Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study

Chung, David Y.; Thompson, Bradford B.; Kumar, Monisha A.; Mahta, Ali; Rao, Singiresu S.; Lai, James Han; Tadevosyan, Aleksey; Kessler, Kathryn; Locascio, Joseph J.; Mohamed, Wazim; Olson, DaiWai M.; John, Sayona; Rordorf, Guy

doi:10.1007/s12028-021-01343-9

Cited by 34 publications

(48 citation statements)

References 28 publications

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“…In study, each delayed in initiating the drain challenge, the overall length of stay increased by an additional 1.25 days. This is consistent with other literature, where the longer it takes to perform the rst wean trial, the longer the patient will remain in ITU and in hospital [5].…”

Section: Principal Ndings and Interpretationsupporting

confidence: 93%

“…A 2022 prospective study of three centres with 139 patients, found the rate of shunting following EVD insertion for SAH was 32% for the rapid wean group, versus 39% for the gradual [5]. Limiting direct comparisons with our results, were that de nitions of rapid and gradual weaning were inconsistent both in study design and between their own participating centres.…”

Section: Principal Ndings and Interpretationcontrasting

confidence: 59%

“…This is likely due to the number of days the weaning adds to the total length of drainage in the RCT, whereas in our study we looked independently at the weaning method and the time to clamp using multivariate analyses. Other multicentre studies have been inconclusive, with some supporting a signi cantly increased hospital length of stay in the gradually weaned group [14] and others showing no difference [5].…”

Section: Principal Ndings and Interpretationmentioning

confidence: 99%

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Discontinuation of CSF drainage in acute hydrocephalus: a prospective cohort study and exploratory data analysis

Pandit

Palasz²,

Harris³

et al. 2023

Preprint

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Purpose The optimal management of CSF drainage in acute hydrocephalus, in particular when to initiate drain weaning, remains uncertain. This study aimed to evaluate the impact of timing and method of drain weaning on patient outcomes. Methods This prospective observational study in a large-volume tertiary neuroscience centre including all adult patients who required temporary CSF drainage for acute hydrocephalus of any cause, between January 2020 and March 2021. Contemporaneous data collection was conducted, including patient demographics, time to clamp, weaning methods, and clinical outcomes of hospital length of stay (LOS), rate of shunt insertion, drain-related infections, and mechanical complications. Univariate and multivariate statistical analyses were performed to identify the independent associations of timing-related factors. Results 69 patients were included (mean age = 59.4 years). 59% had CSF diversion for aneurysmal subarachnoid haemorrhage, and 88% had EVD drainage. The length of drainage prior to the first clamp was significantly associated with overall length of drainage (p<0.0001), LOS (p=0.004) and time to shunt (p=0.02) following multivariate adjustment. For each day delayed in initiating the drain challenge, the overall LOS increased by an additional 1.25 days. There was no association between weaning method and LOS, the rate of shunting, or CNS infection, however those in the gradually weaned group had more mechanical complications such as drain blockage or CSF leakage than those rapidly weaned (p = 0.03) after adjustment. Discussion The study recommends challenging the drain early, via a rapid wean, to reduce LOS, mechanical complications, and possibly infections. The consequences of temporary CSF diversion have significant implications at financial and patient levels, but the quality of evidence regarding weaning remains poor. Further randomized multi-center studies and national databases of practice are required to allow definitive conclusions to be drawn.

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Section: Principal Ndings and Interpretationsupporting

confidence: 93%

Section: Principal Ndings and Interpretationcontrasting

confidence: 59%

Section: Principal Ndings and Interpretationmentioning

confidence: 99%

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Discontinuation of CSF drainage in acute hydrocephalus: a prospective cohort study and exploratory data analysis

Pandit

Palasz²,

Harris³

et al. 2023

Preprint

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“…Overall, it seems that early EVD clamping can lead to a shorter length of stay and fewer complications [ 19 ]. A recent study showed an association between EVD use and various outcomes; in particular a rapid EVD wean (as compared to gradual) was associated with decreased ICU length of stay and rates of VPS placement [ 20 ].…”

Section: Discussionmentioning

confidence: 99%

External ventricular drain use is associated with functional outcome in aneurysmal subarachnoid hemorrhage

Nelson

Suárez

Sigmon

et al. 2022

Neurol. Res. Pract.

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Purpose External ventricular drains (EVD) are commonly used in aneurysmal subarachnoid hemorrhage (aSAH) patients and can be life-saving by diverting cerebrospinal fluid. However, the overall relationship between EVD use and outcome is poorly understood. Methods In an exploratory analysis of an aSAH patient cohort, we examined EVD use in relation to modified Rankin Scale (mRS) at hospital discharge and at 6 months (unfavorable outcome = mRS > 2) using univariable and multivariable analyses. Results EVDs were placed in 31 of 56 (55.4%) patients and more often in women than men (66.7% vs 35.0%, p = 0.022) despite similar rates of hydrocephalus. Women had greater ICU [18 (13.5–25) vs 11.5 (6.5–18.5) days, p = 0.014] and hospital lengths of stay (LOS) [20.5 (16.5–34) vs 13.5 (10.5–27) days, p = 0.015] than men and greater mRS at discharge [4 (3–5) vs 3 (2–3.5), p = 0.011] although mRS at 6 months was similar. Patients with EVDs had longer ICU and hospital LOS and greater mRS at discharge [5 (3–6) vs 2 (2–3), p < 0.001] and at 6 months [4 (2–6) vs 1 (0–2), p = 0.001] than those without an EVD. In multivariable models, EVD use was associated with unfavorable 6-month outcome accounting for age, sex, and admission modified Fisher scale, but not in models adjusting for Hunt and Hess scale and World Federation of Neurological Surgeons scale. Conclusion In an aSAH cohort, the use of EVDs was associated with female sex and longer LOS, and may be linked to functional outcomes at discharge and at 6 months, although these associations warrant further investigation.

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“…1 Instead, it was a mix of approaches using either gradual weaning or rapid closure, and patients in whom weaning failed "received ventriculoperitoneal shunt insertion." 1 The literature regarding these two strategies for EVD weaning has more recently pointed to the superiority of rapid EVD weaning protocols [8][9][10][11] and was summarized in a systematic review and meta-analysis by Palasz et al in 2022, with a conclusion that "patients who underwent rapid EVD weaning had a shorter hospital length of stay and there was no clear clinical advantage in using gradual weaning." 12 Exceptions may exist with some situations, such as the patient with acute low-pressure hydrocephalus, which can occur in a subset of patients after aSAH.…”

mentioning

confidence: 99%

Editorial. Weaning external ventricular drains after aneurysmal subarachnoid hemorrhage: how should we measure success?

Hamilton

2023

Neurosurgical Focus

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Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study

Cited by 34 publications

References 28 publications

Discontinuation of CSF drainage in acute hydrocephalus: a prospective cohort study and exploratory data analysis

Discontinuation of CSF drainage in acute hydrocephalus: a prospective cohort study and exploratory data analysis

External ventricular drain use is associated with functional outcome in aneurysmal subarachnoid hemorrhage

Editorial. Weaning external ventricular drains after aneurysmal subarachnoid hemorrhage: how should we measure success?

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