What are the steps for external ventricular drain (EVD) insertion and setup?

External Ventricular Drain Insertion and Setup Protocol

The implementation and adherence to a standardized EVD bundled protocol that addresses insertion, management, education, and monitoring is essential for reducing complication and infection rates in patients requiring external ventricular drainage. 1

Pre-Procedure Preparation

Infection Prevention

• Administer preprocedural antimicrobials such as cefazolin to reduce the risk of surgical site infections and central nervous system infections 1
• Perform perioperative chlorhexidine shampoo and hair clipping, taking care to avoid skin abrasions 1
• Consider using antibiotic-impregnated catheters (minocycline and rifampin-impregnated or silver-coated) which significantly reduce infection rates (risk ratio 0.31) 1

Equipment Setup

• Prepare sterile field with all necessary equipment
• Select appropriate catheter size and type (consider antibiotic-impregnated options) 1
• Ensure EVD system is properly assembled and ready for connection

Insertion Technique

Positioning and Site Preparation

• Position patient appropriately (typically supine with head elevated 30-45 degrees)
• Mark Kocher's point (standard entry site): 10-11 cm posterior to nasion and 2.5-3 cm lateral to midline
• Perform strict aseptic technique throughout the procedure 1
• Use chlorhexidine for skin preparation 1

Insertion Steps

1. Make a small skin incision at the marked entry point
2. Create a burr hole using a twist drill
3. Open the dura using a small incision
4. Insert the catheter perpendicular to the skull surface, aiming toward the ipsilateral medial canthus
5. Advance the catheter to a depth of approximately 5-6 cm or until CSF return is observed
6. Secure the catheter to the scalp with sutures
7. Consider subcutaneous tunneling of the catheter to reduce infection risk, especially in institutions with high infection rates 1
8. Connect the catheter to the EVD system

EVD System Setup and Management

Initial Setup

• Set the drip chamber at the prescribed height (typically at the level of the foramen of Monro or external auditory meatus)
• Ensure all connections are secure and the system is properly leveled
• Apply sterile dressing to the insertion site 1

Ongoing Management

• Implement standardized protocols for EVD care and maintenance 1
• Use aseptic technique for all EVD manipulations 1
• Minimize manipulation of the device and system 1
• Follow institutional protocols for dressing changes and system maintenance 1
• Monitor for signs of infection or complications

CSF Sampling Protocol

• Limit CSF sampling to when clinically necessary 1
• Use strict aseptic technique when obtaining samples 1
• Clean EVD access ports while wearing mask and gloves 1
• Avoid routine EVD exchange as it has not been shown to reduce infection rates 1

Monitoring and Documentation

• Monitor the number of EVD catheter days 1
• Track infection rates using a uniform definition for ventriculostomy-associated infection 1
• Document all EVD parameters, including:
  • CSF output
  • EVD height setting
  • CSF appearance
  • Neurological status

Staff Education and Training

• Ensure healthcare professional training on insertion and management 1
• Maintain staff education and competency assessment 1
• Use standardized EVD order panels 1

Complication Prevention

• Implement EVD care bundles, which have been shown to reduce infection rates from 21 to 9 cases per 1000 EVD-days 2
• Minimize the duration of EVD placement when clinically feasible 1
• Be vigilant for CSF leakage around the catheter and insertion site dehiscence, which significantly increase infection risk 3

Common Pitfalls and Caveats

• Avoid frequent CSF sampling, as it increases infection risk 2
• Do not perform routine EVD exchange, as it does not reduce infection rates 1, 4
• Be aware that prior brain surgery associated with CSF diversion significantly increases infection risk (HR 8.08) 3
• Recognize that EVD infections lead to prolonged hospital stays (23 vs 16 days) 3
• Implement comprehensive EVD bundles rather than isolated interventions, as this approach has shown sustained reduction in infection rates over long-term follow-up 4

By following this standardized protocol for EVD insertion and management, infection rates can be significantly reduced from rates as high as 27% to as low as 4.8% 5, 4.