▪

Final recommendations

CVR *Round 1Round 2▪Dressing should be performed with 0.9% saline and 0.5% alcoholic chlorhexidine every 24 h, or earlier if necessary, assessing the aspect of the operative wound and inspecting catheter insertion, covering with sterile gauze, wrapping with bandages. Dressing change is usually performed by nurses, and if there is any change with the insertion of catheter, the neurosurgery team must be notified [13].0.77NA▪Dressing changes, when using impermeable film, should be performed weekly, or earlier if the dressing is in unacceptable condition, such as peeling off or dirty, in order to minimize direct contact of the catheter with the external environment [13,19,27]. The transparent dressing provides better visualization of the catheter insertion site and allows monitoring of the catheter insertion site [27].0.55NA▪System handling should be kept to a minimum to ensure that infection risks are minimized. Procedures touching EVD components, such as the sampling port or drainage bag or dressing changes, for example, must be sterile [28].1.00NA▪The drainage bag should be emptied when it reaches 2/3 or 3/4 of its volume capacity, as if it is too full, it can become heavy and could alter or even stop the function of the system and the drainage of CSF [28].0.55NA▪If the catheter has been pulled, it must not be repositioned, or even aspirate or administer solutions when it is obstructed. The neurosurgery team must be called whenever there are any changes, due to the high risk of infection and complications [29].1.00NA▪The nursing team should be aware of any changes in the color of the drained CSF, which may change according to the patient’s clinical condition. If blood is present in the CSF, it may be indicative of cerebral hemorrhage; if there is a cloudy or sedimented appearance it may be indicative of infection. If any atypical staining is noted, the neurosurgery team must be called [29].1.00NA▪CSF collection should be performed only when infection is suspected. Routine CSF collection is not recommended [13].1.00NA▪0.5% alcoholic chlorhexidine is recommended for disinfecting the sample port from the EVD [30,31].1.00NA▪The bedside position of the patient should be kept at a 30° angle, head in neutral position and aligned to the cervical spine. The aim is to facilitate venous return, reducing intracranial pressure without interfering in the EVD drainage system [29,32].0.551.00▪Clamping the EVD system is safe as long as ICP 30]. The system should be kept clamped for as short a time as possible, then unclamped and the entire system checked. It is important to continuously monitor ICP, including during procedures, examinations, and patient transport [29,31].0.110.75▪The EVD system must be reviewed in order to avoid changes in drainage back pressure and to provide the correct measurement of intracranial pressure. The erroneous leveling of the system can cause alterations in the liquoric drainage, and possible complications in this case are intracranial hypertension, ventricular collapse, and subdural hematoma, among others [7,30].0.550.50▪The height of the CSF drainage level corresponds to a horizontal line from the Monro foramen—at the level of the external acoustic meatus (EAM)—to the level of back pressure prescribed by the neurosurgeon, usually between 10 and 20 cmH2O. An open EVD at 10 cm above the EAM means that if the ICP is 0 to 10 cmH2O, there will be no drainage [26,28,29]. However, if the ICP is greater than 10 cmH2O, there will be drainage [33]. It is not possible to estimate ICP based on CSF drainage volume, as this is a measurement obtained by other methods [34].0.110.75▪Check the appearance of dressing every 6 h for moisture indicative of CSF leakage or for signs of inflammation at the catheter insertion. A sterile dressing should be applied to the insertion site when the catheter is properly positioned and there are no signs of infection or CSF leakage, and should be performed by experienced, specialist nurses. It must remain occlusive and dry continuously, covering the insertion. The frequency of dressing change should follow the standardized format of each institution, according to the coverage used and what is indicated by the manufacturer, but it should also be changed whenever it is dirty/wet and should be handled as little as possible [27].0.331.00▪Rigorous evaluations of consciousness level, using the Glasgow Coma Scale, should be performed, especially in cases of confused or cognitively impaired patients, to ensure that the catheter remains adequately secured and is not pulled out or removed accidentally due to some period of psychomotor agitation. It may also detect early neurological deterioration and signs of sensory impairment due to excessive CSF drainage. In addition, pain should be assessed concurrently with the Glasgow Coma Scale, using standardized scales appropriate for the patient, since pain can be one of the causes for agitation [13].0.551.00▪The volume of CSF drained in ml every 6 h shift must be recorded, calculating the 24 h total. Drainage volume depends on numerous variables (for example: individual physiological production–450 to 700 mL/day, underlying disease, communicating or non-communicating hydrocephalus, bleeding, leveling of the system, etc.). In some situations, increased volume is a reflection of the underlying disease, and this physiological response is important to maintain adequate or near normal CPP. However, if there is a significant change in drainage volume in a short period of time, the entire system should be reviewed, as should the positioning of the headboard. If nothing is identified, neurosurgical evaluation should be requested. If an error in the manipulation of the system is identified, the team should be provided with guidance in real time [29].0.550.50▪When the EVD system is open, the transducer may not represent the ICP waveform correctly. To measure ICP with the EVD system, it is necessary to clamp the system every hour as briefly as possible until the P1, P2, and P3 waves are formed, which indicate more accurate ICP, and then to unclamp the system [30].0.331.00▪When drugs are introduced by the neurosurgery team through the EVD catheter, such as tissue plasminogen activator for intraventricular hemorrhage or antibiotics for ventriculitis, for example, the system should be closed for 1 h after administration so that it is not drained along with excess CSF, as long as there is no significant change in ICP and CPP [30].0.330.75▪It is recommended that samples be collected from the proximal port, using aseptic technique. The manipulation of the system itself already carries a higher risk of infection, and routine collection is not recommended, so that the material collected from the proximal port with proper care is more reliable [13]. This procedure is performed by the neurosurgery team or by trained nurses, when the neurosurgery team agrees. In addition, samples should not be collected from the collection bag due to rapid degradation of CSF components [30].0.110.75▪It is important to observe whether the system’s dropper flow is properly positioned. If there is minimal or no drainage, the system should be checked for kinks, obstructions, or any clogging. You can also use the system permeability technique to ensure that there is no obstruction by carefully bringing the system below the level to check for CSF dripping. Reduced drainage can cause remodeling of the hydrocephalus. It is therefore important to record all drainage volumes, as their absence can mean that the catheter is obstructed. It is also important to make sure that there is no catheter traction or CSF leakage [29].1.001.00▪Leveling the system at the height of the external acoustic meatus allows the pressure transducer to be in line with the foramen of Monro. This action ensures the reliability of the monitoring and operation of the system. The leveling check should be performed at every change of patient’s bedside height and at least once per shift [27,29,30].1.001.00▪Early mobilization in patients with EVD is safe and feasible, and no major complications have been related to early mobilization [35,36]. Furthermore, it does not alter ICP and CPP parameters in patients with EVD [37] and, when in favorable clinical conditions (MAP > 80 mmHg, ICP 70 mmHg), can be safely tolerated by the patient with minimal risk for adverse effects. It is important that a nurse and/or physiotherapist accompany the patient on the first time out of bed [37]. The zero point must be reviewed and maintained as prescribed by the medical team. In case of change of angulation or if the patient is sitting on the chair, the system must be reviewed.0.251.00