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Perioperative Management of Adult Patients with External Ventricular

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Perioperative Management of Adult Patients with External Ventricular SPECIAL ARTICLE Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care Abhijit V. Lele, MBBS, MD, MS,* Amie L. Hoefnagel, MD,w Nina Schloemerkemper, MD, Dr. med., FRCA,z David A. Wyler, MD,y Nophanan Chaikittisilpa, MD,8 Monica S. Vavilala, MD,z Bhiken I. Naik, MBBCh,# James H. Williams, MD, PhD,** Lakshmikumar Venkat Raghavan, MBBS, MD, FRCA, FRCPC,ww and Ines P. Koerner, MD, PhD,zz Representing SNACC Task Force for Developing Guidelines for Perioperative Management of External Ventricular and Lumbar Drains Key Words: external ventricular drain, ventriculostomy, lumbar Abstract: External ventricular drains and lumbar drains are drain, guidelines, perioperative, management, leveling, trans- commonly used to divert cerebrospinal fluid and to measure port, checklist, competency cerebrospinal fluid pressure. Although commonly encountered in the perioperative setting and critical for the care of neuro- (J Neurosurg Anesthesiol 2017;29:191–210) surgical patients, there are no guidelines regarding their man- agement in the perioperative period. To address this gap in the literature, The Society for Neuroscience in Anesthesiology & xternal ventricular drains (EVDs) and lumbar drains Critical Care tasked an expert group to generate evidence-based E(LDs) are temporary devices placed into the lateral guidelines. The document generated targets clinicians involved ventricles of the brain and lumbar subarachnoid space, in perioperative care of patients with indwelling external ven- respectively, to facilitate external cerebrospinal fluid tricular and lumbar drains. (CSF) drainage and to monitor CSF pressure. Their Received for publication December 22, 2016; accepted December 27, 2016. From the Departments of *Anesthesiology & Pain Medicine, Neurocritical Care Service; 8Anesthesiology and Pain Medicine; zAnesthesiology and Pediatrics, Harborview Injury Prevention and Research Center (HIPRC), Harborview Medical Center, University of Washington, Seattle, WA; wDepartment of Anesthesiology, University of Florida, UF Health, Jacksonville, FL; zDepartment of Anesthesiology & Pain Medicine, University of California Davis Medical Center, Sacramento, CA; yJefferson Hospital of Neuroscience, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA; #Department of Anesthesiology & Neurosurgery, University of Virginia Health System, Charlottesville, VA; **Department of Anesthesiology, University of North Carolina at Chapel Hill, N2201 UNC Hospitals, Chapel Hill, NC; wwDepartment of Anesthesia and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada; and zzDepartment of Anesthesiology & Perioperative Medicine, Neurosciences ICU, Oregon Health Sciences University, Portland, OR. A.V.L.: manuscript design, manuscript write-up, Tables 1 to 6, Figures 1A, 1B, 2A, 2B, Sections 1 to 6, developing clinical competencies for EVD/LD among clinicians involved in perioperative care, continued medical education and following a perioperative checklist for management of EVD/LD, review and approve final manuscript. A.L.H. and N.S: manuscript write-up, Section 1: Introduction, indications and contraindications, review and final approve manuscript. D.A.W.: manuscript write-up, Section 2: Preoperative assessment of patients with EVD or LD, review and approve final manuscript. N.C. and M.S.V.: manuscript write-up, Section 3: Transporting patients with EVD or LD, review and approve final manuscript. B.I.N. and J.H.W.: manuscript write-up, Section 4: Intraoperative management of external ventricular and lumbar drains, review and approve final manuscript. L.V.R. and I.P.K.: manuscript write-up, Section 5: Management of external ventricular drains (EVD)/lumbar drains (LD) in special clinical scenarios, review and approve final manuscript. A.L.H. has received honoraria from Design Science Consulting Inc.; N.S. has received consulting fee from Mizuho OSI. The other authors have no conflicts of interest to disclose. Address correspondence to: Abhijit V. Lele, MBBS, MD, MS, Department of Anesthesiology & Pain Medicine, Neurocritical Care Service, Har- borview Medical Center, University of Washington, 325, 9th Avenue, Seattle, WA 98104 (e-mail: [email protected]). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.jnsa.com. Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/ANA.0000000000000407 J Neurosurg Anesthesiol Volume 29, Number 3, July 2017 www.jnsa.com | 191 Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved. Lele et al J Neurosurg Anesthesiol Volume 29, Number 3, July 2017 placement is considered one of the most frequently per- incorporating the inputs and suggestions from the formed procedures in neurologically critically ill pa- SNACC Board of Directors, the approved version was tients,1–3 with the majority placed in patients with placed on the SNACC Web site (http://www.snacc.org) subarachnoid hemorrhage (SAH), intracerebral hemor- for member review and comments for a period of 1 rhage, and obstructive hydrocephalus.4 Although the month, with the final version of the guideline confirmed worldwide incidence of placement of EVD and LD is after incorporating member input. largely unknown, it is estimated that 500,000 ven- triculostomies were placed in the United States alone between 1988 and 2010.4 Since its first placement in 1744, EVDs have undergone numerous changes in materials, AVAILABILITY AND STRENGTH OF EVIDENCE techniques, and indications.5–7 The task force worked with a medical librarian to EVDs are commonly encountered in perioperative create a systematic strategy to search PubMed: (external care by clinicians, specifically the anesthesia providers ventricular drain*[tw] OR external ventricle drain*[tw] who might have limited experience in their management. OR extraventricular drain*[tw] OR extra ventricular Furthermore, mismanagement of EVDs can have cata- drain*[tw] OR ventricular catheter*[tw] OR ventricular strophic consequences. Despite their importance, there access device*[tw] OR lumbar drain*[tw] OR cere- are currently no guidelines for the perioperative man- brospinal fluid drain*[tw] OR csf drain*[tw]) OR (ven- agement of EVD and LD. triculostom*[tw] AND (drain*[tw] OR catheter*[tw])). The format of this search was adapted for Embase through Elsevier. Search results were limited to journal METHODOLOGY articles and conference papers published in English and Purpose of the Guidelines last updated on December 26, 2016. The total search re- These evidence-based guidelines aim to provide sults (7936 references) were downloaded to Endnote. recommendations related to EVD and LD regarding (1) After 2729 duplicates were removed, 5207 articles were common indications, contraindications, complications, imported to a Covidence database for team review. Au- and patient preparation for placement and maintenance; thors had previously identified 119 additional articles, (2) preoperative assessment of patients; (3) transporting and 91 articles were found by the authors including patients; (4) intraoperative management including mon- checks of reference lists as the review progressed. itoring and CSF drainage; (5) management of these drains Several rounds of screening were conducted, with under special circumstances; and (6) creating a perioper- review of each of the titles and abstracts from the original ative checklist, clinical competency, and continued med- search by 2 reviewers. Inclusion criteria were all study ical education. types in adults, and exclusion criteria were nonhuman studies, laboratory investigations, and pediatric literature. Application References addressing infectious complications and pre- vention strategies published before the 2015 Neurocritical These guidelines are intended for the use by clini- 8 cians involved in perioperative care of adult patients with Care Society (NCS) guidelines and those addressing CSF EVDs and LDs. drainage for spinal cord protection published before the 2010 ACC guidelines9 were eliminated. Ultimately a pool Task Force Members of 646 references were identified and organized by topic The initial concept and design of “Society for for the individual section authors to draw upon in con- Neuroscience in Anesthesiology & Critical Care struction of the guidelines. (SNACC) EVD/LD project” began in November 2015, We used the American Heart Association methodo- logy for the level of evidence for each recommendations and an EVD/LD task force was finalized in December 10 2015. This task force comprised of 10 neuro- proposed (Table 1). anesthesiologists and neurointensivists practicing at aca- demic medical centers across the United States and Canada. These 10 individuals were chosen after an e-mail SECTION 1: INTRODUCTION TO EVDs AND LDs invitation was sent to all active SNACC members seeking project membership. Applicants were required to have Common Indications for Placement of EVDs published peer-reviewed neuroscience research or have and LDs documented experience in the care of patients with EVD EVDs function as intracranial pressure (ICP) and LD. The task force members agreed on criteria for monitors and as conduits for external CSF diversion. evidence and then evaluated peer-reviewed studies per- LDs, in contrast, function primarily as a conduit for ex- taining to EVD and LD (search strategies described in
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