Patient Education & Consent

Explain the procedure to the patient and family. Consent should be obtained from the patient or a responsible family member. Obtain written consent from the patient or family per institution protocol.

Equipment

Several prepackaged EVD kits are commercially available. Equipment includes the following:

Preoperative gram-positive antibiotic prophylaxis (cefuroxime 1.5 g IV before the procedure)
Hair clipper
Sterile gloves/drapes/mask
Chlorhexidine solution
Sterile fenestrated drape
Sterile marker for drawing standard landmarks on head for placing EVD
Syringe (3 mL) for local anesthetic
Needle (18 gauge, 3/4 in) for injecting local anesthetic
Local anesthetic (usually 1% lidocaine with epinephrine)
Skin knife/scalpel #15
Twist drill
Sterile spinal needle (18 or 20 gauge) to puncture dura
Ventriculostomy drain (antibiotic or nonantibiotic impregnated)
External drainage set/Buretrol (including drainage tubing and sterile collection bag)
Sterile CSF collection tubes for sending CSF as specimen
Suture material
Dressings (4X4)
IV pole and standard ICP transducer setup (similar to arterial-line setup that is used for measuring blood pressure)

Equipment for intraparenchymal fiberoptic catheter placement includes the following:

Sterile gloves/mask/gown
Local anesthetic (usually 1% lidocaine with epinephrine)
Chlorhexidine or Betadine solution
Sterile fenestrated drapes or towels
Syringe (3 mL) for local anesthetic
Needle (25 gauge 3/4 inch) for injecting anesthetic
Sterile spinal needle (18 gauge) for puncturing dura
Small skin retractor
ICP monitor "bolt" to secure the ICP fiberoptic probe
No. 36 drill bit (2.71-mm diameter) with safety stop
Spacer/guard to adjust seating depth of bolt
Strain relief protective sheath
Stylet (1.3-mm diameter) to ensure no debris in the bolt prior to inserting the fiberoptic probe
Hex wrench to secure the drill bit into the drill
Zero adjustment tool for zeroing the fiberoptic probe to the atmospheric pressure
Fiberoptic catheter
Two small plastic dressings (Tegaderm) to place on the zero-adjustment screw so it is not moved during manipulation later

EVD placement

The procedure should be performed in an ICU only under strict sterile precautions.

A “time out” is done for correct site identification, per nursing protocol.

Perform a baseline neurological assessment.

Intraparenchymal fiberoptic catheter placement/intraparenchymal pressure monitor kit

Open the intracranial pressure monitor kit with a sterile technique and inspect expiration dates.

Perform a baseline neurological assessment.

Wash hands.

Illuminate the area.

Intraparenchymal fiberoptic catheter placement

Adequate anesthesia should be ensured for the procedure.

Positioning

The patient should be placed in a supine position.

During placement of the monitor, the physician should be comfortable, so the height of the bed should be adjusted accordingly.

Elevate the head of the bed 15-30° while keeping it in the midline position with pillows or sandbags to enhance cerebral venous outflow. Even slight movement of the head to a few degrees off midline may double the ICP.

After the procedure, an elevation of 30° is optimal for allowing brain perfusion while minimizing ICP.

Technique

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Author

Gaurav Gupta, MD, FAANS, FACS Associate Professor of Neurosurgery, System Co-Director, Cerebrovascular and Endovascular Neurosurgery, Fellowship Director, Endovascular Neurosurgery Fellowship (Site), Department of Surgery, Division of Neurosurgery, Rutgers RWJ Barnabas Healthcare, Rutgers Robert Wood Johnson Medical School

Gaurav Gupta, MD, FAANS, FACS is a member of the following medical societies: American Academy of Neurology, American Association for the Advancement of Science, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, Congress of Neurological Surgeons, Facial Pain Association, Society for Neuroscience, Society of NeuroInterventional Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Sudipta Roychowdhury, MD Clinical Associate Professor of Radiology, Department of Radiology, Rutgers Robert Wood Johnson Medical School; Attending Radiologist/Neuroradiologist, University Radiology Group, PC

Sudipta Roychowdhury, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Neuroradiology, Medical Society of New Jersey, Radiological Society of New Jersey, Radiological Society of North America, Society of NeuroInterventional Surgery

Disclosure: Nothing to disclose.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery, Director of Epilepsy Surgery, Attending Neurosurgeon, University Hospitals Cleveland Medical Center; Director, Functional and Restorative Neurosurgery Center, UH Cleveland Medical Center Neurological Institute; Associate Professor of Neurosurgery, Fellowship Director, Functional and Stereotactic Neurosurgery, Associate Residency Program Director, Department of Neurosurgery, Surgical Director, Neuromodulation Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Epilepsy Society, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Neuromodulation Society, North American Neuromodulation Society, Ohio State Neurosurgical Society, Society of Neurological Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.