Codman ventriculostomy without monitoring

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Hey all you neuro nurses. I have a question that is haunting me.

I worked with a TBI patient in a trauma ICU a few weeks ago. Patient was s/p cranie, readmitted from rehab after change in mental status. Discovered his VP shunt was infected. VP shunt was revised with ventriculostomy inserted for drainage/intrathecal therapy. ICPs never monitored that I know of. Patient is better know, but intrathecal therapy continues, so the ventric remains in. They were using Codmans, but I felt uncomfortable knowing that all his CSF could drain out of her head without any alarms alerting me or any sort of value shut off. Eyeballing was the only guarantee that everything was safe. Order was to leave the drain open post therapy.

Does AANN say anything about this sort of practice?

Thank you!!

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Specializes in Anesthesia.

Was the drain ordered to be set at a specific level? Like 15 cmH20 or something? This is usually the case. If the pt. decides to get up and gravity suddenly causes the drain to dump 20 cc of csf while you leave the room.....just clamp the drain for an hour or so and then re-open as usual. Not sure about the AANN and its been a while since I have worked with ventric's in the ICU. Usually when I deal with them now, they're clamped as I'm dropping my pts. off at PACU s/p crani/VP shunt revision where orders are in place for the nurses to adjust the ventric per neurosurgery.

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Thanks for the reply. Yes, it was ordered to loop at 15. But seems to me a dangerous practice to leave it unclamped, considering the patient was not sedated, and it's only purpose was for therapy.

Thoughts????

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Specializes in Anesthesia.

As long as the pt. was not sedated and A+0x3, you just need to educate them and say that if they want to sit up or stand up they need to call you before they do, so that you can temporarily clamp the ventric and adjust as necessary. Most alert pts. are aware of this and it only takes one or two times for them to learn of this happening. Often when pts. decide to stand up or make a large bodily adjustment, gravity allows the open ventric to drain copious csf (I have seen up to 40-50 cc's). When someone suddenly dumps 40 cc's of csf, a common symptom can be a HA. When this happens, just clamp the drain for a few hours. For example, the pt. puts out an average of 10 cc/hr......and suddenly he stands up and dumps 40cc's. Just clamp the ventric for about 3-4 hours and re-open again. I always made sure to let the NP or attending know just to cover my A$$. Hope this helps.....Best of luck.

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Hey crna1982

just wanted to thank you for the info. It did help. The patient was a TBI, so trusting his movements was part of my concern.

Classicaldreams

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Specializes in Anesthesia.

No problem!

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Specializes in Neuro, Critical Care.

shouldnt be an issue, its open at 15 just like an evd and then you are using the codman basically together with the VP shunt to work like a regular EVD. If its set to 15 it shouldnt "dump" unless the ICP rises above 15 and you would see that on the codman. If they pt. is moving around in be and moving the HOB then id clamp the drain until they arent moving...id do the same with an EVD. pretty much the same thing if you think about it...EVDs stay open and dont have an alert if too much drains off...you just have to check it every half hour or so

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What bad things could happen if:Drain clamped for transport to OR for open craniotomy and drain is left clamped during procedure?

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Specializes in Anesthesia.

A clamped drain for an open crani is ok because the skull is open. The bone flap is removed and the brain is able to expand. ICP is no longer a problem.....Hyperventilation and medications can also be administered to provide for a "slack brain"

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I work on a paediatric neurosurgery ward at the moment and we often have children and babies on the ward with an EVD open and draining. We can't monitor and drain at the same time - so the EVD is open for an hour and once per hour you clamp the drain and open to the ICP monitor, record the ICP and return to drain.

Children and more so babies don't understand that they can't move around, sit up and down, cry, strain etc -- but we have them on the ward and manage them quite well with open EVDs.

I think in this case what you've described is okay and just requires diligent nursing care.

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It is also advantageous to have a sign at the head of bed that states "V-drain in place, do not elevate/lower head of bed" or something along those lines. This is also helpful for xray techs, PT, etc.

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Ok here's the thing about codman VP shunts. Think of them like a pressure release the CSF builds up gets above the programmed pressure and the valve releases. I had one placed and chose that over an LP shunt on September the 14 2012 for intracranial hypertension after serial lp's over 14mths I had 9 of them and over 30 hospital admissions

Mine is set at 150mm H2O and so far Kruger has been a blessing.

Post operative obs are q1hr for 8hrs (such a pain as the patient) then obs PRN no ICP monitoring is indicated and when the valve releases the excess csf drains into the body just like normal and is absorbed by the body

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