External Lumbar Drains - Best Practice Guidelines

Publication: 23/09/2015  --
Last review: 28/08/2018  
Next review: 28/08/2021  
Clinical Guideline
CURRENT 
ID: 4332 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

External Lumbar Drains - Best Practice Guidelines

Introduction

An external lumbar drain (ELD) is a closed sterile temporary system, which allows drainage of cerebrospinal fluid (CSF) from the lumbar subarachnoid space.

The common uses of ELDs within the Neurosciences Unit include:

  • Treatment of communicating hydrocephalus (e.g. in subarachnoid haemorrhage)
  • Prevention and treatment of CSF fistula (i.e. leakage)
  • Facilitation of safe brain retraction during surgery
  • Diagnosis and prognostication of treatment response in normal pressure hydrocephalus

The aim of these guidelines is to outline best practice for the use of ELDs, thus ensuring patient safety and high standard of care.

These guidelines are based on LTHT External Ventricular Drains – Best Practice Guidelines and are meant to be an extension of the lumbar drain section of the document. The reader is encouraged to refer to the original document, which contains background information on anatomy and physiology of CSF as well as recommendations on CSF drainage.

This is the 1st edition of the guidelines.

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Background

 ELDs are inserted by appropriately qualified and trained staff as outlined in Appendix D. While insertion can be done at the bedside, operating department should be preferred whenever possible (especially in stable patients who do not require critical care) to maximise aseptic conditions. In cases where it is necessary to deviate from this recommendation, the responsible Consultant must be informed. Regardless of the location chosen, a protected area around the patient is established, and maximum precautions are taken to prevent contamination of the drain.

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Procedure

  1. Confirm patient identity and rule out contraindications to ELD placement (Appendix B). Explain the procedure to the patient (where possible), and complete the relevant consent form.
  2. Prepare a lumbar drain insertion trolley (see Appendix C). The procedure is carried out in the presence of an assistant, who at the same time acts as a chaperone (refer to LTHT Chaperoning policy for more details).
  3. Place the patient in lateral decubitus position (sitting position is also possible), maximising flexion of the spine by bringing the knees up and flexing the neck. Maintain the patient's dignity at all times and only expose the area that is required for the procedure.
  4. Having washed hands with soap and water in accordance with LTHT Hand Hygiene Policy, establish the midline and the Tuffier's line (the line connecting the iliac crests that usually corresponds to the L3/4 interval or L4 spinous process). Estimate the level of insertion: L3/4 or L4/5 is usually preferred.
  5. At this stage, put on surgical hat and face mask, perform surgical scrub (using chlorhexidine or povidone iodine surgical soap) as detailed in LTHT Surgical Scrub, Gowning & Gloving Policy, and put on sterile gown and gloves aseptically.
  6. Clean the surgical site with chlorhexidine (0.5% in 70% alcohol); alternatively, alcoholic povidone iodine may be chosen where chlorhexidine is contraindicated (e.g. allergy). If chlorhexidine spray is used, it is advised to soak a swab with it rather than applying the spray directly on the skin. It is felt that in addition to antimicrobial action, using a swab will assist in removing possible microparticles from skin surface. The swab should be held with an artery clip (included in minor op pack) to prevent glove contamination with chlorhexidine. Should contamination occur, gloves ought to be changed to avoid the possibility of chlorhexidine coming into contact with neural tissues. Apply the disinfectant by pressing the swab against the centre of the chosen area and work your way out, allowing it to dry. Be sure to clean the area near the natal cleft last before disposing of the swab.
    Currently no safety information is available regarding use of 2% chlorhexidine in procedures involving potential contact with CSF/neural tissues; for that reason, only 0.5% chlorhexidine in 70% alcohol solution should be employed.
  7. Cover the surgical site with a fenestrated drape. Sterility of the field is further facilitated by the use of additional adhesive drapes, where necessary.
  8. Lidocaine is the local anaesthetic of choice; 1% should be used (refer to British National Formulary for safe dosing). After checking the local anaesthetic with the assistant, infiltrate the skin using a 25G needle. Once the skin has been anaesthetised, administer the remaining anaesthetic to deeper tissues with a 21G needle, aspirating the syringe after each repositioning of the needle to ensure the tip is not within a vessel or the subarachnoid space.
  9. After checking that the skin has been adequately anaesthetised, ensure that the bevel of the spinal needle is directed towards the flank, and insert the needle. Continue to advance until a fall in resistance is felt (upon traversing the interspinous ligament).
  10. Remove the stylet. If no CSF is obtained, replace the stylet and advance the needle in increments, re-checking for CSF.
  11. As soon is CSF egress is achieved, insertion of the ELD has to be robust to prevent excessive CSF losses. If indicated, opening pressure can be measured at this stage. Tunnelling may be performed depending on the preferences of the Consultant responsible.
  12. The needle is rotated so that the bevel of the needle is directed cephalad. The stylet is then discarded, and 15-20 cm of the drain (estimated using the markings on the drain) is threaded in. The spinal needle is withdrawn. The tip protector is fed over the distal end of the drain, and the adaptor is attached. A silk tie is used to secure the adaptor, and the protector is pulled back over the tie until it engages with the adaptor. If desired, a CSF sample can now be collected although routine sampling on insertion is discouraged.
  13. Prior to securing the drain, further local anaesthetic is given around the insertion site using a 25G needle. The drain is pig-tailed and sutured to skin using three-point fixation.
  14. The area covered with appropriate interactive dressing, and the drain is connected to a sterile closed drainage system. It is crucial that the dressing is placed well away from the natal cleft to avoid faecal contamination. Bringing the drain around the flank and out to the front helps to keep it visible for the patient at all times, thus reducing the chance of disconnection.

After procedure

Ensure an operation note is built on Bluespier. A copy should be printed, signed and included in the medical notes. Be sure to specify opening pressure (where measured), whether a CSF sample has been sent, what drainage parameters and position of the patient are desired.

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Nursing care and management of the patient with an ELD

Nursing staff can play an important role in educating and supporting patients even before an ELD is placed. The aim is to improve compliance with activity restrictions and reduce complications. Patients and families should be explained about restrictions such as the need to maintain the head of bed at a chosen angle and the need for the patient to request nursing assistance prior to any movement. In addition, patients are advised to avoid sneezing, coughing, and straining, because those actions increase intracranial pressure and thus affect CSF drainage. The nursing routine of drain maintenance and patient assessment should be described to the patient. Patients and their relatives should have an opportunity to ask questions before the drain is inserted (Thompson, 2000).

Continuous assessment of both the patient and the drain is vital in preventing complications and in meeting the goal of lumbar drainage. The patient is normally kept in bed while the drain is in place. The operation note and the care plan should specify if strict bed rest is required. CSF should be assessed hourly for colour, clarity, and amount drained. Generally, the drain can be clamped for brief periods during care activities and patient movement.

The insertion site is assessed for signs and symptoms of infection or leakage at least twice every day. Dressing changes are usually carried out only if the dressing is soiled and interactive (e.g. Tegaderm) dressing is preferred. The drainage bag is changed when ¾ full using aseptic technique and the 3-way-port proximal to the bag is clamped to prevent flow of CSF before change.

The reader is encouraged to refer to the "Summary of nursing care" section of LTHT External Ventricular Drains – Best Practice Guidelines for further details on nursing care. 

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Positioning of the ELD and CSF drainage

The head of the bed position is determined by the rationale for drain placement. For example, in patients with a CSF leak associated with a base-of-skull fracture, the head of the bed is elevated in an attempt to tamponade the site of the leak with the brain and meninges. In contrast, a dural tear in the lumbar spine would require a flat position to reduce the gravitational pressure at the leak site (Thompson, 2000).

After positioning the patient, the drainage system is placed at the level prescribed in the operation note. This level is determined by the management approach for patients with ELDs. Two main methods are used: draining at a specific anatomic level, and draining to a specified volume of CSF.

Draining at a specific level is used primarily in patients with subarachnoid haemorrhage who have communicating hydrocephalus. The level for drainage is determined by the responsible Consultant, although generally it will be at the external auditory meatus (EAM) which is the reference point for the foramen of Monro.

Draining to a specific volume is used mainly in the repair of CSF leaks. In this case, the volume of CSF that is to drain during a specific period is ordered, for example 10-15 ml/h. Gravity is used to achieve the desired volume of CSF output. Lowering the drain below the previous level increases output whereas raising the drain above the previous level decreases output. The upper and lower limits of manipulation may vary, but the drain should not be raised above the level of the EAM because backflow of CSF may occur.

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Complications associated with ELD

Inadequate drainage of CSF in patients with hydrocephalus may cause the ventricles to enlarge with subsequent rises in ICP.
This may occur if:

  1. The drainage system is placed too high above the level of the foramen of Monro thus minimising CSF drainage.
  2. CSF drainage is obstructed. This may occur if the tubing is kinked or inadvertently clamped, the three way tap is turned the wrong way, the drainage bag is full or tissue/thick CSF blocks the system.

Overdrainage of CSF may also occur if the system is placed too far below the level of the foramen of Monro, if there is disconnection in the drainage system, or with CSF bypassing the drain resulting in CSF leak. This excessive drainage may cause the ventricles to collapse and pull the brain tissue away from the dura. While usually resulting in low-pressure headaches that may be associated with nausea/vomiting (Governale et al, 2008; Puzzilli et al, 1998), in extreme cases this can cause tearing of the blood vessels and lead to a subdural (1.3%) or subarachnoid haemorrhage (0.4%) (Governale et al, 2008).

Tentorial herniation may be caused by either excessive or insufficient drainage of CSF. Symptoms include:

  • Severe headache
  • Lethargy
  • Drowsiness
  • Irritability
  • Apnoea
  • Sluggish pupillary responses
  • Abnormal reflexes
  • Changes in BP and heart rate

All of the above signs and symptoms require prompt intervention (Scheinblum and Hammond, 1990).

In patients who have ELD placed as a treatment for CSF fistula, the head-up position may precipitate a negative gradient between atmospheric pressure and intracranial pressure, leading to enlarging pneumocephalus. If the exchange of CSF and air is rapid, the thermally expansile air can act as a space occupying lesion creating mass effect, especially if there is a one-way valve action at the fistula (Graf et al, 1981).

Other complications of ELD include procedural complications potentially requiring fluoroscopic guidance (4.3%), radicular pain (2.6-14%) and shearing/retention of catheter tip (0.4%) (Governale et al, 2008; Puzzilli et al, 1998).

Infection

Infection remains one of the most significant complications of ELD. The incidence of ELD-related infections is described at 0.8-7.8% (Hetem et al, 2010; Leverstein-van Hall et al, 2010; Governale et al, 2008; Schade et al, 2005; Coplin et al, 1999; Greenberg and Williams, 2008; Al-Tamimi et al, 2012; van Aken et al, 2004; Acikbas et al, 2002). Because of limited and at times conflicting evidence available regarding infection prevention in patients with ELDs, the ensuing represents a consensus agreement within Leeds Centre for Neurosciences and follows a consultation with Microbiology and Anaesthesiology colleagues.

Some authors recommend the use of prophylactic antibiotics on insertion (Leverstein-van Hall et al, 2010; Governale et al, 2008; Coplin et al, 1999) or continuously until the catheter is removed (Puzzilli et al, 1998; Shapiro and Scully, 1992). This practice is not advocated within the unit at the LGI.

An appropriate interactive dressing should be applied over the insertion site. The dressing should not be routinely changed unless visibly soiled, in which case full asepsis must be assumed.

The nurse at the bedside must observe the ELD for evidence of CSF leakage. Leakage can occur as a result of CSF bypassing the insertion site, in which case the dressing will become wet. It can also occur at any connection ports throughout the system or as a result of damage to the drain tubing. A routine check of these must be made at least once per shift. It is paramount that the leakage is stopped at the earliest opportunity to prevent complications of CSF infection and overdrainage. In case the leakage is caused by disconnection or damaged tubing, it is important to avoid excessive CSF losses by applying an artery clip or similar proximal to the defect, and prevent contamination of the system by putting sterile cover over the disconnected/damaged portion. Regardless of the cause, medical review must be sought promptly. Where continuity of the drainage system has been compromised, strong consideration ought to be given to changing the drain.

Drain-associated infection may clinically present with neurological symptoms (headache, meningeal signs, cranial nerve signs), fever, and/or abnormal blood results. When there is clinical suspicion of drain-associated infection, the following steps must be taken:

  • CSF sample obtained (prior to initiating treatment)
  • Computed tomography of the brain with contrast considered to rule out ventriculitis
  • Empirical antimicrobials commenced
  • Change of the drain or a drain-free period considered whenever possible
  • Antibiotics stopped after 72 hours if CSF cultures are negative

CSF should be sampled for Gram-stain, microbiology and cultures only when an infection is suspected to reduce the risk of introducing contamination in the system. CSF sampling is the responsibility of qualified medical staff who have had the relevant training and been deemed competent (see Appendix D). All the precautions used with external ventricular drains apply when undertaking maintenance and access of the ELD system.

A survey carried out within the unit has demonstrated that drain-related infections peak approaching 7 days of drainage (see Appendix A). While the limited literature does not suggest an association between duration of drainage and ELD-related infections, this correlation has been supported in a number of studies dealing with external ventricular drains. Although routine (“prophylactic”) change of ELDs is not recommended unless there is evidence of malfunction or infection, the unit advocates the need for the ELD to be reviewed 5-6 days after insertion.

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Removal of ELD

The ELD is removed by a neurosurgeon. The skin must be sutured at the insertion site with non-silk material using an aseptic technique, with strict adherence to LTHT Hand Hygiene, Standard Precautions and Asepsis policies and covered with an appropriate interactive dressing and the stitch removed after 5-7 days. Removal documentation must mention whether the tip of the drain was visualised.

Tips should only be sent for culture if infection is suspected. Tip cultures were shown to be false-positive for infection in 48% of cases (Hetem et al, 2010), and with any clinical suspicion of ELD-related infection both CSF and tip should be sent for culture. More weight should be given to CSF microscopy/cultures than tip cultures. On removal of the ELD, the patients’ neurological observations must be monitored closely. As patients can present with ELD-associated infection after removal of the drain (Hetem et al, 2010), it has been agreed that the patients are monitored in the hospital for at least 24 hours prior to discharge.

A neurosurgeon must be informed immediately if the patient's condition deteriorates or if there is any CSF leakage.

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Provenance

Record: 4332
Objective:

Aims

To decrease the rate of ELD-related complications.

Objectives

To provide recommendations for insertion, management and removal of ELDs in Neurosciences patients as well as to create a protocol of managing the most common complications of external lumbar drains.

Clinical condition:

Handling external lumbar drains (ELDs)

Target patient group: Any patient undergoing insertion of ELD
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Evidence level: D (Leeds consensus).
References:

  • Açikbaş SC, Akyüz M, Kazan S, Tuncer R. Complications of closed continuous lumbar drainage of cerebrospinal fluid. Acta Neurochir (Wien). 2002 May;144(5):475-80.
  • Al-Tamimi YZ, Bhargava D, Feltbower RG, Hall G, Goddard AJ, Quinn AC, Ross SA. Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage: a prospective, randomized, controlled trial (LUMAS). Stroke. 2012 Mar;43(3):677-82.
  • British National Formulary: Lidocaine Hydrochloride.
    https://www.medicinescomplete.com/mc/bnf/current/PHP8697-lidocaine-hydrochloride.htm
  • CDC/NHSN Surveillance Definitions for Specific Types of Infections. 2015.
    http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf
  • Coplin WM, Avellino AM, Kim DK, Winn HR, Grady MS. Bacterial meningitis associated with lumbar drains: a retrospective cohort study. J Neurol Neurosurg Psychiatry. 1999 Oct;67(4):468-73.
  • Governale LS, Fein N, Logsdon J, Black PM. Techniques and complications of external lumbar drainage for normal pressure hydrocephalus. Neurosurgery. 2008 Oct;63(4 Suppl 2):379-84; discussion 384.
  • Graf CJ, Gross CE, Beck DW. Complications of spinal drainage in the management of cerebrospinal fluid fistula. J Neurosurg. 1981 Mar;54(3):392-5.
  • Greenberg BM, Williams MA. Infectious complications of temporary spinal catheter insertion for diagnosis of adult hydrocephalus and idiopathic intracranial hypertension. Neurosurgery. 2008 Feb;62(2):431-5; discussion 435-6.
  • Hetem DJ, Woerdeman PA, Bonten MJ, Ekkelenkamp MB. Relationship between bacterial colonization of external cerebrospinal fluid drains and secondary meningitis: a retrospective analysis of an 8-year period. J Neurosurg. 2010 Dec;113(6):1309-13.
  • Leeds Teaching Hospitals NHS Trust (2013) External Ventricular Drains - Best Practice Guidelines.
    detail.aspx?ID=913
  • Leeds Teaching Hospitals NHS Trust (2014) Positive Identification of Patients Policy.
    detail.aspx?ID=528
  • Leeds Teaching Hospitals NHS Trust (2014) Consent to Examination or Treatment Policy.
    detail.aspx?ID=890
  • Leeds Teaching Hospitals NHS Trust (2015) Policy for the Chaperoning of Patients During Examination, Investigation or Clinical Recording.
    detail.aspx?ID=890
  • Leeds Teaching Hospitals NHS Trust (2014) Hand Hygiene Policy.
    detail.aspx?ID=673
  • Leeds Teaching Hospitals NHS Trust (2014) Surgical Scrub, Gowning & Gloving.
    detail.aspx?ID=3936
  • Leeds Teaching Hospitals NHS Trust (2013) Standard Precautions Policy.
    detail.aspx?ID=895
  • Leeds Teaching Hospitals NHS Trust (2013) Asepsis Guideline.
    detail.aspx?ID=1672
  • Leeds Teaching Hospitals NHS Trust (2014) Positive Identification of Patients Policy
    detail.aspx?ID=528
  • Leverstein-van Hall MA, Hopmans TE, van der Sprenkel JW, Blok HE, van der Mark WA, Hanlo PW, Bonten MJ. A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections. J Neurosurg. 2010 Feb;112(2):345-53.
  • Puzzilli F, Mastronardi L, Farah JO, Ruggeri A, Lunardi P. Cytochemical and microbiological testing of CSF and catheter in patients with closed continuous drainage via a lumbar subarachnoid catheter for treatment or prevention of CSF fistula. Neurosurg Rev. 1998;21(4):237-42.
  • Schade RP, Schinkel J, Visser LG, Van Dijk JM, Voormolen JH, Kuijper EJ. Bacterial meningitis caused by the use of ventricular or lumbar cerebrospinal fluid catheters. J Neurosurg. 2005 Feb;102(2):229-34.
  • Scheinblum ST, Hammond M. The treatment of children with shunt infections: extraventricular drainage system care. Pediatr Nurs. 1990 Mar-Apr;16(2):139-43.
  • Shapiro SA, Scully T. Closed continuous drainage of cerebrospinal fluid via a lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula. Neurosurgery. 1992 Feb;30(2):241-5.
  • Thompson HJ.  Managing patients with lumbar drainage devices. Crit Care Nurse. 2000 Oct;20(5):59-68.
  • van Aken MO, Feelders RA, de Marie S, van de Berge JH, Dallenga AH, Delwel EJ, Poublon RM, Romijn JA, van der Lely AJ, Lamberts SW, de Herder WW. Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis. Pituitary. 2004;7(2):89-93.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix A. Cumulative risk of infection with external lumbar drainage in the Leeds Centre for Neurosciences (based on 37 consecutive drains, September 2014).

Cumulative risk of infection
Text Box: Risk per day
Days after insertion

Appendix B. Contraindications to external lumbar drain placement.

  • Non-communicating hydrocephalus or intracranial mass lesion.
  • Coagulopathy (check INR, APTT, platelets).
  • Local sepsis.
  • Ventriculitis (patient will usually require an external ventricular drain instead).

Appendix C. Trolley contents for external lumbar drain insertion.

  • Medtronic EDM Lumbar Drainage Kit (ref: 27303).
  • Medtronic Becker External Drainage and Monitoring System (ref: 27702).
  • Racialle minor op pack (silver): sterile instruments and a fenestrated drape (ref: RSET5004).
  • Surgical hat, face mask, appropriately sized sterile gown and gloves.
  • 0.5% alcoholic chlorhexidine spray or povidone iodine alcoholic solution.
  • 2% lidocaine (5 ml) or 1% lidocaine (10 ml, drawn from two 5 ml ampoules).
  • 5-10 ml syringe.           
  • Needles: G25 (orange), G21 (green), hypodermic with a filter.
  • Nylon suture 3-0.
  • Silk suture 2-0.
  • Large Tegaderm (or similar interactive) dressings.
  • Hypofix strips.
  • Gauze.
  • Barrier Adhesive Op Sheet (ref: 777025) - optional.
  • Skin marker - optional.
  • Spinal manometer - optional.
  • 25 ml universal container (white top) for CSF sampling - optional.

Appendix D - Declaration of competence

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