Ventriculostomy is a surgical procedure!

[Elenaster]

I will attempt not to rant and rave about this, but I just wanted to know if any of you have a similar situation in your units.

Here's the situation: I work in an 11-bed Neurosurgical ICU at a level I Trauma center. We see tons of aneurysms and all of these patients were formerly managed by the Neurosurgery team. Well now we have a new policy where the patients who are deemed inoperable (meaning no clip/coil) are dumped on the MICU service. They get a EVD and then Neurosurgery just consults with MICU.

There are many problems with this, the main one being that MICU has no clue what to do with these patients. I actually had the resident ask me what CPP stands for and why my patient kept pulling out her lines (like, he didn't understand that brain injured people tend to get confused) The other key problem is there is a huge communication breakdown between Neurosurgery and MICU and we end up either keeping the patients in ICU way too long, or MICU tries to send them to the step-down units with their drains still in place. I actually kept a patient that had been declared clinically brain dead (in NC that means dead) by neurosurgery on Neo all night because the MICU resident said the wrong things to the family and "didn't know what to do."

Needless to say, this is creating a huge headache for the nursing staff and management is trying to present a case in our favor of why this isn't working. One of our key arguments is that a ventriculostomy is a surgical procedure, therefore the patient needs to be managed by surgeons. The rationale for this arrangement initially was that Neurosurgery had more patients than they can manage. If anyone has a similar situation, suggestions are welcome. Thanks for listening.

[DeniseRNBSN]

Ventriculostomy is a surgical procecedure that is performed by the Neurosurgeon. We have a 12 bed-NeuroICU. Our overflow patients will go the the other ICU's (Medical, surgical, and Burn).

Our neurosurgeons have to follow those patients because if the ventric clots off, no more CSF is allowed to drain. That can cause cerebral edema and subsequently herniation which means death.

I find it hard to believe that the neurosurgeon would sign off on a patient that still has a ventric let alone send them to a step down floor. We are a level 1 trauma center but if one of our neuro patients still has a ventric, bolt, or any type of device that is draining CSF; they are definitely not allowed to be transferred out of the unit.

Hope this helps!!!:)

[stevierae]

I am an operating room nurse, and I agree with you that ventriculostomy is a surgical procedure. I also agree that these patients need to be followed by neurosurgery.

However, we used to do them all the time not in the operating room, but at the bedside in ICU.

I don't know if this is the practice at your facility, but if it is--

Could this be part of the reason for the confusion among your medical residents? They see it being done at the bedside, so they conclude (erroneously) thatit is a relatively innocuous procedure--i.e., akin to inserting a CVP line?

They may, (incorrectly) be seeing the subarachnoid screw or lumbar drain or ventriculostomy as just one more invasive line--and conclude (incorrectly) that they are capable of managing it.

You have taught them that CPP= Cerebral Perfusion Pressure--really, they should have known in the first place--

But quiz the medical residents as to who among them knows the formula for determining CPP using the "big lines" they consider themselves experts at handling--

It is: MAP-ICP= CPP

Heck, I remember that from nursing school. Shouldn't THEY know the anwer?

If they DON'T know the answer--then they shouldn't be handling ventriculostomies, lumbar drains or subarachnoid screws.

[Elenaster]

Thanks for the responses!

It's been awhile since I posted that information, and since then the problem has improved somewhat. Neurosurgery still will place drains in "inoperable" patients and then have MICU team manage their ICU care while NS consults.

We always place the drains at the bedside and the patients are required by hospital policy to remain in ICU if they have a ventric, bolt, etc. Those poor MICU residents are just clueless about NS procedures and rely on the nurses a little too heavily.

What I've learned since I posted about this subject is that our Neurosurgeons don't like to "get their hands dirty" or so to speak, meaning they like to do backs, tumors, and a-clippings. They don't want to fool with neurolgic injuries that don't require a trip to the OR and are likely to have multi-system problems (i.e., trauma). Kind of disappointing given the reputation of the facility I work at. I long for a big, messy CHI/trauma every now and then.

Thanks again for your input.