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Review
. 2019 Nov 26;19(12):94.
doi: 10.1007/s11910-019-1009-9.

Evidence-Based Management of External Ventricular Drains

David Y Chung  1   2 , DaiWai M Olson  3 , Sayona John  4 , Wazim Mohamed  5 , Monisha A Kumar  6 , Bradford B Thompson  7 , Guy A Rordorf  8
Affiliations
Review

Evidence-Based Management of External Ventricular Drains

David Y Chung et al. Curr Neurol Neurosci Rep. .

Abstract

Purpose of review: The optimal management of external ventricular drains (EVD) in the setting of acute brain injury remains controversial. Therefore, we sought to determine whether there are optimal management approaches based on the current evidence.

Recent findings: We identified 2 recent retrospective studies on the management of EVDs after subarachnoid hemorrhage (SAH) which showed conflicting results. A multicenter survey revealed discordance between existing evidence from randomized trials and actual practice. A prospective study in a post-traumatic brain injury (TBI) population demonstrated the benefit of EVDs but did not determine the optimal management of the EVD itself. The recent CLEAR trials have suggested that specific positioning of the EVD in the setting of intracerebral hemorrhage with intraventricular hemorrhage may be a promising approach to improve blood clearance. Evidence on the optimal management of EVDs remains limited. Additional multicenter prospective studies are critically needed to guide approaches to the management of the EVD.

Keywords: External ventricular drain; Length of stay; Vasospasm; Ventriculoperitoneal shunt; Wean.

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Conflict of interest statement

Conflict of Interest David Y. Chung, Sayona John, Wazim Mohamed, Monisha A. Kumar, and Guy A. Rordorf each declare no potential conflicts of interest. DaiWai M. Olson is the Editor in Chief, Journal of Neuroscience Nursing. Bradford B. Thompson reports Investigator Meeting travel-related reimbursements from BARD.

Figures

Fig. 1
Fig. 1
Number of predefined wean attempts alone can determine rate of ventriculoperitoneal shunt (VPS) placement between rapid and gradual wean groups. The figure defines a hypothetical scenario where a rapid or gradual wean is started on day 5 following EVD placement. Only 2 wean failures are tolerated prior to placing a VPS. The rapid wean consists of immediate clamping of the EVD. The gradual wean consists of stepwise raising of the EVD that culminates in a clamp trial. A 24-h period is used to determine success or failure of wean. The scenario assumes in both cases that the EVD could be successfully discontinued on or after day 10, unbeknownst to the clinician.
See this image and copyright information in PMC

References

    1. Gigante P, Hwang BY, Appelboom G, Kellner CP, Kellner MA, Connolly ES. External ventricular drainage following aneurysmal subarachnoid haemorrhage. Br J Neurosurg. 2010;24(6):625–32. - PubMed
    1. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711–37. 10.1161/STR.0b013e3182587839. - DOI - PubMed

    1. Fried HI, Nathan BR, Rowe AS, Zabramski JM, Andaluz N, Bhimraj A, et al. The insertion and management of external ventricular drains: an evidence-based consensus statement: a statement for healthcare professionals from the Neurocritical Care Society. Neurocrit Care. 2016;24(1):61–81

      •• A consensus statement from the Neurocritical Care Society which systematically reviewed the evidence on the insertion and management of EVDs and concluded that “EVD weaning should be accomplished as quickly as is clinically feasible so as to minimize the total duration of EVD monitoring and [ventriculostomy-related infection] risk.”.

    1. Olson DM, Batjer HH, Abdulkadir K, Hall CE. Measuring and monitoring ICP in Neurocritical Care: results from a national practice survey. Neurocrit Care. 2014;20(1):15–20. - PubMed

    1. Chung DY, Leslie-Mazwi TM, Patel AB, Rordorf GA. Management of external ventricular drains after subarachnoid hemorrhage: a multi-institutional survey. Neurocrit Care. 2016. 10.1007/s12028-016-0352-9

      • This study surveyed neurocritical care units in the United States. The authors found high practice variance and that the majority of institutions take a continuous CSF drainage and a gradual EVD wean approach.

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