subdural drain...what to do?

[APNgonnabe]

I am a new grad in a critical residency (we orient ect. for 6months in Neuro/Burn & Cardiac Icu)...so with that said. I had a pt with subdural hematoma. I did find that it is common to put a subdural drain in however I was unable to find what is best practice to care for that drain. The drain stopped putting out (it was draining about 10ml/hr). We received order to irrigate w/ 5-10ml q1hr. Any insight is welcomed.

[beatarmy]

A subdural drain will stop putting out, once the blood is evacuated and the bleeding has stopped. Generally, then the surgeon d/c's the drain, and everyone gets on with their lives.

[APNgonnabe]

so have you heard of irrigating?

[beatarmy]

Never heard of irrigating a subdural drain, but I assume it's to ensure that the line there's no more drainage, rather than the line being clotted.

[GrnHonu99, RN]

I have irrigatated a SD drain, however, usually if it stops putting out then that means there isnt anything else to come out.

[gasmaster]

Yes, have irrigated them as well. Typically you never insert more than 5ml at a time per AANN standards. Also make sure it's non-bacteriostatic saline. Usually though we just pull the darn things once they stop. You run a high risk with irrigation because many patients will develop pneumocephaly once the blood has drained and flushing can trap the air resulting in tension pneumocephaly.

[Indy, LPN, LVN]

Allright, silly question. What's the difference between saline and bacteriostatic saline? My facility's pharmacy doesn't stock bacteriostatic saline per policy.

[gasmaster]

Bacteriostatic saline has preservatives in it. You have to use the preservative free saline for the brain. Bacteriostatic saline can cause brain tissue necrosis, abcess, seizures, and/or meningitis. Not anything you want to subject your patient to. That's why you want to make sure that all meds given intrathecal are preservative free as well.

[LadyNASDAQ]

Yep, I've seen that irrigating order lots of times. I always, always refuse to follow that. I tell the Doc that I was taught this was a Dr. only thing to do and will NEVER follow that order. It's easy to do and it can also get you into court really fast! Any changes after you as the Nurse do it is all the way your fault. My ICU Teacher was an awesome Nurse. This was >20 years ago but that one lecture has kept me safe and sound for almost 30 years of practice.

[auzzieneuronurse]

I've never irrigated a subdural drain or heard of them being irrigated. ???fairly uncommon practice. Post evacuation of SDH the pt would be lying flat for 24-48/24 with the drain tube on thumb print suction and lower that the patients head. Once the drainage has slowed/stopped its generally time for the medical staff to remove them. Surely instructions to irrigate every hour would dramatically increased the risks of infection opening up a sterile system each time????

[Aquarian]

I think that you are ALL CORRECT!

The post above is referring to management of Chronic SDH where elevation of ICP is unusual post-operatively, thus pxs are generally maintained supine with minimal elevation of the head for at least 24 hrs to allow some re-expansion of the brain. No external ventricular drainage (ventriculostomy) maintainance for relieving inc. ICP and for ICP measurement.

While the original post and the others following it were referring to post-surgical management of Acute SDH such as those resulting from trauma where ICP is continiously monitored and relieved via venticulostomy (among other modalities of tx). Irrigation is done to clear debris or fibrin deposits from the ICP catheter to allow better waveform transmission and drainage of CSF. But this is often considered an advance practice procedure. Therefore, only physicians, or ARNPs and PAs under a neurosurgeon's guidance may irrigate/instill a solution into the ventriculostomy. Only after proper instruction and with physician's order should an RN does it ( depends on your hospital's policy and procedure manual). The one who irrigates must be familiar with ICP dynamics and the potential adverse outcome from both non-functioning ventriculostomy and irrigation of the catheter.

Procedure:1. Obtain MD order to irrigate with PFNS (preservative-free normal saline).

2. Draw up ordered amount of the solution.

3. Apply mask and sterile gloves.

4. Cleanse the injection port closest to the insertion site of the ventriculostomy drainage system for a full minute w/ betadine and air-dry.

5. Clamp ventriculostomy drain with the clamp attached to the set-up.

6. Make sure the system is free of air bubbles.

7. Inject the solution gently.

8. Do not aspirate to avoid pulling brain tissue into the catheter.

9. Reopen drain per MD order.

10. Observe drain and waveform.

11. Notify MD if the amount of irrigant or drainage does not return to normal.

12. Document procedure, date, time, type and amount of irrigation, waveform pre- and post-procedure and the pressure recordings.

[Creamsoda, ASN, RN]

In our hospital, RN's NEVER irrigate the drain. We can irrigate the tubing if needed, as long as the drain is off to the patient. We have been taught that flushing it towards the patient is something nuerosurgery, or the attending does.

Cher