Standardized Ventriculostomy Protocol without an Occlusive Dressing: Results of an Observational Study in Patients with Aneurysmal Subarachnoid Hemorrhage

Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions

BACKGROUND

External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications.

METHODS

We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t² and I² tests were utilized. To evaluate for publication bias, a funnel plot was developed.

RESULTS

There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I²) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I²: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I²: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I²: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies.

CONCLUSIONS

In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.

External Ventricular Drains: Development and Evaluation of a Nursing Clinical Practice Guideline

External ventricular drains (EVDs) are common in intensive care for neurocritical patients affected by different illnesses. Nurses play an essential role to ensure safe care, and guidelines are tools to implement evidence-based care. Thus, the aim of this study was to develop and evaluate the quality of a clinical guideline for critically ill patients with EVDs. Methodological research was conducted. The guideline development was based on a scoping review about nursing care to patients with EVDs. The guideline evaluation occurred in two phases: evaluation of its methodological rigor, with application of the Appraisal of Guidelines Research and Evaluation II to four experts on guidelines evaluation; and the Delphi technique, with a panel of nine specialists in neurocritical care, performed in two rounds. Data were analyzed by descriptive statistics and content validity ratio. In the first phase of the evaluation, three domains did not reach consensus, being reformulated. The second phase was conducted in two rounds, with nine and eight participants respectively, with 13 recommendations being reformulated and reassessed between rounds, inclusion of an EVD weaning category, and two flowcharts on patient's transport and mobility. Therefore, the guideline can be incorporated into nursing care practices. Further studies are necessary to assess its impact on clinical practice.

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.

Predictors of ventriculostomy-associated infections: A retrospective study of 243 patients

OBJECTIVE

Risk factors of ventriculostomy-associated infection (VAI) reported in the literature are variable due to heterogeneity of external ventricular drainage (EVD) procedures and management. This study aimed to assess the rate of VAI and its risk factors.

METHODS

The authors retrospectively reviewed the medical records of patients older than 18 years who received EVD catheterizations between January 2015 and December 2020.

RESULTS

Among 243 patients with 355 catheters, twenty-three VAIs were identified, yielding VIA rates of 9.5% per patient and 6.5% per catheter. VAI was associated with a longer total EVD duration (29.2 days vs. 15.8 days, P < 0.001), a longer procedural time (72 minutes vs. 40 minutes, P < 0.001), intraoperative ventriculostomy (39.1% vs. 9.1%, P < 0.001), craniotomy (87.0% vs. 60.9%, P = 0.014), and other systemic infections (30.4% vs. 8.2%, P = 0.004). On multivariate analysis, a longer total EVD duration (OR = 1.086, P < 0.001), intraoperative ventriculostomy (OR = 6.119, P = 0.001), and other systemic infections (OR = 4.620, P = 0.015) were associated with VAI. There was no statistical difference between the VAI rates of patients with and without prophylactic EVD exchanges at mean 12.6 days (7.1% vs. 2.2%, P = 0.401).

CONCLUSIONS

Intraoperative ventriculostomy was independently associated with VAI. Prophylactic EVD exchange at 12.6 days did not lower VAI rate.

Effectiveness of a Standardized External Ventricular Drain Placement Protocol for Infection Control

INTRODUCTION

Placement of an external ventricular drain (EVD) is a common procedure routinely completed at bedside by neurosurgical residents. A standardized protocol for placement and maintenance of an EVD is potentially useful.

METHODS

This single-institution retrospective review analyzed all patients who underwent placement of an EVD over a 5-year span using a standardized protocol.

RESULTS

A total of 428 EVDs in 381 patients were placed as per this protocol. Overall compliance with the practice protocol was 98.7%. Overall, our infection rate was 1.86% (8 external ventricular drain-related infection [ERIs] over 428 EVDs). There was no difference in age for the ERI cases (median 55, range (50.5-60.5), compared with the non-ERI cases (median of 53, range [38-65]) (P = 0.512). Indications for placement of EVD were hemorrhage (51.9%, n = 198), tumor (16.2%, n = 62), trauma (12.8%, n = 49), hydrocephalus (11.5%, n = 44), cerebellar stroke (2.8%, n = 11), infection (3.1%, n = 12), unknown (1.3%, n = 5). Most EVDs (77.6%, n = 296) were placed bedside by second-year residents (median PGY level 2, interquartile range 1-2.75). Computed tomography confirmed placement in the ipsilateral frontal horn in 72% (n = 277) of EVDs. EVD-related complications were noted in 8.3% of EVDs (n = 32, with 8 infections and 24 tract hemorrhages). The median EVD duration was 10 days; duration of EVD had no statistically significant impact on the risk of an ERI (P = 1). Only replacement of an EVD was associated with an increased risk of infection.

CONCLUSIONS

Adherence to a standard EVD placement protocol is useful in maintaining a low risk of ERI regardless of the duration of catheter utilization. Replacement of the catheter through the same access hole as the original catheter is associated with an increased risk of ERI.