External Ventrikulo Drainage
DEFINISI
EVD dikenal sebagai extraventicular drain atau ventriculostomy, merupakan alat yang digunakan dalam bedah saraf berfungsi mengurangi tekan intracranial yang meningkat ketika aliran CSS disekitar otak terhambat. Tabung pelastik ditempatkan oleh ahli bedah saraf, ahli saraf atau perawat ICU dan paramesid perawatan kritis untuk menglirkan cairan dari ventrikel otak yang akan menyebabkan dekompresi dan memantau tekanan intracranial.
Tujuan drainage adalah untuk mengalirkan CSS ke ruang lain dan untuk menurunkan tekanan intracranial. Dikenal beberapa metode drainage, antara lain External Ventricular Drainage, dimana CSS dikeluarkan dari intrakranial melalui suatu lubang.
INDIKASI
Indikasi untuk EVD atau monitor cairan intracranial termasuk:
Hydrocephalus
Hemorrhage
Tumor
Meningitis atau
Trauma kepala
KONTRAINDIKASI
Pasien menjalani terapi antikoagulan pada pasien gangguan sirkulasi
Pasien memiliki infeksi permukaan kepala
Pasien memliki brain abscess
MANIFESTASI KLINIS
Peningkatan cairan intracranial jika terkanan lebih dari 15 mmHg. Tanda-tanda klinis umum dari awal hipertensi intracranial yaitu:
Muntah proyektil
Sakit kepala
Kejang
Fotofobia
Lemas
Nistagmus
Diplopia
Pada beberapa peningkatan darah intracranial terjadi kesadaran melemah, perubahan reflek anggota tubuh berubah, pupil melebar, gerakan sepontan tubuh menurun dan reaksi pupil pada cahaya menurun. Tanda yang muncul terjadi secara unilateral atau bilateral tergantung penyebab peningkatan tekanan intracranial.
Pada pre-morbid high level tekanan intracranial:
Pernapasan sepontan terdepressed
Terjadi hipertensi
Detak jantung melambat/ triad Cushing
KOMPLIKASI
EVD is an invasive procedure. It is associated with several complications categorised as below:-
Hemorage
Commonly occurs along the EVD insertion tract. The risk or haemorrhage is increased if the patient is having coagulopathy.
Malplacement
Infection
EVD is a foreign inserted into human body. It can serve as an object for the bacterial attachment and causing ascending infection.
Obstruction
Obstruction/occlusion of EVD commonly due to fibrinous/clot like material or kinking of the tube. The brain can swell due to pressure build up in the ventricles and permanent brain damage can occur. Physicians, nurses, and Critical Care Paramedics often have to adjust or flush these small diameter catheters to manage medical tube obstructions and occlusions at the intensive-care bedside.[2] Pressure settings are generally measured in cmH2O. The equilibrium pressure of the EVD apparatus is adjusted based on cerebrospinal fluid output, ICP waveform, imaging including CT or MRI of the brain, and clinical response.
Migration
During the EVD insertion, the EVD is tunneled subcutaneously and anchored with suture. However, it is common for the EVD to dislodge or migrate. This will cause the tip of the drain migrated away from its supposed position and provides inaccurate ICP measurement or total occlusion of the drain
PENATALAKSANAAN, PERSIAPAN DAN PROSEDUR
Management pengeluaran cairan intracranial dapat dilakukan drainage EVD. Manajemen lainnya termasuk urgent surgical decompression, pemberian agen osmotic seperti manitol, diuretic, hiperventilasi mekanik sementara untuk mengurangi peningkatan CO2 dalam darah yang menyebabkan vasokonstriksi serebral.
Pasien yang telah masuk perawatan operasi memerluhkan monitoring ketika kembali ke ruang PICU, NICU sampai hilang efek anastesi dan penilaian neurologi.
Pengambilan sampel CIS dilakukan secara steril pada pagi hari setiap 24 jam, kecuali permintaan dari ahli saraf. Pelaksanaan prosedur akan membutuhkan 1-2 perawat yang kometen dan percara diri pada prosesur ini dan telah memiliki sertifikat dalam tindakan EVD.
Persiapan :
Gaun steril
Chlorhexadine 0,5% dalam alcohol 70%
Handscoun steril
CSF tubes steril
Syringe 10ml
Cap
Kain kasa
Betadin
APD
Procedure:
Explain to the patient/family what is about to occur
Ensure the EVD is off to the patient
After preparing equipment and opening tubes, perform sterile scrub (3 minute wash-, 2% chlorhexidine, green hand wash/ microshield) and don sterile gloves
Assistant to clamp the EVD and remove old Integra Stopcock Protection Box furthest from the patient and hold line in air
Assistant to ensure 3 way tap at base of CSF collection chamber is closed to the collection bag
Sterile RN to place sterile towel under line and clean 3 way tap on Medtronic Exacta EVD kit
Perform sterile cleaning of 3 way tap with Chlorhexadine 0.5 % in Alcohol 70% solution and allow antiseptic solution time to dry completely, (this can take up to 2 minutes).
Cap from side access point (usually red cap) to be removed and discarded, do this with dry sterile gauze to remove
3 way tap to be off to the EVD system, therefore open to the patient (to collect to freshest CSF)
Collect minimum of 1.0 ml (around 20 drops) CSF in sterile CSF tube (Never aspirate CSF from an EVD, allow drops to drip out)
Turn 3 way tap off to side access
Place new red cap on side access
Ensure 3 way tap is open from the patient to the drain
Assistant to open both Integra Stopcock Protection Boxes and fill with Betadine Solution using syringe, close boxes
Ensure the EVD transducer is at a horizontal level to the FOM
Turn the EVD on and ensure drain is oscillating / draining
N.B If collection bag needs to be emptied after CSF specimen is taken, remain sterile to clean the access at the base of the bag with Chlorhexadine 0.5% in Alcohol 70% solution and allow antiseptic solution time to dry completely, (this can take up to 2 minutes), before removing red cap and drain CSF into collection jug and replace with new sterile red cap. Ensure CSF is discarded into pan flusher.
Dressing changes
Dressings of the EVD site need to be observed hourly and this documented on the fluid balance chart (MR730/A) to ensure a leak has not occurred. If a leak is identified, place pressure combine/dressing and notify the AUM and Neurosurgical team. Dressings should be changed using sterile technique as per the treatment order (MR660/A) or when soiled.
Changing the EVD System Set
The entire system needs to be changed using sterile technique every 7 days. The procedure will require 2 registered nurses who are competent and confident with this procedure.
Equipment:
Sterile Dressing Pack and extra Gauze, Chlorhexadine 0.5 % in Alcohol 70%, Sterile Gloves, 2 Sterile Integra Stopcock Protection Boxes (External reference number 901400), Medtronic Exacta EVD Kit (Stores Number 309634), 0.9 % Normal Saline, 10ml and 20ml Syringes, Drawing Up Needle, Betadine Solution, Forceps
Procedure:
Explain to the patient/family what is about to occur
After preparing equipment, perform sterile scrub (3 minute wash :green 2% chlorhexidine / microshield wash) and don sterile gloves
Prime Medtronic Exacta EVD kit with 0.9% Normal Saline (ensuring all 3 way taps are primed and the system has no air in it)
Fill Integra Stopcock Protection Boxes with Betadine Solution using syringes
Assistant to clamp/turn off the EVD and remove old Integra Stopcock Protection Box closest to the patient and hold line in air
Sterile RN to place sterile towel under line
Assistant to use forceps and gauze to clamp Silastic tubing as close to the patient's head as possible and remove old Medtronic Exacta EVD kit from laser level device
Sterile RN to clean the connection between Medtronic Exacta EVD set and silastic tubing with Chlorhexadine 0.5 % in Alcohol 70% solution and allow antiseptic solution time to dry completely (this can take up to 2 minutes).
Disconnect old line (discard in infectious waste at end of procedure)
Connect new Medtronic Exacta EVD kit to the patient
Ensure connection is secure
Apply new Integra Stopcock protection boxes to both sections of the Medtronic Exacta EVD kit
Fill both Stopcock boxes with Betadine solution and close both boxes
Ensure line is open to the patient (draining to the burette)
Load new Medtronic Exacta EVD kit into laser level device at appropriate H20 level / height as per Neurosurgeon's instructions
Remove forceps from silastic tubing at patient's head
Ensure Medtronic Exacta EVD kit is leveled to the patient's FOM
Turn on EVD and ensure it is oscillating or draining
DAFTAR PUSTAKA
http://www.aann.org/uploads/AANN11_ICPEVDnew.pdf
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/External_Ventricular_Drains_and_Intracranial_Pressure_Monitoring/
