External Ventricular Drain Misadministration Events: Systematic Literature Review and Report of a Case

Abstract

BACKGROUND AND OBJECTIVES: External ventricular drain (EVD) is a common neurosurgical procedure with potential complications, including catheter misplacement, infection, mechanical obstruction, and inadvertent catheter pull-out. A less discussed but critical complication is the misadministration of medications into EVD. This project aimed to review the literature on EVD misadministration and discuss preventative measures, emphasizing the new International Organization for Standardization (ISO) standard for neuraxial connectors. METHODS: A systematic review of PubMed, Embase, and SCOPUS databases was conducted to identify studies reporting misadministration in EVD systems. We also present a case of misadministration of a blood product into an EVD. Factors contributing to these events were researched, relevant guidelines from professional organizations were reviewed, and preventive strategies, including the novel NRFit® connector designed to prevent such errors, were discussed. RESULTS: The literature review identified 7 reports of 8 cases of misadministration involving substances such as gadolinium-based contrast agents, anesthetic agents, and antiepileptic drugs. In addition, we report a case of an 87-year-old man with multiple traumatic brain injuries, where a blood transfusion line was mistakenly connected to the EVD. This incident is the first reported case of blood misadministration through EVD. Despite immediate drainage and flushing of the EVD system with saline, the patient's condition did not improve, and he eventually died. Contributing factors included unfamiliarity with the EVD system, similarity to IV connectors, and poor visibility during procedures. Importantly, the novel ISO 80369 standard for all neuraxial connectors, including NRFit® connectors that have a 20% smaller nozzle outside diameter than traditional Luer connectors, has been recommended to prevent misconnection errors and mitigate associated risks. CONCLUSION: Misadministration to EVD connectors is a preventable event that highlights the need for enhanced safety solutions. Adoption of ISO standard neuraxial connectors, thorough training, and the use of distinctly marked equipment are critical steps in minimizing risks.