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The preparation for placement of external ventricular drains and lumbar drains is the same as the preparation for any other surgical procedure. An initial patient assessment is performed. The medical history and imaging of the patient are reviewed. Antithrombotic medication is reversed, and coagulopathy is managed. Then, the equipment is procured and prepared. Finally, the patient is positioned and prepped for surgery.


The successful surgeon treats all types of procedures, however minor, with the same respect and degree of preparation. As with any surgical procedure, preparation for placement of an external ventricular drain (EVD) or a lumbar drain (LD) starts with the patient. The first step is a detailed review of the patient’s history, medical examination, vital signs, imaging results, medications, and allergies. In this chapter, we review key factors to consider in preparing for both types of procedures and the equipment needed for each.


Preliminary Survey

As is the case with any patient interaction, a preliminary assessment must be conducted not only of the patient undergoing placement of an EVD or an LD but also of the scene. First, what is the physical setting in which the drain is being placed? A chaotic emergency department presents a different challenge than the spacious and controlled environment of the operating room. A plan should be made for working among other care teams or taking priority over them and for moving around objects such as tables, monitors, and ventilators. The availability of staff should also be considered. Both EVD and LD placement are procedures that require at least two persons. A nurse, technician, advanced practice provider, or another physician can help position and monitor the patient while the procedure is ongoing or can help with handing off supplies.

Second, the condition of the patient is evaluated. The ABCs of basic life support (airway, breathing, circulation) must be assessed. Is the patient intubated? Or will intubation be needed before the drain is placed? Is the patient hypotensive or in cardiac arrest? If the patient is immediately moribund for nonneurologic reasons, this must be strongly considered when deciding whether a drain is appropriate. Is the patient combative or unable to follow commands? Innumerable examples of observations made by the neurosurgeon during this preliminary survey directly impact the care being given by the primary team.

History, Physical Examination, and Imaging

When preparing for an EVD placement, the surgeon should note whether the patient has had a previous cranial procedure. A prior craniotomy with plates or a craniectomy with mesh can alter the entrance site. Opening over mesh may not allow the catheter to pass through or may cause the catheter to be cut, damaged, or easily occluded. Pushing down on a bone flap may cause it to become ...

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