Subdural Drain

BARNES-JEWISH HOSPITAL

CRITICAL CARE POLICIES/PROCEDURES

TITLE: Subdural Drain

SUBMITTED/REVIEWED BY:                                  Mary Sauer, RN, MSN

Clinical Educator

Neuroscience Intensive Care Unit, 104ICU

LAST REVIEWED/REVISION DATE:           April 2017

Policy Statement

The neurosurgeon places a subdural catheter to drain blood from the subdural space through a sterile, closed drainage system. The catheter may be placed at the bedside in the ICU or in the operating room.

  1. A qualified neurosurgeon inserts, repositions and removes the catheter.
  2. Informed consent must be obtained from the patient or his/her designee as specified by the BJH Organizational Policy and Procedure “Informed Consent”, with the exception of emergent situations.
  3. Only a neurosurgeon may aspirate, irrigate or remove drainage from the system. Irrigation is done with preservative-free 0.9% normal saline (NS) only.
  4. Sterile technique is to be used throughout the set-up/placement/flushing/irrigation procedure.
  5. The ICU RN may assist with the procedure if done at bedside and may set up the drainage system prior to connection to the subdural catheter.
  6. A qualified ICU PCT may assist with patient positioning before/during the procedure.
  7. Strict adherence to Standard Precautions regarding the handling of blood/body fluids is mandatory.
  8. Neurosurgery orders should include the following:
  9. Clamp position (drain or clamped), and HOB level
  10. Frequency of neurological checks
  11. Nursing observations for which neurosurgery should be notified
  12. Sedation/analgesia before, during, and post-procedure as needed
  13. Restraints if needed (Follow the BJH Organizational Policy & Procedure “Restraints: Management of Non Violent and Non Self Destructive Behaviors”)
  14. Prophylactic I.V. antibiotics as ordered
  15. Patients with subdural drains may also be admitted to stepdown per physician order/preference.
  16. Perform universal protocol (time out).

Procedure

Equipment (*Items available in 104ICU)

Neuro Monitoring Drill Kit*

External Drainage System with Catheter*

Sedation/Analgesia as ordered

Hair clippers*

4×4 gauze – 2 tubs

Sterile gloves/sterile gown/sterile towels

Head covers and masks

Hospital-approved disinfecting solution

1% or 2% lidocaine without epinephrine

Syringes (3-ml and 10-ml)

25-ga. needle

Sterile 4×4’s– use 2 to cover the insertion site

2-in. silk tape

Benzoin swab stick

Goggles

Sterile red caps

I.V. pole

Restraints if needed (Follow the BJH Organizational Policy & Procedure “Restraints: Management of Non Violent and Non Self Destructive Behaviors”)

  1. Assessment
  1. Assess the patient/family educational needs and reinforce the neurosurgeon’s explanation of the rationale for the procedure and expected outcomes.
  2. Verify correct patient using two identifiers. Perform a pre-procedure verification and time out if nonemergent.
  3. Assess and document baseline neurological status and vital signs. Subtle changes in neurological status or vital signs can indicate improvement or deterioration of a patient’s condition.
  4. Obtain a baseline CBC with platelet count and PT-INR/PTT—report any aberrant results to the neurosurgeon immediately. Infection and coagulopathy can preclude drain placement.
  1. Fresh frozen plasma may be administered just prior to the procedure to correct coagulopathy.
  2. Appropriate blood product administration consent form must be signed prior to blood product administration. See the BJH organizational policy “Blood Administration.”
  1. Assess patient’s need for sedation and/or pain medication before and during procedure to help maintain sterile field and prevent injury.
  2. Restrain with soft restraints if necessary. Must have a physician order.
  1. Follow the BJH Organizational Policy & Procedure “Restraints: Management of Non Violent and Non Self Destructive Behaviors” for restraint documentation requirements.
  2. Plan
  3. Gather equipment for drain placement.
  1. Equipment with an asterisk (*) may be obtained from 104ICU
  2. Have prophylactic I.V. antibiotic available for administration as ordered. Continue as ordered.
  1. Have appropriate personal protective equipment and necessary sterile items on hand.
  2. Prepare the drainage collection system prior to connecting the subdural catheter.
  3. Verify that safety measures are in place with time out for verification of correct information prior to the start of the procedure. Follow the BJH Organizational P&P “Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.”
  4. Assist the neurosurgeon during the procedure with patient positioning, medication administration, and connection of the catheter to the drainage system.
  5. Have appropriate sedation/analgesia available if needed.
  6. Obtain order for restraints if needed during catheter placement. Follow the BJH Organizational Policy & Procedure “Restraints: Management of Non Violent and Non Self Destructive Behaviors” for restraint documentation requirements.
  7. Set up the electronic medical record for documentation.
  1. I&O flowsheet for drain output at the prescribed intervals
  2. Nursing assessment flowsheet—presence/location of drain, drainage description (include color, character, and consistency of drainage) document under Neuro Monitoring; also document procedure and patient response upon insertion.
  3. Implementation
  4. Subdural drainage collection system set-up
  1. Sterile technique is used throughout the set-up/insertion/flushing/sampling procedure, following strict USP guidelines. Anyone in the room during the insertion of the catheter must wear a mask and head cover. Room door(s) must remain closed through the duration of the procedure. The neurosurgeon and anyone assisting will wear a sterile gown and gloves, mask and head cover for the insertion procedure.
  2. Open the collection device package maintaining content sterility, if not already opened by the physician.
  3. The neurosurgeon performs the subdural drain procedure using sterile technique. Close the stopcock between the collection chamber and the drainage bag to ensure drainage is collected in the collection chamber and not directly draining into the collection bag.
  4. Apply sterile red caps to all open ports, maintaining a closed system.
  5. The neurosurgeon removes the cap from the distal end of the subdural drain and attaches the connector to the drainage line. Subdural drainage will prime the drainage line until the first drop of fluid falls to the collection chamber.
  6. Position the subdural drainage system at the lowest possible height for drainage.
  7. NEVER CONNECT THE SUBDURAL DRAINAGE SYSTEM TO A PRESSURE BAG
  8. The neurosurgeon will apply the initial dressing.
  9. The RN may reinforce the dressing as needed.
  10. The neurosurgeon secures the subdural catheter and dresses the site, then writes orders for the following:
  1. HOB elevation in degrees, or HOB flat
  2. Collection chamber height
    • The drainage system is usually ordered for placement at the lowest level possible.
    • If drainage system is to be positioned on the floor, the collection chamber must remain upright. A barrier (e.g. pad) must be on the floor under the collection bag.
    • Suspend the drainage system from the bed. The drainage system cord can be shorted and secured around the I.V. pole.
  3. Drain clamp position (open vs. closed)
    • Clarify with the neurosurgeon whether the drain may be clamped for any patient activities and whether patient may sit up for meals.
  4. Sedation/analgesia, if appropriate.
  5. Antibiotic prophylaxis continues as ordered.
  6. Frequency of subdural drainage measurement, usually documented every 1-2 hours. Document this amount on the I&O flowsheet.
  7. Frequency of neurological checks
  1. Perform a neuro assessment post-procedure—notify neurosurgeon of any changes unrelated to   sedation or analgesia (e.g., a fixed/dilated pupil)
  2. Transporting the patient:
  1. Measure the drainage and empty the collection chamber before leaving the unit.
  2. Clamp the system and adjust its height to prevent touching the floor or to avoid getting caught in the bed wheels.
  3. Lock HOB at the ordered height whenever possible.
  4. Keep the drainage collection system upright at all times, the filter must remain dry. A wet filter will not drain properly.
    • If the filter does become wet, notify the neurosurgeon, the entire drainage collection system may need replaced.
  5. Removing the subdural catheter – The neurosurgeon removes the catheter using sterile technique.
  6. Equipment

1)   Sterile gloves and mask

2)   2-0 silk suture with needle

3)   Needle driver or Kelly clamp

4)   2×2 or 4×4 gauze

  1. 1-inch silk tape
  2. Assist the physician with the removal of the catheter and dressing the site.
  3. Document the integrity of the device and the insertion site appearance upon removal; include patient response to procedure.
  4. Dispose of the catheter and drainage collection system following USP precautions (biohazard container).
  5. Notify the neurosurgeon with any redness/swelling/drainage from the site.
  6. Remove the dressing in 24 hours.
  1. Evaluation/Documentation
  2. Monitor and document the patient’s neurological status, subdural drainage, height of the collection chamber, vital signs and respiratory status as ordered. Notify the physician with changes in any of the above.
  3. Note the HOB elevation and collection chamber level along with vital sign assessment and drain output measurement.
  4. Lock patient control or unplug the bed, so that HOB is not inadvertently adjusted.
  5. Observe the dressing at the insertion site for signs and symptoms of infection or drainage. Document every shift and prn. Notify the neurosurgeon with any redness/swelling/drainage at the site or with any changes in color/character of subdural drainage.
  6. Troubleshooting
  7. Assess for kinked or occluded catheter—may reposition patient.
  8. Assess for closed or clamped tubing, check position of stopcock(s).
  9. Assess height of the collection chamber or drainage system.
  10. Rule out disconnection or displacement of the subdural catheter.
  11. Assess filter for wetness/fluid collection—may need to replace drainage system.
  12. Turn patient from side to side or have patient cough will facilitate drainage.
  13. Notify neurosurgeon immediately with the following:
  14. Non-functioning device after troubleshooting measures have failed.
  15. Dislodged or disconnected catheter– clamp the catheter tubing and wrap with sterile 4×4’s. Anticipate a head CT to assess the amount of fluid collection and/or prepare for subdural catheter replacement per physician order.
  16. Change in neurological status associated with any of the above issues.
  17. Filter becomes wet and system is not draining. Obtain a new drainage collection system and prepare for the neurosurgeon to change it.
  18. Subdural drainage changes to bright red from a previously different color.
  19. Patient/Family Teaching
  20. Insertion, rationale, positioning, risks, expected outcomes, and placement procedure.
  21. Activity restrictions – bed rest, HOB remaining flat, assistance with movement.

References/Resources

Hickey J.V. (2009). The Clinical Practice of Neurological and Neurosurgical Nursing, 6th ed. Philadelphia: Lippincott.

Littlejohns, L., & Bader, M. (2009). AACN-AANN Protocols for Practice: Monitoring Technologies in Critically Ill Neuroscience Patient. Sudbury, MA: Jones and Bartlett Publishing.

Approval                                                                                                                                             Date

Critical Care Policy & Procedure Committee                                          April 2017

Coreen Vlodarchyk, RN – Chief Nurse Executive                       June 2017

Barnes-Jewish Hospital

Critical Care Skills Checklist

Subdural Drain

Name ___________________________________ Unit: ______________   Date: _________________

Refer to:           BJH Critical Care Policy & Procedure “Subdural Drain”

Clinical Objective:  Demonstrate proper care of patients with subdural drainsValuators Initials/Date (if more than 1 person evaluating)
 1.  Explains purpose of subdural drainage along with complications of under-drainage 
 2.  Gathers equipment to set up and/or change drainage system, performs hand hygiene 
 3.  Assists physician with subdural drain placement and connection to drainage collection system 
 4.  Describes patient activity restrictions and HOB position/locked bed controls (prn) while subdural drain is present; verbalizes need for drainage collection system to be placed as low as possible (e.g. on floor on a pad) 
 5.  Describes/demonstrates the following troubleshooting techniques

 

a.    Assesses for kinked or occluded catheter—may reposition patient.

b.    Assesses for closed or clamped tubing, checks position of stopcock(s).

c.     Assesses height of the collection chamber and/or drainage system.

d.    Rules out disconnection or displacement of the subdural catheter.

e.   Assesses filter for wetness/fluid collection—may need to replace drainage collection system.

f.   Turns patient from side to side or has patient cough

 
 6.   Assures that the collection device is not placed flat during transport or other patient activity to maintain the purpose of subdural drainage 
 7.   Describes considerations when transporting the patient. 
 8.   Describes the nurse’s role when the subdural drain is removed along with proper assessment and documentation. 
 9.   Documents subdural drainage according to BJH policy & procedure. 

Comments: _____________________________________________________________________________________

If assistance is required, your manager or clinical educator will develop an action plan with you:

Action plan:

Evaluator(s) (Initials/Signature):_____________________________________________________________________

_____________________________________________________________________________________

Signature indicates successful completion unless otherwise indicated above.

Review/Revised date:     April 2017        Author or person reviewing/revising: Mary Sauer RN, MSN

Clinical Educator 104ICU