Lowering External Ventricular Drain Infection Rates in the Neurocritical Care Unit: 12-Year Longitudinal Experience at a Single Institution

Object The authors explored the relationship among the duration of external ventricular drainage, revision of external ventricular drains (EVDs), and cerebrospinal fluid (CSF) infection to shed light on the practice of electively revising these drains. Methods In a retrospective study of 199 patients with 269 EVDs in the intensive care unit at a major trauma center in Australasia, the authors found 21 CSF infections. Acinetobacter accounted for 10 (48%) of these infections. Whereas the duration of drainage was not an independent predictor of infection, multiple insertions of EVDs was a significant risk factor. Second and third EVDs in previously uninfected patients were more likely to become infected than first EVDs. An EVD infection was initially identified a mean of 5.5 ±0.7 days postinsertion (standard error of the mean); these data—that is, the number of days—were normally distributed. Conclusions This pattern of infection is best explained by EVD-associated CSF infections being acquired by the introduction of bacteria on insertion of the drain rather than by subsequent retrograde colonization. Elective EVD revision would be expected to increase infection rates in light of these results, and thus the practice has been abandoned by the authors' institution.

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

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000094 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Sachin A Kothari ◽

Mevish S Siddiq ◽

Scott Rahimi ◽

Manan Shah ◽

Klepper A Garcia

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Vasospasm ◽

Neurocritical Care ◽

External Ventricular Drain ◽

Third Ventriculostomy ◽

Chi Square ◽

Normal Limits ◽

Chi Square Analysis ◽

Weaning Criteria

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 <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<0.001) and EVD wean failures (p<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).

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The implementation of an external ventricular drain care bundle to reduce infection rates

British Journal of Neurosurgery ◽

10.1080/02688697.2020.1725436 ◽

2020 ◽

Vol 34 (2) ◽

pp. 181-186

Author(s):

Sayed Samed Talibi ◽

Adikarige HD Silva ◽

Fardad T. Afshari ◽

James Hodson ◽

Stuart AG Roberts ◽

...

Keyword(s):

External Ventricular Drain ◽

Care Bundle ◽

Infection Rates

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A Retrospective Quality Analysis of External Ventricular Drain Infection Rates Following Stroke Diagnoses and Other Brain Injuries: Comparison of Emergency Room and ICU/OR Setting

Cureus ◽

10.7759/cureus.7173 ◽

2020 ◽

Cited By ~ 1

Author(s):

David Altschul ◽

Mousa K Hamad ◽

Andrew Kobets ◽

Rose Fluss ◽

Christopher Lin ◽

...

Keyword(s):

Emergency Room ◽

Brain Injuries ◽

External Ventricular Drain ◽

Quality Analysis ◽

Infection Rates

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Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism

The Neuroradiology Journal ◽

10.1177/19714009211024633 ◽

2021 ◽

pp. 197140092110246

Author(s):

Fawaz Al-Mufti ◽

Stephan A Mayer ◽

Gurmeen Kaur ◽

Daniel Bassily ◽

Boyi Li ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Care Management ◽

Neurocritical Care ◽

External Ventricular Drain ◽

High Grade ◽

Selective Treatment ◽

Poor Grade ◽

Cardiopulmonary Support ◽

Aggressive Care ◽

Improvement In Survival

Background and purpose Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. Materials and methods We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. Results Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. Conclusions Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.

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External ventricular drain infection: improved technique can reduce infection rates

British Journal of Neurosurgery ◽

10.3109/02688697.2011.578770 ◽

2011 ◽

Vol 25 (5) ◽

pp. 632-635 ◽

Cited By ~ 36

Author(s):

William J. Kitchen ◽

Navneet Singh ◽

Sharon Hulme ◽

James Galea ◽

Hiren C. Patel ◽

...

Keyword(s):

External Ventricular Drain ◽

Infection Rates ◽

Improved Technique

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

Journal of Neurosurgery ◽

10.3171/2018.5.jns172881 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1620-1624

Author(s):

Debayan Dasgupta ◽

Linda D’Antona ◽

Daniel Aimone Cat ◽

Ahmed K. Toma ◽

Carmel Curtis ◽

...

Keyword(s):

Infection Rate ◽

Perioperative Care ◽

Best Practice ◽

Simulation Training ◽

External Ventricular Drain ◽

Sampling Technique ◽

Care Bundle ◽

Infection Rates ◽

Improvement Project ◽

Csf Diversion

OBJECTIVETemporary 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.METHODSA 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.RESULTSBaseline 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%.CONCLUSIONSSimulation training and standardizing the perioperative care of patients requiring EVDs dramatically improved placement accuracy, reduced infection rates, and reduced EVD displacement rate.

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