continuous monitoring with EVD???

Specialties Neuro

Published

Specializes in PICU/NICU.

Ok all you Neuro ICU RNs- need some help here. So, I'm on my last day of orientation and my preceptor has to leave early today. So I continue on and give report to this "not so welcoming" RN that releived me. Let me first say that neurosurgeries are new to this unit, however, I have worked with head trauma pts with EVDs at previous jobs. Anyway, this pt had an EVD set at +20 open to continuous drain. - not a camino- just a simple EVD drain. I was always taught that you either drain or monitor- not able to do both at the same time. You are off to the transducer and open to drain, then to get an accurate ICP you turn the drain off and then get your waveform and ICP number. That being said, as you are draining, your transducer is off- right?

The oncoming nurse got her panties in a wad because the alarm was off- (because you are not able to continually monitor) so- the number on the monitor is not accurate unless the stopcock is off to drain and such there is no need to alarm a number that is not accurate right?

So, she is telling me that you can monitor trends and you should not need to turn the stopcock to get a reading. How can you monitor a trend when you are off to the transducer? Am I completely nuts? Have I had it all wrong? I know you can do continuous monitoring via camino. But this is just a simple drain.

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there are two issues here; how to position the stop cock on the evd, and turning patient alarms off. i'll address the alarm issue first.

i never turn off alarms, particularly to invasive devices. this can be a big safety issue. if the limits are appropriately set then they alert you to changes in your patient's condition. leaving the alarms on will also notify you if any of you monitoring devices have become dislodged or disconnected.

i am not sure which system you are using so the following is applicable to the becker evd and monitoring system. the 3-way stop cock can be positioned to allow the following:

off to transducer, open to drain: only allows for drainage of csf; does not monitor pressure or display true wave form.

off to drain, open to transducer: if properly zeroed and leveled will display an accurate icp and appropriate wave form; does not allow for drainage of csf.

open to both drain and transducer: allows for drainage of csf and will display icp and wave form. due to the fact that the csf is going to take the path of least resistance and flow into the drip chamber neither the icp or waveform is going to be accurate. it has been my experience that regardless of what the icp actually is, the displayed value typically remains 1 - 3. this will allow you to leave the alarms on.

if the patient is ordered to be "open at x" i will leave the stop cock open to both the transducer and drain. when i come in to do my hourly checks, i turn the stop cock off to the drain. this allows me to obtain an accurate icp and that hours csf drainage. i also suction, reposition, etc. while i have the drain closed. when done i reposition the drain and open the stop cock to both the transducer and drain.

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Specializes in PICU/NICU.

Thanks Char! I totally understand the safety of turning off monitors and do not turn off alarms of waves that I am actually measuring. I will even usually leave the CVP alarm on and set way high even when I am infusing meds through it.

However, as you mentioned in your post.........

the stopcock is off to the transducer and open to drain-- OFF to the transducer-- not measuring anything right? So why alarm this number? (The system we use does not allow open to both- either or.)

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You might side step this issue with predetermined time frames to open to drain and in between monitoring the waveform. for example order open to drain q 15min for 5 minutes. could be q 30 or q 1hr but you get the idea. This allows for drainage and monitoring. You would need the doc to order this. You could silence the alarm for this short time frame without turning it off.

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Specializes in ICU/PACU.

I hear what you are saying. Even if it is open to the transducer too, it's not an accurate reading, it involves air pressure or something....so my present manager has told me. But, at one place I worked at we were able to monitor the icp while draining (I can't remember the name of the evd).

So, not sure which EVD you are using...as the above poster said, you can measure ICP while draining, but I have used a drain where you couldn't, even if was open to the transducer, it was not an accurate reading. Generally though, best to keep all alarms on. Even if you clamp it for a minute while turning your pt or etc.. , it's nice to hear that alarm when the icp is really high...so you know, oh, i need to open it back up.

I hate ****** nurses, I really do. God does it ruin my day when I have to give report to someone like that.

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Specializes in MICU, NSICU.
there are two issues here; how to position the stop cock on the evd, and turning patient alarms off. i'll address the alarm issue first.

i never turn off alarms, particularly to invasive devices. this can be a big safety issue. if the limits are appropriately set then they alert you to changes in your patient's condition. leaving the alarms on will also notify you if any of you monitoring devices have become dislodged or disconnected.

i am not sure which system you are using so the following is applicable to the becker evd and monitoring system. the 3-way stop cock can be positioned to allow the following:

off to transducer, open to drain: only allows for drainage of csf; does not monitor pressure or display true wave form.

off to drain, open to transducer: if properly zeroed and leveled will display an accurate icp and appropriate wave form; does not allow for drainage of csf.

open to both drain and transducer: allows for drainage of csf and will display icp and wave form. due to the fact that the csf is going to take the path of least resistance and flow into the drip chamber neither the icp or waveform is going to be accurate. it has been my experience that regardless of what the icp actually is, the displayed value typically remains 1 - 3. this will allow you to leave the alarms on.

if the patient is ordered to be "open at x" i will leave the stop cock open to both the transducer and drain. when i come in to do my hourly checks, i turn the stop cock off to the drain. this allows me to obtain an accurate icp and that hours csf drainage. i also suction, reposition, etc. while i have the drain closed. when done i reposition the drain and open the stop cock to both the transducer and drain.

i completely agree. this has been my experience. i won't turn off an alarm for invasive lines either simply because i may forget to turn them back on or forget to pass on to the next nurse that the alarm is off (although they need to check their alarms) but one of the biggest reasons is liability. if you get busy with pt b and pt a get their ventric pulled out, who will notice? at least an alarm will bring attention to you or another nurse or monitor tech, etc. btw-go herd!!

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Turning the alarm off should not be confused with silencing the alarm. I always keep the alarm on but may hit the silence button while turning, repositioning etc. The first thing I do is check the alarm parameters and make sure the silence parameter is set for no more than a minute or two. Using the silence doesn't set one up for a big surprise the way turning an alarm off can. Not all monitors allow fine tuning of the silence duration so if yours doesn't don't turn off the alarm for any reason.

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