Hi guys- I posted this on the Neuro ICU thread- wanted your opinion too!
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.
Sep 24, '08
I believe you are correct. In order to drain the EVD, the stopcock would have to be off to the transducer, in which case your numbers on your monitor would not reflect your true ICP.
Did your nurse following you go postal because the montitor alarm was turned off? Is this against your policy and procedure for montioring ICP via EVD's? Was your charting in step with your documentation policy and procedures?
Review those things for future reference to know what the expectations of your new unit are. Things are done differently everywhere. Your understanding of the procedure of monitoring and draining EVD's was correct in my book.
BTW- was there an order to open the drain if ICP > 15 or 20 for more than 5 minutes or was it draining continuously. If your bag was 20 cm above the EAM- probably not putting a ton out anyhow.
Sep 25, '08
The drain was continuously open at +20- so there wasn't too much drainage your right(only drains when ICP>20). And you're right- everyplace is different. I'm used to an EVD pt also having a camino ICP monitor in - so that you can monitor ICPs continuously. Like I said- neuro is a new thing for this unit so they haven't gotten in all of their equipment yet. In fact, this might have been the first EVD pt this unit has even seen.
I'm really not sure what this person's problem was. I think it was just a "be mean to the new gal" and tell everyone how stupid she is thing- except for she clearly did not know what she was talking about.
I did look and there is no clear policy for this kind of situation that I could find. I mean obviously I would never turn off my A line alarm just because it had a poor wave or something. But, if you are off to the transducer, than you are not monitoring anything for gods sake! Just a spot check hourly as ordered.
I saw my preceptor the next day she said that this nurse is just one of those confrontational types and not to worry about it. It just makes my blood boil the way people treat new staff! Just because you have never worked with me before does not mean I'm stooooopid!!
Sep 27, '08
you were completely right. most places that have an evd in (esp if it's main purpose is to drain) will just spot check ICP q 1 or whatever their policy is. The monitior of "trends" on some evds is possible but totally unreliable. I have had them same 4 as a trend and clamp and with a waveform it's 15. not a good way or safe way to trend anything....if you curious you just clamp and check. Esp if you don't have a camio in place.
Some Evds you can turn the stop cock and drain and read but as I stated before it is very very unreliable.
Oct 4, '08
We just had the Camino reps out for an inservice for the monitor the unit will be getting. And the Neurosurgeon is giving a lecture/inservice next week on "care of the EVD pt"---- apparently this was the first EVD pt this unit had ever seen. So I guess it was just a case of the "be nasty to the new gal" syndrome! Thanks for the replys-I was begining to question myself!
Apr 18, '12
Do you guys find that if the EVD is open to both drain and monitoring that the transducer gets filled with either CSF or blood (or both at times) then allowing the filter to get wet. whent he filter is wet, the ICP readings and waveforms become inaccurate. Do you guys find that too? We are having this debate at the moment and all places i have worked have NEVER had the EVD open to drain and monitor at the same time specifically because of this reason. If you were concerned about a patient's ICP you would do regular assessments by turning the EVD off to drain and open to monitoring. Any help would be great, thanks!!
Apr 19, '12
What filter are you talking about? In the transducer? I was never taught to leave the drain that way, although I did have to teach some micu RNs that they were not transducing. They were surprised when they saw my "good" waveform. The drain should be either open or closed to transduce pressures. I believe icp waveforms are as sensitive as art lines when coming to reliability.
Apr 23, '12
The transducer we use needs to be filled with NS anyway in order to get a reliable ICP (a standard pressure transducer) otherwise you have an air-fluid level in your measuring system and that influences the measurement. Since the transducer prevents backflow I can't say that I've ever had CSF reaching the transducer when measuring ICP's continuously.
The only filter I know of in ICP monitoring that isn't allowed to get wet is on a SpiegelbergTM measurement system. And that is the connection between the EVD and the Spiegelberg monitor itself (small white luer lock hub). We aren't allowed to spray it with alcohol or it is ruined and the patient needs a new drain.
I was always told that measuring ICP and draining at the same time isn't possible with a classical EVD (at least the ICP measurements aren't reliable). You need a specialized drain for that (in our hospital it is either the Spiegelberg system or the special CodmanTM system that allows for measuring and outflow at the same time). Having your transducer measure on an actively draining line is comparable to measuring your arterial line with a disconnect in the circuit. You'll see a pulsatile curve but the actual value is much lower than it is in reality. So it creates a false sense of security.
May 27, '12
Sounds like two different issues being discussed in this thread- but in regards to the filter getting wet, I assume you're talking about an EVD with a buretrol? If the filter gets wet, my understanding is that the system is contaminated and needs to be changed.