External Ventrikulo Drainage

A. DEFINISI
EVD dikenal sebagai extraventicular drain atau ventriculostomy, merupakan alat
yang digunakan dalam bedah saraf berfungsi mengurangi tekan intracranial yang
meningkat ketika aliran CSS disekitar otak terhambat. Tabung pelastik ditempatkan oleh
ahli bedah saraf, ahli saraf atau perawat ICU dan paramesid perawatan kritis untuk
menglirkan cairan dari ventrikel otak yang akan menyebabkan dekompresi dan memantau
tekanan intracranial.
Tujuan drainage adalah untuk mengalirkan CSS ke ruang lain dan untuk
menurunkan tekanan intracranial. Dikenal beberapa metode drainage, antara lain External
Ventricular Drainage, dimana CSS dikeluarkan dari intrakranial melalui suatu lubang.

B. INDIKASI
Indikasi untuk EVD atau monitor cairan intracranial termasuk:
1. Hydrocephalus
2. Hemorrhage
3. Tumor
4. Meningitis atau
5. Trauma kepala

C. KONTRAINDIKASI
1. Pasien menjalani terapi antikoagulan pada pasien gangguan sirkulasi
2. Pasien memiliki infeksi permukaan kepala
3. Pasien memliki brain abscess

D. MANIFESTASI KLINIS
Peningkatan cairan intracranial jika terkanan lebih dari 15 mmHg. Tanda-tanda klinis
umum dari awal hipertensi intracranial yaitu:
1. Muntah proyektil
2. Sakit kepala
3. Kejang
4. Fotofobia
5. Lemas
6. Nistagmus
7. Diplopia

Pada beberapa peningkatan darah intracranial terjadi kesadaran melemah, perubahan

reflek anggota tubuh berubah, pupil melebar, gerakan sepontan tubuh menurun dan
reaksi pupil pada cahaya menurun. Tanda yang muncul terjadi secara unilateral atau
bilateral tergantung penyebab peningkatan tekanan intracranial.
 Pada pre-morbid high level tekanan intracranial:

1. Pernapasan sepontan terdepressed

2. Terjadi hipertensi
3. Detak jantung melambat/ triad Cushing

E. KOMPLIKASI
EVD is an invasive procedure. It is associated with several complications categorised as
below:-
a. Hemorage
Commonly occurs along the EVD insertion tract. The risk or haemorrhage is
increased if the patient is having coagulopathy.
b. Malplacement
c. Infection
EVD is a foreign inserted into human body. It can serve as an object for the bacterial
attachment and causing ascending infection.
d. Obstruction
Obstruction/occlusion of EVD commonly due to fibrinous/clot like material or
kinking of the tube. The brain can swell due to pressure build up in the ventricles and
permanent brain damage can occur. Physicians, nurses, and Critical Care Paramedics
often have to adjust or flush these small diameter catheters to manage medical tube
obstructions and occlusions at the intensive-care bedside.[2] Pressure settings are
generally measured in cmH2O. The equilibrium pressure of the EVD apparatus is
adjusted based on cerebrospinal fluid output, ICP waveform, imaging including CT or
MRI of the brain, and clinical response.
e. Migration
During the EVD insertion, the EVD is tunneled subcutaneously and anchored with
suture. However, it is common for the EVD to dislodge or migrate. This will cause
the tip of the drain migrated away from its supposed position and provides inaccurate
ICP measurement or total occlusion of the drain

F. PENATALAKSANAAN, PERSIAPAN DAN PROSEDUR

Management pengeluaran cairan intracranial dapat dilakukan drainage EVD. Manajemen
lainnya termasuk urgent surgical decompression, pemberian agen osmotic seperti
manitol, diuretic, hiperventilasi mekanik sementara untuk mengurangi peningkatan CO2
dalam darah yang menyebabkan vasokonstriksi serebral.
Pasien yang telah masuk perawatan operasi memerluhkan monitoring ketika kembali ke
ruang PICU, NICU sampai hilang efek anastesi dan penilaian neurologi.

Pengambilan sampel CIS dilakukan secara steril pada pagi hari setiap 24 jam, kecuali
permintaan dari ahli saraf. Pelaksanaan prosedur akan membutuhkan 1-2 perawat yang
 kometen dan percara diri pada prosesur ini dan telah memiliki sertifikat dalam tindakan
EVD.

Persiapan :
1. Gaun steril
2. Chlorhexadine 0,5% dalam alcohol 70%
3. Handscoun steril
4. CSF tubes steril
5. Syringe 10ml
6. Cap
7. Kain kasa
8. Betadin
9. APD

Procedure:

 Explain to the patient/family what is about to occur

 Ensure the EVD is off to the patient
 After preparing equipment and opening tubes, perform sterile scrub (3 minute wash-, 2%
chlorhexidine, green hand wash/ microshield) and don sterile gloves
 Assistant to clamp the EVD and remove old Integra Stopcock Protection Box furthest
from the patient and hold line in air
 Assistant to ensure 3 way tap at base of CSF collection chamber is closed to the
collection bag
 Sterile RN to place sterile towel under line and clean 3 way tap on Medtronic Exacta
EVD kit
 Perform sterile cleaning of 3 way tap with Chlorhexadine 0.5 % in Alcohol 70% solution
and allow antiseptic solution time to dry completely, (this can take up to 2 minutes).
 Cap from side access point (usually red cap) to be removed and discarded, do this with
dry sterile gauze to remove
 3 way tap to be off to the EVD system, therefore open to the patient (to collect to freshest
CSF)
 Collect minimum of 1.0 ml (around 20 drops) CSF in sterile CSF tube (Never aspirate
CSF from an EVD, allow drops to drip out)
 Turn 3 way tap off to side access

 Place new red cap on side access

 Ensure 3 way tap is open from the patient to the drain
 Assistant to open both Integra Stopcock Protection Boxes and fill with Betadine Solution
using syringe, close boxes
 Ensure the EVD transducer is at a horizontal level to the FOM
 Turn the EVD on and ensure drain is oscillating / draining
N.B If collection bag needs to be emptied after CSF specimen is taken, remain sterile to clean the
access at the base of the bag with Chlorhexadine 0.5% in Alcohol 70% solution and allow
antiseptic solution time to dry completely, (this can take up to 2 minutes), before removing red
cap and drain CSF into collection jug and replace with new sterile red cap. Ensure CSF is
discarded into pan flusher.

Dressing changes

Dressings of the EVD site need to be observed hourly and this documented on the fluid balance
chart (MR730/A) to ensure a leak has not occurred. If a leak is identified, place pressure
combine/dressing and notify the AUM and Neurosurgical team. Dressings should be changed
using sterile technique as per the treatment order (MR660/A) or when soiled.

Changing the EVD System Set

The entire system needs to be changed using sterile technique every 7 days. The procedure will
require 2 registered nurses who are competent and confident with this procedure.

Equipment:

Sterile Dressing Pack and extra Gauze, Chlorhexadine 0.5 % in Alcohol 70%, Sterile Gloves, 2
Sterile Integra Stopcock Protection Boxes (External reference number 901400), Medtronic
Exacta EVD Kit (Stores Number 309634), 0.9 % Normal Saline, 10ml and 20ml Syringes,
Drawing Up Needle, Betadine Solution, Forceps

Procedure:

 Explain to the patient/family what is about to occur

 After preparing equipment, perform sterile scrub (3 minute wash :green 2% chlorhexidine
/ microshield wash) and don sterile gloves
 Prime Medtronic Exacta EVD kit with 0.9% Normal Saline (ensuring all 3 way taps are
primed and the system has no air in it)
 Fill Integra Stopcock Protection Boxes with Betadine Solution using syringes
 Assistant to clamp/turn off the EVD and remove old Integra Stopcock Protection Box
closest to the patient and hold line in air
 Sterile RN to place sterile towel under line
 Assistant to use forceps and gauze to clamp Silastic tubing as close to the patient's head
as possible and remove old Medtronic Exacta EVD kit from laser level device
 Sterile RN to clean the connection between Medtronic Exacta EVD set and silastic tubing
with Chlorhexadine 0.5 % in Alcohol 70% solution and allow antiseptic solution time to
dry completely (this can take up to 2 minutes).
 Disconnect old line (discard in infectious waste at end of procedure)
 Connect new Medtronic Exacta EVD kit to the patient
 Ensure connection is secure
 Apply new Integra Stopcock protection boxes to both sections of the Medtronic Exacta
EVD kit
  Fill both Stopcock boxes with Betadine solution and close both boxes
 Ensure line is open to the patient (draining to the burette)
 Load new Medtronic Exacta EVD kit into laser level device at appropriate H20 level /
height as per Neurosurgeon's instructions
 Remove forceps from silastic tubing at patient's head
 Ensure Medtronic Exacta EVD kit is leveled to the patient's FOM
 Turn on EVD and ensure it is oscillating or draining

DAFTAR PUSTAKA

http://www.aann.org/uploads/AANN11_ICPEVDnew.pdf

http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/External_Ventricular_Drains_a
nd_Intracranial_Pressure_Monitoring/