Intracranial Pressure Monitor Placement Procedure Note (Bedside)

Date/Time: [Start date/time — End date/time / Duration]

Location: [ICU / ED / Other bedside location]

Primary Operator: [Name, credentials]

Assistant(s): [None / Name(s), credentials]

Procedure Type: [Intraparenchymal ICP monitor (bolt/fiberoptic) / Ventricular catheter (EVD)]

Urgency: [Elective / Urgent / Emergent]

Indication

[Clinical problem prompting ICP monitoring, objective triggers, and monitoring goal] (2–4 sentences. Include ICP trending, CPP-guided therapy, and/or CSF diversion if EVD. Do not imply imaging was reviewed if not explicitly documented.)

Safety Screening

• Anticoagulation/Antiplatelet Status: [Medication(s), last dose/time / None]
• Coagulation Labs: [Platelets: __ (date/time); INR: __ (date/time); aPTT: __ (date/time) / Not available] (Do not infer normal values if absent.)
• Site-Specific Concerns: [Prior cranial surgery / Skull fracture / Infection at planned site / Implanted hardware / None]
• Emergent Placement Without Labs: [Not applicable / Labs unavailable due to __; proceeded given risk of delay]

Consent

(Document exactly one pathway. Do not auto-populate as obtained. If unclear, insert: [Consent documentation incomplete—specify pathway].)

• Informed consent obtained: [Consenter: patient with capacity / surrogate (name, relationship)]. Risks discussed: hemorrhage, infection/meningitis, malposition, CSF leak (if EVD), need for replacement, seizure, neurologic injury. Benefits and alternatives including no procedure discussed. Questions answered.
• Emergency exception: Emergent due to [imminent neurologic harm]. Patient unable to consent: [comatose / intubated / lacks capacity]. Surrogate unavailable despite [reasonable efforts/attempts]. Plan to update family when reachable.
• Prior consent on chart: [Location of documentation]. Confirmed matches procedure and laterality.

Pre-Procedure Verification

• Time-out: [Performed / Not performed] (If performed: correct patient, procedure, device type, site, laterality, equipment, and allergies confirmed.)
• Laterality: [Right / Left] (Include rationale if deviating from service default. If not stated, insert: [Laterality not documented].)
• Antibiotic Prophylaxis: [Drug, dose, route, time administered / None given (reason)]
• Team Members Present: [Names/roles]

Procedure Details

Site: [Right / Left] [Anatomic site/landmark, e.g., Kocher's point] (State deviation from standard landmarks with rationale if applicable.)

Positioning and Monitoring: [Patient position]. [Head positioning]. [Physiologic monitoring in place].

Sedation/Analgesia: [Local only / IV sedation / General anesthesia]. [Agents and doses].

Sterile Preparation: [Hair management]. [Antiseptic agent]. [Sterile barriers]. [Local anesthetic: drug, concentration, volume].

Technique: [Skin incision]. [Burr hole or twist-drill creation]. [Dural access]. [Device insertion: bolt/fiberoptic probe or ventricular catheter; depth: __ cm]. [Secured with: bolt tightened / catheter tunneled __ cm and sutured]. [Dressing applied]. [Device manufacturer/model if available].

EVD-Specific Details: [CSF obtained: Yes/No; appearance]. [Drain setup: closed system]. [Initial drainage height: __ cm H₂O]. (Include only for ventricular catheter/EVD.)

Immediate Results

• Opening ICP: [__ mmHg at __] (Required. If not obtained, use: [Opening ICP not documented—reason: __].)
• Waveform Quality: [Appropriate pulsatile waveform / Dampened / Flat / Unreliable]
• Troubleshooting: [Cable/zeroing checked / Transducer adjustment / Repositioning] → [Current status] (Only if waveform unreliable.)
• Patient Tolerance: [Tolerated well / Discomfort / Hemodynamic changes]

EVD-Specific Results: [CSF return and appearance]. [Drain status: clamped / open at __ cm H₂O]. [Leveling reference: tragus]. (Include only for ventricular catheter/EVD.)

Complications and Specimens

• Complications: [None / Hemorrhage / Malposition / CSF leak / Seizure / Other] (Required even if none.)
• Estimated Blood Loss: [Minimal / __ mL]
• Specimens: [CSF sent for: cell count, protein, glucose, Gram stain/culture / No specimens sent]
• Post-Procedure CT Head: [Ordered / Deferred (rationale)]

Monitoring Plan and Alert Thresholds

Monitoring Setup: [ICP display location]. [Neuro check frequency]. [Head positioning precautions].

EVD Drainage Strategy: [Continuous / Intermittent]. [Clamp rules]. (Include only for ventricular catheter/EVD.)

Targets: ICP goal: <[__ mmHg]. CPP goal: [__–__ mmHg]. (Specify service default vs patient-specific.)

Alert Thresholds:

• ICP sustained >[__ mmHg] for [__ minutes] → notify [service/team]
• CPP sustained <[__ mmHg] for [__ minutes] → notify [service/team]
• Loss of waveform or malfunction → troubleshoot (check connections, zero/level) → notify if unresolved
• EVD: Sudden change in drainage, CSF leak, or CSF appearance change → notify [service/team]
• Signs of infection (fever, meningismus, worsened mental status) → notify [service/team]

Disposition

[Procedure completed with/without complication]. [Device status: functional, waveform acceptable, secured, dressing intact]. [Patient disposition and handoff]. [Pending items: post-procedure CT / device replacement / none].