Steps

Rationale/Points of Emphasis

1 Perform hand hygiene and gather all necessary equipment and supplies for device placement.

KidKare Request sedation or analgesia for the awake child before starting the invasive procedure.

Hand hygiene reduces the transmission of microorganisms. Assembly of all necessary equipment facilitates quick and efficient insertion of an EVD for ICP monitoring or ventricular drainage.

2 Obtain baseline data (i.e., vital signs, level of consciousness, pupil response, skeletal motor function, and sensory function).

Two healthcare providers may be needed to assist the neurosurgeon in placement of the catheter device. One nurse to interact with patient as needed and the other to assist the surgeon.

Assists in identifying any acute changes in child during and after procedure. Prompt treatment of critical illness is associated with improved chances of survival.

3 Assess sedation and pain management needs of child in collaboration with the physician throughout the procedure. Administer sedation and pain management medications as indicated.

The child’s comfort will be enhanced by administration of medications to manage sedation and pain.

4 Perform hand hygiene and prepare sterile field, and place EVD on field. Prime ventricular catheter setup with preservative-free normal saline.

Assist physician as needed.

Reduces transmission of microorganisms. Priming the line avoids the introduction of air into the ventricular space.

5 Don full barrier attire and sterile gloves.

Standard precautions for sterile procedure—reduces transmission of microorganisms.

6 Position the child for access by the physician and hold the child’s head securely in midline position throughout, while maintaining sterile access for physician.

Ease of access; facilitates catheter insertion. The right frontal and temporal scalp area is the preferred access point for most physicians as this site is the least likely to cause neurologic sequelae.

7 Perform universal protocol to ensure a “time out” is completed before start of procedure.

Implements universal protocol for preventing wrong site, wrong procedure, wrong person surgery.

8 Assist physician in draping head in sterile fashion for catheter system setup.

Protects insertion site from contamination.

9 Assist physician in shaving the scalp and prepping the area with sterile antiseptic wipes or swabs.

KidKare Save child’s hair and place in a plastic bag; the family or child may wish to keep the hair.

Visualizes insertion site, reduces risk of infection from microorganisms.

10 The physician injects subcutaneous lidocaine (Xylocaine) to the insertion site on the scalp and makes an incision. Then, using the hand drill and scalpel, the physician bores through the skull and dura mater.

Allows for insertion of ventricular catheter.

11 The physician threads a ventricular catheter through the brain to the ventricles, then sutures it into place (Figure 116-1).

Allows direct access to the ventricle for monitoring of pressure, draining of CSF/blood, and providing a route for medication administration.

12 Continually assess the child for neurologic and vital sign changes.

Provides baseline for ongoing monitoring.

Figure 116-1 The ventricular catheter is threaded through the brain to the ventricles. Placement of the tube allows for monitoring of ventricular pressure, draining of cerebrospinal fluid and blood, and providing a route for medication administration.

13 When the ventricular catheter is in place and sutured, assist in placing a transparent dressing if appropriate or ordered by surgeon.

Protects the site from microorganisms.

14 Check the system for tight connections.

Identifies any loose connections, which may leak CSF and be a potential site for infection, or cause an erroneous decrease in pressure readings.

caREminder

The physician may want to read and visualize ICP and waveforms from the ventriculostomy catheter. If so, the setup for ICP monitoring should be provided (see Chapter 52 ).

15 If requested by the physician, assist in dressing the entire scalp with rolled gauze dressing.

Further protects the site from contamination or from accidental disconnection by the child.

16 Position the child with head in midline position and the head-of-bed (HOB) at 15-30 degrees to promote venous return. Use leveling device to position the drip chamber at the prescribed height.

The amount of ventriculostomy drainage that occurs is partially based on gravity and partially based on the intracranial pressure. Lowering the drip chamber enhances CSF drainage. Raising the drip chamber reduces CSF drainage.

If the drip chamber is too low, inappropriate CSF decompression may occur leading to hemorrhage and/or pain. If the drip chamber is too high, the intracranial pressure may inappropriately increase leading to herniation and death.

17 Maintain the child’s head midline at all times with HOB up to 15-30 degrees (or as ordered by physician).

Flexion or rotation of the head/neck can obstruct venous return and thereby increase intracranial pressure. Elevating the HOB to 15 to 30 degrees promotes venous return.

18 Dispose of equipment and waste in appropriate receptacle.

Standard precautions.

19 Remove gloves and sterile attire. Perform hand hygiene.

Reduces transmission of microorganisms. Standard precautions.