see a picture depicting this device on the resource page. It is a multi-orifice catheter that is positioned into the ventricle in the brain which is a space containing cerebrospinal fluid or CSF. These drains are placed to help monitor pressure and remove CSF in patients with altered absorption and or circulation due to pathology.

So far, we haven’t talked about anesthesia care, but this is an important area for anesthesia professionals to be knowledgeable and prepared to provide care for patients with external ventricular drains in place. Every year in the United States, over 25,000 patients have an EVD placed and there are many more placed around the world. Many of these patients with EVDs require surgery and anesthesia care. During the perioperative period anesthesia and critical care professionals may be responsible for management of the EVD. Patients with EVDs are at risk for complications related to the EVD during this time and worse neurological outcomes. Complications may include the following:

• Over-drainage
• Under-drainage
• Inadvertent administration of unwanted medications into the brain
• And Intrahospital transport-associated complications of elevated intracranial pressures.

Anesthesia professionals are called upon to be perioperative clinicians. When patients with EVDs present to the operating room or ICU, we must be proficient in EVD management in order to help keep patients safe.

Now, let’s go through the EVD safety campaign. This is a global patient safety initiative with an EVD Knowledge Hub which provides valuable resources to provide the highest quality of care to patients with EVD. Check out the link in the show notes to take you to the knowledge hub. The goal for this campaign is to improve patient outcomes by ensuring the highest standards of care for the management of external ventricular drains or EVDs.  Here are the objectives:

1. “Raise Awareness:
   1. Increase awareness about the importance of EVD management among healthcare professionals.
   2. Highlight the risks associated with improper EVD management.
2. Provide Education:
   1. Develop and disseminate educational resources and materials for perioperative clinicians.
3. Promote Standardized Guidelines:
   1. Promote evidence-based guidelines for the perioperative care of patients with EVDs.
   2. Encourage the adoption of these guidelines in healthcare institutions globally.
4. Enhance Clinical Proficiency:
   1. Improve the clinical skills of anaesthesiologists and critical care providers in managing EVDs.
   2. Ensure healthcare professionals are comfortable and competent in EVD management practices.
5. Reduce Complications:
   1. Identify and mitigate risks associated with EVD management.
   2. Work towards reducing the incidence of EVD-related complications such as over drainage, under-drainage, and infections.
6. Foster Collaboration:
   1. Promote collaboration among different healthcare teams to ensure cohesive and comprehensive patient care.
   2. Engage with stakeholders to support and enhance EVD management protocols.”

Now, that we have outlined the objectives of the EVD Safety Campaign, let’s review the guidelines for EVD management. In 2017, SNACC created a task force to develop evidenced-based practice recommendations for the perioperative care of patients with external ventricular drains. We love a good set of guidelines to help us keep patients safe. Here is a summary:

1. “Comprehensive Preoperative Assessment: It is critical to perform a detailed baseline neurological examination, check the setting and output of the EVD and review any trends in intracranial pressure (ICP) and cerebrospinal fluid (CSF) characteristics before surgery. This ensures that any changes during the procedure or post-procedure can be quickly identified and addressed.
2. Preparation for Transporting Patients: When transporting patients with EVD, specific measures must be confirmed such as the clamping status of the drain, head-of-bed (HOB) elevation, and ensuring proper levelling at the external auditory meatus. These measures are crucial to maintain drain function and prevent complications during movement. Intracranial pressure monitoring should be carried out in every transport.
3. Intraoperative Management: During surgery, it is important to continuously monitor and manage the indwelling drains. This includes confirming tubing identification, HOB status, and levelling of EVD to ensure accurate function and pressure readings.
4. Communication and Documentation: Detailed communication and documentation between caregivers, especially during handoffs between intensive care and anaesthesia providers, are emphasized. Providing complete details of the EVD settings, along with any significant intraoperative changes, is essential for ongoing patient management.
5. Monitoring and Response to Changes: Key indicators such as sudden changes in CSF drainage, CSF colour, and ICP waveform should be monitored closely. Specific thresholds for drain output and other changes are set to prompt immediate clinical response, ensuring timely intervention to prevent complications.”

We encourage you to check out the full guidelines by Lele and colleagues, “Perioperative Management of Adult Patients with External Ventricular and Lumbar Drains: Guidelines from the Society for Neuroscience in Anesthesiology and Critical Care.” I will include a link to the PDF in the show notes as well.

We have been talking about EVD management for a little while, so I think it is time for a quiz. If you head over to the EVD safety campaign resource page, you will find the EVD quick to test your knowledge on EVD management. The questions will test essential concepts from the fundamentals of EVD placement and monitoring to management and troubleshooting complications. This quiz will provide you with an opportunity to build knowledge, sharpen decision-making skills, and develop a better understanding of best practices for EVD management. We will be back next week and the following week for a three-part discussion on the EVD safety campaign, so we hope that you will take a moment during the week to complete the quiz.

There are a few more items to check out. SNACC developed an educational video to provide additional information about how to level and zero the EVD collecting system. This may be really helpful to review if you know that you will be providing care for a patient with an EVD.

Another great resource is the EVD Education Document created by the SNACC task force in 2017. Let’s take a look at it for a quick education review and we hope that you tune in during Part 3 of this series as we dive even further into EVD education.

First up, here are some of the indications for EVD placement:

• Acute symptomatic hydrocephalus which may involve Aneurysmal Subarachnoid Hemorrhage (SAH), Intracerebral and Intraventricular Hemorrhage with decreased level of consciousness, and Acute ischemic cerebellar stroke in concurrence with decompressive craniectomy
• ICP Monitoring in Traumatic Brain Injury which may involve TBI with post resuscitation GCS of 3-8, and abnormal CT scan defined as one with hematomas, contusions, swelling, herniation or compressed basal cisterns, Severe TBI with a normal CT scan if two or more of the following features are noted on admission (age over 40 yrs., unilateral or bilateral motor posturing, or SBP < 90 mmHg, and for the management of patients with intracranial hypertension after TBI
• Malfunctioning or infected ventriculo-peritoneal shunts, and other neurological emergencies occurring due to infective, and neoplastic diseases which may involve facilitation of intraoperative brain relaxation and targeted therapeutic interventions such as Recombinant tissue Plasminogen Activator in patients with IVH and in patients with SAH, Treatment of vasospasm after aneurysmal SAH, and Antibiotics in management of central nervous system infections.

Here are the complications associated with EVD placement:

• Hemorrhage including Intracerebral hemorrhage, tract hematoma or tract hemorrhages (0-41%)
• Neuraxial hematoma (0-3.2%)
• Neural injury
• Infection (0-28% EVD)
• Malposition
• Occlusion and malfunction
• Over drainage of CSF which may lead to Subdural or epidural hematoma, Re-bleeding from a ruptured cerebral aneurysm, Intracranial hypotension, Cerebellar tonsillar herniation, Paradoxical herniation, or Pneumocephalus
• Iatrogenic vascular injury (arteriovenous fistula, cerebral pseudo aneurysm)
• Fracture of catheters, with retained fragment of catheter
• Inadvertent injections of drugs
• Post dural puncture headache

We will continue our education review next week, but we are definitely off to a good start. Let’s continue to make our way through the EVD Safety Campaign.

Anesthesia professionals are also called upon to be leaders in the hospital to help keep patients safe. Are you planning on revising your hospital’s policy and procedures regarding EVDs? Check out the evidence-based policy and procedure template that can be found on the resource page or in the show notes. This will help you to be able to implement best practices at your institution with our customizable template The template is based on evidence-based guidelines regarding insertion and maintenance of EVDs.

Another important way to keep patients safe is by gather more information and we have resources so that you can collect data on quality and safety regarding EVDs. SNACC has created a list of electronic clinical quality metrics that you can start implementing at your hospital. These metrics are based on the evidence-based recommendations. Check it out on the EVD Safety Campaign page or in the show notes.

We will be back next week to continue our discussion on the EVD Safety Campaign, starting with an interview with Abhijit Lele, who developed this incredible resource and was the lead author for the 2017 EVD Guidelines. The EVD Safety Campaign provides the foundation for an education session that you can go through on your own or invite a few colleagues and reviews these materials with your perioperative team or anesthesia department. With the APSF resource, all you need to do is bring the coffee.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

How would you like some APSF gear? We have all-new APSF branded vests. You could stay warm while showing your support for the ASPF just by making an annual recurring contribution of $250 or more to the APSF. That’s right individuals making annual recurring contributions of $250 or greater will receive a free APSF vest. Plus, these contributions are listed in the quarterly publications of the APSF Newsletter and on the APSF website. Check out the Donors page over at apsf.org under the donors heading and I will include a link in the show notes. Just think you could be wearing an APSF vest while listening to the Anesthesia Patient Safety Podcast.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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