Is this a sentinel event?

[ZSimzNeuroNurse, BSN, RN, EMT-B]

I work in the neurosurgery ICU, and on my unit, the typical unspoken protocol for drawing CSF from EVDs mandates drawing off an absolute maximum of 1-1.5 cc of CSF for labs/cultures over 1-1.5 min (at an approximate rate of 1 cc per min) when we receive CSF collection orders. Ask my manager and my supervisors and this is what they tell you. This is also what preceptors on my unit will teach; however, I cannot find this in writing anywhere.

This event happened a few months ago, maybe even last year when I was newer to the neuro population, and was the first time I had drawn CSF for labs, however...I am wanting to check my story with some neuro nurses to ask about whether or not this was a huge no-no or if this is a rare exception. This just recently resurfaced at work when I asked, and my coworkers always don a face of sheer panic when I tell them. Please let me know if any of you can help clear this up for me:

I had a super sick patient with an EVD and multiple comorbidities. I received orders to draw extensive CSF labs from the patient's drain. Over the phone (not through text), the provider nonchalantly ordered for me to draw off an alarming 10 cc of CSF from the patient's drain. I quadruple clarified this order with the provider over the phone, asking more than once to make sure they indeed meant 10 (!!) and asked my charge nurse multiple times as well. I was explained that this is not a normal order by my charge, but to be sure to document that notification and to follow through with the task as ordered. I probably spent almost literally 20 min straight drawing the CSF as slowly as possible, as not to cause any harm to the patient. Like I stated above, my coworkers literally freak out when I tell them this story, so I am curious to know if this is something anyone else has experienced as well.

I often pride myself on being a safe nurse, however, even a year later this still gets to me and I always wonder if I made the right decision ?

[chare]

Considering normal CSF volume and production withdrawing 10 mL over 20 minutes was probably fine.

From your comment "drawing off" I presume you are withdrawing it directly from the patient. If so, I do find it concerning that either your facility doesn't have, or can't find, a policy/procedure addressing this.

[ap_NRN]

Heck no, you are fine. I worked a neuro med surgical floor (not nearly as critical as yours) and it was standard to receive an order to open up a csf line and allow up to 20-30 cc to drain into the sterile bag over 20 minutes. This was explained to me coming directly from a neurosurgeon. He did state that you don't want to do more than 30cc at a time, though. The body would have a tough time creating more csf to keep up at that point, and patient would probably experience a wicked headache. Hope that helps:)

[brownbook]

The human body makes 30 to 100 millimeters of CSF daily. Drawing off 10 is within an acceptable range. It's unfortunate you have to struggle with a lack of clear guidance in a neurosurgery ICU.

Policies and procedures are intentionally vague, and often no help in situations like this. Ask your charge nurse if a friendly neurosurgeon or someone from nursing education could inservice your unit about when, if, how much, CSF is reasonably safe to draw up.

It's never going to be written in black and white as a policy. A policy that states no more than 10 mls in 24 hours, then for perfectly good reasons 13 mls are drawn up, is just begging for a lawyer to bring a malpractice suit against a hospital.

[adventure_rn, MSN, NP]

I don't know much about neuro, but I feel like this isn't a sentinel event because, by definition, a sentinel event results in death or seriously bodily injury. If the patient had died or profoundly decompensated it would be a sentinel event; otherwise it's just an error.

[brownbook]

1 hour ago, adventure_rn said:

I don't know much about neuro, but I feel like this isn't a sentinel event because, by definition, a sentinel event results in death or seriously bodily injury. If the patient had died or profoundly decompensated it would be a sentinel event; otherwise it's just an error.

I honestly don't know if it's even an error? Is ten mls to much? I'm not a Neuro expert, I'd like a Neuro nurse to chime in. ap_NRN stated ten mls was fine? She seemed to know what she was talking about.

[ZSimzNeuroNurse, BSN, RN, EMT-B]

On 8/13/2019 at 11:32 PM, ap_NRN said:

Heck no, you are fine. I worked a neuro med surgical floor (not nearly as critical as yours) and it was standard to receive an order to open up a csf line and allow up to 20-30 cc to drain into the sterile bag over 20 minutes. This was explained to me coming directly from a neurosurgeon. He did state that you don't want to do more than 30cc at a time, though. The body would have a tough time creating more csf to keep up at that point, and patient would probably experience a wicked headache. Hope that helps:)

You're totally right. What's weird to me is that we get lumbar drains and EVDs ALL THE TIME--daily--and some patients dump a lot more and a lot faster than others, especially depending on a multitude of factors. For instance, if I have a super combative and wild patient with an EVD in 5-points, he could still be moving around enough to dump 10-15 mL of CSF in a matter of 5-10 min. This is to be "expected" of such a patient in this situation, though we should always do our best to keep the patient as calm as humanly possible (neurosurgeons HATE paralytics and sometimes don't like sedation based on patient prognosis). However, it's a crime to everyone on my unit that I took my honey sweet time drawing off 10 cc in a controlled manner, and according to an order from the neurosurgical team? It makes no sense....The lines are super blurred here, in my opinion.