Lumbar Drain Placement Procedure Note

Date/Time: [Procedure date and time; start and end times if available]

Location: [ICU bedside / Operating room / Interventional radiology suite / Other]

Primary Operator: [Name, credentials]

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

Attending Physician: [Name, credentials / Same as primary operator]

Brief Operative Summary

• Indication: [Primary indication and brief rationale]
• Procedure: [Lumbar drain placement at level and approach (e.g., L4–L5 midline)]
• Guidance: [None / Surface landmarks / Ultrasound / Fluoroscopy]
• Anesthesia: [Local only / Moderate sedation / General anesthesia]
• CSF obtained: [Yes / No]; Opening pressure: [Value] cm H2O / [Not obtained — reason]
• CSF appearance: [Clear / Xanthochromic / Bloody; clarity]
• Complications: [No immediate complications observed / Complication and management]
• Disposition: [Drain status; initial settings; patient disposition]

Indication and Clinical Context

[Primary indication: CSF leak treatment/prevention / Intracranial pressure management / Spinal cord protection for aortic procedure / Other]. [Clinical trigger prompting placement]. [Planned duration or removal strategy if established]. (Document the treating team's stated rationale only; do not infer diagnoses.)

Pre-procedure Assessment

• Coagulopathy/antithrombotic exposure: [Present / Absent / Not applicable]; [Relevant agents and timing of last dose if applicable]
• Pertinent labs: Platelets [value, timestamp]; INR [value, timestamp]
• Elevated ICP with mass effect/herniation risk: [Present / Absent / Unable to verify prior to emergent placement]
• Local infection at insertion site: [Present / Absent]
• Anatomic considerations: [Prior lumbar surgery / Spinal deformity / None]

(If proceeding emergently with incomplete contraindication verification, document risk-benefit rationale.)

Time-out: Performed prior to procedure: patient identity verified, correct procedure confirmed, essential equipment available, team members present and in agreement.

Consent

Consent obtained from [patient / surrogate (relationship)]. Risks discussed included bleeding/epidural hematoma, infection/meningitis, nerve injury, CSF leak/headache, overdrainage complications, and catheter malfunction. Benefits and alternatives reviewed; questions answered. (If consent not obtained, document reason and basis for proceeding.)

Anesthesia and Sedation

Anesthesia type: [Local only / Moderate sedation / General anesthesia]. [Local anesthetic agent and volume if local only]. [Sedation medications with doses if administered by proceduralist]. (If anesthesia service involved, state "See anesthesia record for details.")

Procedure Details

Positioning: [Lateral decubitus / Sitting]; [flexion achieved]; [padding/protection]; [patient tolerance].

Site and Approach: [Interspace level (e.g., L3–L4, L4–L5)]; [midline / paramedian approach].

Sterile Technique: [Skin prep agent] applied and allowed to dry; sterile barriers (gloves, drape, mask/cap); [local anesthetic infiltration details]; [guidance: none / ultrasound / fluoroscopy].

Needle and Catheter Insertion: [Needle type and gauge (e.g., Tuohy)]; [catheter type]; [number of attempts/redirections if clinically meaningful]; CSF return confirmed at needle hub; catheter advanced with CSF return confirmed; catheter depth at skin [value] cm; secured with [suture / adhesive device]; [dressing applied]; tunneling [performed / not performed]. (If unsuccessful, document reason and next steps.)

Opening Pressure: [Value] cm H2O measured in [lateral decubitus / other position]; [factors affecting accuracy if any]. (If not obtained, state "Opening pressure not obtained" with reason.)

CSF Characteristics: [Appearance: clear / xanthochromic / bloody]; [volume removed at placement if any]; specimens sent for [tests ordered] / no specimen sent — [reason].

Results and Complications

• Technical outcome: [Successful placement with drain patent / Attempted and aborted — reason]
• Estimated blood loss: [Minimal / Volume in mL]
• Complications: [No immediate complications observed / Complication, management, and patient response]
• Post-procedure assessment: [Neurologic exam findings]; [pain assessment]

Drain Management Plan

Drainage Strategy: [Pressure/height-based relative to (landmark) / Volume-based (mL/hr or intermittent) / Conditional (open when symptomatic)]

• Parameters: Maximum output [value] mL/hr; target pressure/height [value with units]; clamp for [HOB changes / transport / ambulation]
• Escalation criteria: Notify provider for [neurologic change / severe headache / output exceeding maximum / bloody CSF / fever or meningismus / drain malfunction]
• Positioning and mobility: HOB [restrictions]; [bedrest / mobilization allowances]; drain clamped for [activities]
• Infection prevention: Periprocedural antibiotic [given / not given — reason]; [antimicrobial-impregnated catheter if used]; CSF samples to be obtained from sampling port, not drainage bag
• Anticoagulation coordination: VTE prophylaxis [held / continued]; [service managing anticoagulation]; timing per institutional neuraxial anticoagulation policy for catheter in situ and removal

Disposition and Follow-up

• Notifications: [Teams notified]
• Reassessment schedule: [Planned drain checks]; [clamp trial timing if applicable]
• Removal criteria: [Defined criteria if established]