Intermittent CSF drainage and rapid EVD weaning approach after subarachnoid hemorrhage: association with fewer VP shunts and shorter length of stay

Abstract

OBJECTIVEThere is variability and uncertainty about the optimal approach to the management and discontinuation of an external ventricular drain (EVD) after subarachnoid hemorrhage (SAH). Evidence from single-center randomized trials suggests that intermittent CSF drainage and rapid EVD weans are safe and associated with shorter ICU length of stay (LOS) and fewer EVD complications. However, a recent survey revealed that most neurocritical care units across the United States employ continuous CSF drainage with a gradual wean strategy. Therefore, the authors sought to determine the optimal EVD management approach at their institution.METHODSThe authors reviewed records of 200 patients admitted to their institution from 2010 to 2016 with aneurysmal SAH requiring an EVD. In 2014, the neurocritical care unit of the authors’ institution revised the internal EVD management guidelines from a continuous CSF drainage with gradual wean approach (continuous/gradual) to an intermittent CSF drainage with rapid EVD wean approach (intermittent/rapid). The authors performed a retrospective multivariable analysis to compare outcomes before and after the guideline change.RESULTSThe authors observed a significant reduction in ventriculoperitoneal (VP) shunt rates after changing to an intermittent CSF drainage with rapid EVD wean approach (13% intermittent/rapid vs 35% continuous/gradual, OR 0.21, p = 0.001). There was no increase in delayed VP shunt placement at 3 months (9.3% vs 8.6%, univariate p = 0.41). The intermittent/rapid EVD approach was also associated with a shorter mean EVD duration (10.2 vs 15.6 days, p < 0.001), shorter ICU LOS (14.2 vs 16.9 days, p = 0.001), shorter hospital LOS (18.2 vs 23.7 days, p < 0.0001), and lower incidence of a nonfunctioning EVD (15% vs 30%, OR 0.29, p = 0.006). The authors found no significant differences in the rates of symptomatic vasospasm (24.6% vs 20.2%, p = 0.52) or ventriculostomy-associated infections (1.3% vs 8.8%, OR 0.30, p = 0.315) between the 2 groups.CONCLUSIONSAn intermittent CSF drainage with rapid EVD wean approach is associated with fewer VP shunt placements, fewer complications, and shorter LOS compared to a continuous CSF drainage with gradual EVD wean approach. There is a critical need for prospective multicenter studies to determine if the authors’ experience is generalizable to other centers.

Complications of external cerebrospinal fluid drainage in aneurysmal subarachnoid haemorrhage

“…This reservoir is calibrated at the height of the foramen of Monro which hinders a patient's movements as the reservoir needs to remain at the level of the foramen of Monro at all time to prevent severe fluctuations in CSF draining. Digital systems enabling mobilization and early EVD weaning with an external cerebrospinal fluid drain might contribute to early mobilization and therefore might help reducing the number of complications [32,43].…”

Intracranial Pressure during External Ventricular Drainage Weaning Is an Outcome Predictor of Traumatic Brain Injury

“…Moreover, it allows for observation of ICP changes based on the Monro-Kellie doctrine [ 10 ]. Available literature shows that details regarding the steps and evaluation criteria vary across medical centers and physicians [ 11 , 12 ]. A randomized trial by Klopfenstein et al [ 13 ] on patients with an aneurysmal subarachnoid hemorrhage (aSAH) compared rapid and gradual weaning protocols.…”

Lessons from the CONSCIOUS-1 Study

“…Adding clinical and laboratory parameters may improve DCI prediction although some of these factors like age, aneurysm location, cigarette smoking and preexisting hypertension are inconsistently found to relate to DCI [ 77 , 78 ].…”