External Ventricular Drain Placement Procedure Note (Bedside)

Procedure: External Ventricular Drain (EVD) Placement

Date/Time of Procedure: [Start date/time – End date/time] (Required)

Location: [ICU bedside – unit/room / OR / ED / Other location] (Default to ICU bedside; specify exact location)

Primary Operator: [Name, credential] (Required)

Assistant(s): [Names and roles] (Include if applicable)

Laterality: [Right / Left] (Required)

Procedure Status: [Successful / Aborted / Converted to OR / Multiple attempts required]

Brief Summary

[1–3 sentence procedure summary including: procedure performed (EVD placement), side, primary indication, whether CSF was obtained, opening pressure with units and method, CSF appearance, and immediate complications status] (If opening pressure not obtained, state explicit reason)

Indication and Clinical Context

• Primary indication: [Acute hydrocephalus/CSF diversion / ICP monitoring and treatment / Intraventricular hemorrhage management / Ventriculitis requiring drainage access / Other]
• Underlying diagnosis/clinical context: [Brief description of the condition driving placement]
• Urgency: [Key clinical findings supporting urgency]
• Imaging reviewed: [Study type, date/time, and critical findings relevant to ventricular size, midline shift, IVH, or catheter planning]

Pre-Procedure Assessment

• Coagulation status:
  • Platelets: [value] (date/time)
  • INR: [value] (date/time)
  • aPTT: [value] (date/time)
• Antiplatelet agents: [Agent and last dose time / None]
• Anticoagulants: [Agent and last dose time / None]
• Reversal/optimization: [Products, doses, timing / Not performed – rationale] (If labs unavailable at time of emergent placement, document clinical justification for proceeding)
• Skin integrity at insertion site: [Intact / Compromised – description]
• Active infection concerns: [None / Description of concerns]

Consent

Consent obtained: [Yes / No] (Required – never infer; must explicitly document)

• If Yes: Consent provided by [patient with capacity / surrogate – relationship]. Risks, benefits, and alternatives discussed. Key risks reviewed included hemorrhage, infection/ventriculitis, malposition requiring replacement, CSF leak, overdrainage complications, and neurologic injury.
• If No – Emergency exception: [Documentation of imminent threat to life or neurologic function and why delay for consent posed unacceptable risk]

Time-Out Verification

Pre-procedure verification and time-out performed immediately prior to the procedure: patient identity verified with two identifiers; procedure and site/side verified; allergies reviewed; coagulation status reviewed; team agreement achieved. [If emergent: Time-out performed to extent feasible – brief explanation]

Anesthesia and Sedation

• Airway status: [Intubated / Not intubated]
• Sedation approach: [Local anesthesia only / Moderate sedation / Patient already sedated on ICU infusions]
• Local anesthetic: [Agent, concentration, volume]
• Additional sedatives/analgesics: [Agent, dose, route, time] (Include if administered)
• Monitoring: [Monitoring modalities used]

(If sedation documented elsewhere, reference that record and list agents used)

Sterile Technique

Hand hygiene performed; hair clipped at insertion site. Skin antiseptic [agent] applied and allowed to dry. Maximal sterile barrier precautions used (cap, mask, sterile gown, sterile gloves, large sterile drape). Catheter type: [Standard / Antimicrobial-impregnated – type]. Closed drainage system maintained throughout.

[Any deviation from sterile technique: description, reason, and mitigation] (Only include if deviation occurred)

Procedure Description

Positioning and Entry Site: [Patient positioning]. Entry point: [Kocher's point / Alternative site – rationale]. Side: [Right / Left].

Access and Catheter Placement: [Skin incision made / not made]. Burr hole created via [twist drill / perforator / existing craniectomy]. Dura opened via [method]. Trajectory: [description]. Number of passes: [number]. CSF obtained at depth: [depth in cm from skull surface]. (If CSF not obtained, document troubleshooting steps and resulting plan)

Securing and System Connection: Catheter [tunneled – length / not tunneled]. Secured with [suture type / fixation device]. Dressing applied: [type]. Catheter connected to closed drainage system.

Findings and Measurements

• Opening Pressure / Initial ICP: [Value and units] via [manometer opening pressure / transduced ICP after leveling] (Required – if not obtained, state explicit reason)
• CSF appearance: [Clear / Blood-tinged / Frankly bloody / Xanthochromic / Cloudy / Purulent]
• CSF samples sent: [Yes – studies ordered and indication / No – sampling deferred to minimize system manipulation]
• Estimated blood loss: [Volume] (Include if applicable)

EVD Settings and Orders

• Reference point for leveling: [External auditory meatus/tragus / Institutional alternative]
• Drain height setting: [Numeric value] cm H₂O (Required – must include numeric value and units)
• Drainage mode: [Continuous drainage at set height / Intermittent drainage – parameters / Clamped for monitoring only – criteria to open]
• ICP monitoring: [Active with adequate waveform / Not monitored]
• Repositioning instructions: EVD to be clamped prior to repositioning or transport; re-level and re-zero after position change.
• Escalation parameters: [Sustained ICP threshold, CSF output abnormalities, change in CSF appearance, dressing concerns, neurologic deterioration]
• Order set: [Formal EVD order set placed / Not placed]

Complications

Complications: [None apparent / Hemorrhage – suspected or confirmed / Malposition suspected / Failure to obtain CSF / CSF leak / Break in sterility / Hemodynamic or respiratory instability / Other]

[If any complication or uncertainty: details, diagnostic steps, interventions, and monitoring plan] (Only include if applicable)

Post-Procedure Status and Plan

• Immediate neurologic status: [Brief comparison to pre-procedure baseline]
• Dressing status: [Dry and intact / Concerns – description]
• Post-procedure imaging: CT head to confirm position and evaluate for hemorrhage, [timeframe]
• Antibiotic plan: [Peri-procedural prophylaxis given – agent, time / Not given – reason] (Note: prolonged prophylaxis for EVD duration is not routinely recommended)
• Infection prevention: Maintain closed system; CSF sampling only if clinically indicated.