Introduction Externalized ventricular drains (EVDs) are commonly used in pediatric intensive care units (PICU) but few data are available regarding infection rates, infection risks, or factors associated with conversion to permanent cerebrospinal fluid (CSF) diversion. Methods Retrospective observational study of patients managed with EVDs admitted to a tertiary care PICU from January 2005 to December 2009 Results Three hundred eighty patients were identified. Neurologic diagnostic groups were externalization of existing shunt (EXSHUNT) in 196 patients (52%), brain tumor in 122 patients (32%), intracranial hemorrhage (ICH) in 23 patients (6%), traumatic brain injury (TBI) in 17 patients (5%), meningitis in 9 patients (2%) or other in 13 patients (3%). Six percent of all patients (24/380) had new infections associated with EVD management for an infection rate of 8.6 per 1000 catheter days. The median time to positive cultures was 7 days (interquartile range 4.75, 9) after EVD placement. Patients with EVD infections had significantly longer EVD duration 6 vs. 11.5 days (p=0.0001), and higher maximum EVD outputs 1.9 vs. 1.5 mL/kg/hr (p=0.0017). Need for permanent CSF diversion was associated with higher maximum EVD drainage (1.3 vs. 1.6 mL/kg/hr p < 0.0001), longer EVD duration (5 vs. 4 days, p < 0.005), and younger age (4.5 vs. 8 years, p < 0.02) but not intracranial hypertension (72% vs. 82% of patients, p = 0.4). Conclusion In our large pediatric cohort, EVD infections were associated with longer EVD duration and higher maximum EVD output. Permanent CSF diversion was more likely in patients with higher maximum EVD drainage, longer EVD duration, and younger age.

Objective Dysnatremia is common in critically ill children due to disruption of hormonal homeostasis. Children with brain injury are at risk for SIADH, cerebral salt wasting and sodium losses due to externalized ventricular drain (EVD) placement. We hypothesized that among pediatric intensive care unit (PICU) patients managed with an EVD, hyponatremia is common, hyponatremia is associated with seizures and in-hospital mortality, and greater sodium fluctuations are associated with in-hospital mortality. Design Retrospective observational study Setting Tertiary care PICU Patients All pediatric patients treated in the PICU with an EVD from January 2005 to December 2009. Patients were identified by searching the physician order entry database for EVD orders. Hyponatremia was defined as the minimum sodium during patients’ EVD time and was categorized as mild (131-134 meq/L) or moderate-severe (≤130 meq/L). Magnitude of sodium fluctuation was defined as the difference between a patient’s highest and lowest sodium during the time in which an EVD was in use (up to 14 days). Seizure was defined as a clinically evident convulsion during EVD presence. A priori confounders were age, history of epilepsy, and EVD indication. Multivariable regression was performed to test the association between sodium derangements and outcomes. Interventions None. Measurements and Main Results Three hundred eighty patients were eligible. One hundred nine (29%) had mild hyponatremia, and 30 (8%) moderate-severe hyponatremia. Twenty eight (7%) patients had a seizure while hospitalized. Eighteen patients died (5%) prior to discharge. Survivors had a median daily sodium fluctuation of 1 [0, 5] vs non-survivors 9 [6, 11], (p< 0.001) and a median sodium fluctuation of 5 meq/L [interquartile range 2, 8] vs non-survivors 15 meq/L [9, 24] (p<0.001) during EVD management. After controlling for a priori covariates and potential confounders, hyponatremia was not associated with an increased odds of seizures or in-hospital mortality. However, greater fluctuations in daily sodium (OR 1.38, 95% CI (1.06, 1.8)) and greater fluctuations in sodium during EVD management were associated with increased odds of in-hospital mortality (OR 1.59, 95% CI (1.2, 2.11)). Conclusion Hyponatremia was common in PICU patients treated with EVDs but not associated with seizures or in-hospital mortality. Greater sodium fluctuations during EVD management were independently associated with increased odds of in-hospital mortality.

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