Placement of a lumbar catheter allows for continuous and/or intermittent drainage of cerebrospinal fluid (CSF) or measurement of intrathecal pressure in the lumbar subarachnoid space through a closed sterile system. A catheter can be placed in the lumbar subarachnoid space (usually L3-L4 or L4-L5, no higher than L2-L3) for treatment of dural tears (reduces moisture and pressure), temporary external drainage in individuals with infected shunts, or diagnosis/management of normal pressure hydrocephalus (NPH), pseudotumor cerebrii and communicating hydrocephalus (secondary to hemorrhage). Lumbar catheters may be utilized for alleviation of spinal cord edema or to improve cord perfusion after thoracoabdominal aortic aneurysm repair, and may be cautiously used in the management of meningitis.  These are usually in place for 5 to 10 days.  CSF drainage is contraindicated if supratentorial and infratentorial pressures are unequal as evidenced by the following findings on head CT scans:  midline shift (herniation risk), presence of an intracranial or posterior fossa mass, loss of cisterns (i.e., suprachiasmatic and basilar, quadrigeminal plate, superior cerebellar), epidural abscess (spinal), obstructive noncommunicating hydrocephalus, and spinal arteriovenous malformation (AVM).

The LimiTorr™ CSF drainage system by Integra Neurosciences and the AccuDrain™ system are the two CSF drainage systems in use at Barnes-Jewish Hospital.

  • The LimiTorr™ CSF drainage system has a volume-limiting valve that reduces the risk of CSF over drainage. This safety mechanism allows drainage up to a certain amount (approximately 30 ml.), then it stops additional output from the lumbar catheter until the drip chamber is emptied.
  • The AccuDrain™ system is a latex free, MRI safe closed external CSF drainage system.

Policy Statements

  • A qualified neurosurgeon, anesthesiologist, or intensivist inserts, repositions, and removes the lumbar catheter using aseptic technique. An approved RN assists with the procedure.
  • Informed consent must be obtained from the patient or his/her designee as specified by the BJH Organizational policy and procedure “Informed Consent.
  • Only a neurosurgeon or approved advanced practice staff member may aspirate, instill medications, irrigate, or remove CSF from the system.
  • The drainage system is not routinely flushed. If the system needs to be flushed, only the neurosurgeon or anesthesiologist does so with preservative-free 0.9% normal saline.
  • Orders related to the lumbar CSF drain should include the following:
    • The level (zero-reference) of the drainage/collection system (e.g., tragus of the ear, shoulder height, or at the level of catheter insertion (use consistent anatomical landmark at all times and adjust with position changes or patient transport/mobilization)
    • Specific drainage parameters (minimum/maximum of drainage per hour– 5-15 ml/hr. is common)
    • The position of the stopcock (open vs. closed, continuous drain or intermittent drain)
    • Occasionally the pressure level (as indicated on the actual drainage collection device—hydrostatic pressure drives CSF drainage)-typically 10mmHg
    • Frequency of neurological checks
    • Nursing observations for which the physician is to be notified
    • Activity restrictions, including head of bed (HOB) position
    • I.V. antibiotic orders per MD order
  • The drainage bag should be changed only when 3/4 full by a physician or an approved RN. Non-approved staff may contact 104ICU nursing staff (ext. 2-5138) for assistance with changing the drainage bag.
  • Strict adherence to Universal Standard Precautions (USP) regarding the handling of blood/body fluids is mandatory.
  • Patients with lumbar drains may also be admitted to progressive care and general patient care areas.

Procedure

Equipment (asterisk * indicates items available in 104ICU)

Lumbar catheter accessory kit *

External drainage system (AccuDrain or LimiTorr)

AccuDrain

LimiTorr drainage system (20-ml. or 30-ml. drip chamber) by Integra*

Integra pole mount with laser leveling device* for use with the LimiTorr drainage system

Preservative-free 0.9%saline*

I.V. pole

Sterile towels/drapes

4×4 gauze tubs – 2

Sterile gloves/sterile gown

Mask and goggles

Hospital-approved disinfecting solution

Syringes (3-ml, 10-ml)

25-ga. ¾” needle

Suture (2-0 silk)

Basic set

Needle holder

Transparent dressing (large)

Benzoin swab stick or skin prep

2-inch silk tape

Sterile red caps – 3

Assessment

Assess the patient/family education needs and reinforce the physician’s explanation of the rationale for the procedure and expected outcomes.
Perform a pre-procedure verification and time-out according to the BJH Organizational P&P “Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.”
Assess and document baseline neurological status and vital signs. Subtle changes in neurological status or vital signs can indicate improvement or deterioration in a patient’s condition.
Obtain pre-procedure labs as ordered (CBC, platelets, PT-INR, PTT) and review results with the physician. Infection and/or uncorrected coagulopathy may preclude drain placement.
Assess the patient’s need for sedation and/or analgesia before and during the procedure to help maintain the sterile field and prevent injury.

Plan    

Gather equipment for drain placement.
Equipment with an asterisk (*) may be obtained from 104ICU.
The physician will order prophylactic antibiotics to infuse 30 minutes prior to insertion Antibiotic prophylaxis must continue as ordered
Have appropriate personal protective equipment and necessary sterile items on hand.
Prepare the drainage system in sterile fashion (attach syringe with preservative-free NS to distal aspect of tubing, turn stopcock “off” to drainage collection system before priming tubing, then “off” to distal end of tubing to finish priming) prior to connecting the lumbar catheter.
Verify that safety measures are in place as described above in the assessment.
Assist the neurosurgeon or anesthesiologist during the procedure with patient positioning, medication administration, and connection of the catheter to the drainage system.
Obtain physician order if restraints are required. Follow the BJH Organizational P&P “Restraints: Management of Non Violent and Non Self Destructive Behaviors.”
Set up the electronic medical record for documentation
I&O flowsheet for drain output at the prescribed intervals
Nursing assessment flowsheet every shift and prn

Tubes & drains category– presence of lumbar drain, drainage description (color, clarity, consistency)
Skin integrity at the insertion site, plus description of the occlusive dressing
Document insertion and removal procedures including the patient’s responses and assessment findings.

Implementation

  • All personnel in the room must be appropriately dressed in mask, head covering, and gloves.  The neurosurgeon or anesthesiologist and anyone assisting will also wear sterile gowns.
  • Position patient in lateral decubitus (fetal) position, knees/hips flexed to chest. Assist the patient in remaining still while maintaining this position during insertion of the catheter. An alternate position for the patient is sitting up at the bedside, leaning forward over a bedside table. Advise the patient not to cough, strain, or breathe too deeply during procedure (and also whenever drain is open).

Prepare the LimiTorr or AccuDrain

  • LimiTorr drainage system
    • Insert the post of the mounting bracket through the slot located on the back of the burette (drip chamber) top cap. The yellow indicator on the pole mount must align with the drip level noted on the burette.
    • Slide the pressure transducer manifold into the pole mount slot, fitting the bracket over the post, and then tighten the locking knob until the bracket is flat/ secure against the post.
    • Open the package, maintaining sterility of the connection tubing for the catheter. Tighten all fittings.
    • If the physician desires pressure monitoring, refer to the following: PRIOR TO   connecting to the patient]
  • Turn the pressure transducer stopcock to “open” to the patient line and “open” to the transducer.
    • Remove the sterile red cap from the pressure transducer and remove the end cap at the catheter connection.  Attach 10-ml syringe of preservative-free 0.9% NS to the transducer stopcock port, then prime the patient line tubing to the catheter connection.
    • Replace the sterile end cap after priming and then turn the stopcock “off” to the patient line.
    • If the physician DOES NOT desire pressure monitoring, the decision to prime the tubing or not is physician specific.
  • After the physician connects the drainage system to the lumbar catheter, check placement of the I.V. pole to ensure a proper length of drainage tubing between the patient and the I.V. pole.
  • Do not secure the drainage tubing to the bed. Patient movements may dislodge the catheter.
  • After the lumbar catheter is in place then secured with a transparent occlusive sterile dressing, the physician orders should include the following:
  • Position of the HOB
    • If the patient can potentially change the height of the bed or the degree of HOB position on his/her own when the drain is open, consider locking the patient control so the HOB or bed height is not inadvertently adjusted. This helps to prevent under- or over drainage of CSF.
  • Level of collection device or parameters for CSF drainage per hour.
  • Stopcock position (leave open for continuous drainage, “off” with scheduled times for drainage)
  • Antibiotic prophylaxis as ordered
  • Document as described above under “Plan.”
  • The neurosurgeon, anesthesiologist or qualified advanced practice staff member applies the initial dressing and performs ALL subsequent dressing changes. Be sure it is labeled with date/time.
  • The RN may reinforce the dressing as needed.
  • All healthcare providers must ensure that the catheter is secured in a manner to prevent accidental removal.

Changing the patient’s position

  • When increasing or decreasing the HOB elevation, close the drainage system to prevent over drainage.
  • Do not place either drainage system flat during transport or during patient activities. The LimiTorr system must be in a vertical position (tilting < 5 degrees in any direction) for the volume-limiting valve to function properly.
  • Avoid completely draining the tube between the burette and the drainage bag—an air lock can occur and delay drainage.
  • Moving the sliding bracket will increase or decrease the pressure height, controlling the drainage rate.  Align the top of the sliding bracket with the prescribed pressure level (cmH2O per neurosurgery preference or mmHg if off service), then secure it using the thumb screw on the pole mount.

Catheter removal

  • A neurosurgeon, an anesthesiologist or qualified advanced practice staff member removes the catheter
  • If the catheter is pulled out, immediately notify the physician who is managing the drain.
  • Document the integrity of the catheter (e.g., “catheter tip intact”, and the insertion site upon removal.
  • The neurosurgeon may enter an order to keep the HOB below 20 degrees for 4 hours post-removal to prevent spinal headache.
  • Monitor the patient’s neurological status every hour for 4 hours and then at least every 4 hours, and report any neurological changes or evidence of CSF drainage from site.

Documentation/Evaluation

  • Evaluate and document neurological checks at least every 2 hours, unless ordered otherwise by the physician.
  • Verify order set is completed
  • Assess for symptoms of meningeal irritation (i.e., headache, photophobia, neck stiffness, temperature elevation, nausea, vomiting, and irritability).
  • Record CSF output every hour or every two hours as ordered by physician.
  • Assess and document the integrity/condition of the dressing (e.g., occlusive, dry, intact, etc.), record the date/time on it per nursing documentation policy. Notify physician of any signs or symptoms of site infection.
  • Evaluate the following conditions with complete documentation and physician notification of any aberrant findings:
    • Sudden or gradual change in level of consciousness, pupil size and reaction, sensation, bowel or bladder dysfunction, pain, nausea, vomiting, visual changes, sensorimotor assessment changes (i.e., lower extremity weakness and/or radicular pain, numbness/tingling, decreased or lost deep tendon reflexes).
    • Any signs or symptoms of infection, over drainage, absence of, or underdrainage
    • Leaking around the catheter or at the insertion site (assess for kinking of catheter, incorrect stopcock position, or clamped tubing)
    • Pain unrelieved by pain medications or other interventions
  • Assess for dislodged catheter. Do NOT reconnect. Cover the disconnected catheter (or the insertion site if catheter removed) with sterile 4×4’s. Use a sterile red cap or clamp the catheter to avoid an excessive loss of CSF.
  • Document color and clarity of the CSF drainage every 12 hours (charted in assessment) and output every 1-2 hours. Notify the physician if CSF becomes bloody, red-tinged, cloudy, or appears purulent.

Troubleshooting

  • Assess for a kinked or occluded catheter—may reposition patient. Keep the patient’s head, neck and back in a neutral position. Avoid hyperextension, rotation or extension of the hips or neck because these positions may impede drain outflow.
  • Assess for closed or clamped tubing, check position of all stopcocks. Verify the physician’s orders.
  • Assess the height of the burette (drip chamber) with respect to physician orders.
  • Rule out possible disconnection or displacement of the lumbar catheter.
  • Assess filter for wetness/fluid collection—may need to replace the drainage system.

Patient Teaching

  • Insertion rationale, positioning, and placement procedure.
  • Activity restriction including bedrest, HOB position, assistance with movement.
  • Activities to avoid (sneezing, coughing, and straining)

References/Resources

Hickey, J.V. (2013). The Clinical Practice of Neurological and Neurosurgery Nursing. 7th ed.

Philadelphia, PA: Lippincott.

Integra LifeSciences Corporation. (2017). LimiTorr volume limiting external CSF drainage and monitoring  system (package insert).  Plainsboro, NJ:  Integra LifeSciences Corporation.

Khan. (2012) Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Cochrane Vascular Group.

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

Makic, M.B., & Wiegand, D.J. (2011). Lumbar subarachnoid catheter insertion (assist) for cerebral spinal fluid pressure monitoring and drainage. In AACN Procedure Manual for Critical Care, 6th Edition (p. 826-835). St. Louis, MO: Elsevier.

American Association of Neuroscience Nurses (2011). Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage. AANN Clinical Practice Guideline Series. Glenview, IL.

Ann Petlin, RN, MSN, CCRN-CSC, CCNS, PCCN, Clinical Nurse Specialist, Cardiothoracic Surgery

Carrie Sona, RN, MSN, RN, MSN, CS, CCRN, Clinical Nurse Specialist, Surgical ICU

Drain Management