KNOWLEDGE BASE: 1. These patients will be cared for in the following nursing departments: critical care, 5ET (Neuro), PACU, Radiology or ECC.

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1 SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: LUMBAR INTRATHECAL SUBARACHNOID CEREBROSPINAL FLUID CATHETER (Set Up and Maintenance) - ADULTS (neu02) Nursing DATE: REVIEWED: PAGES: RESPONSIBILITY: *RN 1/88 1/18 1 of 7 PURPOSE: To provide a procedure for the safe nursing care of a patient with an intrathecal lumbar catheter. KNOWLEDGE BASE: 1. These patients will be cared for in the following nursing departments: critical care, 5ET (Neuro), PACU, Radiology or ECC. 2. A physician places the catheter at the patient s bedside, in the OR or in Radiology. Perform timeout per hospital policy (01.PAT.18) to re-verify correct patient, procedure and site. If procedure is done at the bedside, document timeout on the Bedside or Outpatient Procedural Record Flow Sheet in SCM. 3. Placement of a lumbar drainage device is used for the treatment of postoperative or traumatic dural fistulae, such as a CSF leak, treatment of shunt infections, the diagnostic evaluation of idiopathic normal pressure, and to reduce ICP during a craniotomy. They are also indicated for thoracoabdominal aortic aneurysms to improve spinal cord perfusion. 4. The catheter/drainage system is not to be replaced unless specifically ordered by the physician. This keeps the system closed to prevent contamination (infection). 5. If CSF must be removed from the system for diagnostic testing, strict sterile technique must be maintained. 6. Positive patient identification is required prior to performing the procedure. Refer to SMH Policy (01.PAT.09) Patient Identification: Inpatient/Outpatient. PATIENT EDUCATION: 1. Explain the procedure to the patient. 2. Teach the patient and family the rationale for drain placement, function and potential adverse symptoms such as headache or mild discomfort at insertion site. 3. Teach the patient to avoid sneezing, coughing and straining

2 whenever possible. 4. Inform the patient/family that the bed control will be locked to reduce the risk of overdrainage and potential adverse effects. 5. Explain the need to notify the nurse for: a. change in position or getting OOB or back into bed. b. increasing headache c. leg paresthesia d. saturated dressing at catheter site e. an equipment disconnection EQUIPMENT: a. Codman EDS3 CSF External Drainage System b. Tuohy needle, 14-gauge } in CSS c. Povidone-iodine swabs or swab sticks d. Sterile gloves, gown, cap, and mask e. Sterile towels or drape f. 18-gauge needle for drawling up lidocaine g. 12 ml syringe with 23-gauge needle for lidocaine administration h. Lidocaine 1% or Lidocaine 2% without epinephrine per MD order i. 3-4 sterile tubes for CSF sampling j. Sterile occlusive dressing k. Sterile, preservative-free 0.9% saline to prime drainage system l. Non-vented Sterile red caps for Drainage system m. Rolling IV pole 2. For withdrawal of CSF a. Sterile drape (optional) b. Sterile gloves and mask c. Povidone iodine wipes (3) d. 3-ml syringe (1) e. Vis-U-All II Container OR sterile specimen glass bottles with caps

3 PROCEDURE: 1. SET UP AND MAINTENANCE: a. Ensure informed consent is obtained and a time out is completed. b. Assist with patient positioning; lateral decubitus or sitting upright and flexed forward with support. c. Wear sterile gloves to set up equipment (lumbar tray). d. The LDD is inserted by a physician into the lumbar subarachnoid space at the L2-L3 level or below (using a Touhy needle) thus avoiding injury to the spinal cord which ends at L1-L2 vertebral bodies. e. Assemble the drainage set. The drainage device should be primed with sterile normal saline (NS) prior to attaching the system to the patient s catheter. Maintain sterile connections. f. The catheter insertion site is covered with a sterile occlusive dressing. Ensure there are no kinks in the drainage system beneath the dressing and that the catheter is secured to the patient. g. The nurse assisting in the procedure should document the name of the practitioner who placed the LDD, date/time of insertion, color, clarity, and volume of initial CSF drainage, condition of the insertion site, dressing, and patency of the drainage system. h. The drainage bag and tubing will be connected below the collection chamber. The stopcock and hand clamp should be OFF to the bag so the CSF is collected and measured in the chamber, then drained into the bag and recorded hourly or per MD order in the I/O flow sheet. i. The connector port of the catheter will be joined to the small diameter tubing of the drainage set. j. The catheter/drainage tubing connection will be secured to the upper shoulder area with tape (run along the back). For patients with aneurysm repair, the connection may be secured to the patient s right flank. k. Attach system to rolling IV pole using blue screw. Insert laser leveling device. l. Make sure system is level to the floor by adjusting gray screw so that the bubble is centered in the bubble level. m. Rotate laser to engage (turn on) laser. n. The system is set to zero by lining up the laser with the external ear canal (tragus of ear which is the cartilage projection mid-ear). o. If the MD specifies the height of the chamber, adjust with white screw until black line lines up with correct height. Otherwise, the chamber remains at zero.

4 PROCEDURES: (cont d) Use cmh2o (green). The anatomic reference point will be determined by physician and may be the external auditory meatus, shoulder height or the level of the catheter (AACN, Procedure Manual for Critical Care, 2011) The height of the pressure level in relation to the ventricles determines the flow of CSF. (The higher the chamber, the slower the flow; the lower the chamber, the faster the flow.) EXCEPTION: The 0 zero level may also be placed at a point other than patient s ear per MD order. EXAMPLE: The order reads, Keep the chamber 8 cm above the external ear canal. The pressure level line on the chamber should be 8 cm* above the anatomic landmark. (Note 8 cm = 80 mm.) p. The chamber will always be kept upright to keep the air filter dry. If the filter becomes wet, the setup must be changed immediately as drainage will no longer be possible. q. Notify physician of need to change drainage system. Perform hand hygiene and Use sterile gloves and mask. r. When the patient changes position, the chamber must be adjusted to maintain the correct relationship to the landmark as specified by the physician s order. This is done by moving the pole mount assembly up or down the IV pole and setting the 0 zero level at the external ear canal (of tragus ear). For example: when the patient (in the previous example) stands up, turn the distal stopcock off towards the patient prior to the patient getting out of bed. When patient is in the chair or standing, readjust the pole mount assembly and open stopcock. This prevents backflow and inadvertent sucking in of air. s. Neurological assessment of the patient should be completed every hour in the ICU setting and every 2 hours for floor setting. The dressings and system connections will be examined every hour in ICU and every 2 hours on floor for kinks in the tubing, amounts and type of drainage, and/or leaks. More frequent checks may be required while ensuring level of drain is yielding appropriate amounts of CSF for volume-regulated drainage (e.g. provider orders 10 ml/hr of drainage). t. The amount of drainage will be monitored and recorded every shift as part of Intake and Output

5 (I&O). The CSF in the chamber will be drained into the drainage bag at the end of each shift by opening of the hand clamp and stopcock. The clamp and stopcock will be in the closed position after emptying the chamber so that CSF will again collect in the chamber only. u. If the drainage bag fills to three-quarters full, a replacement bag can be obtained from CS and changed, using sterile technique. v. DO NOT remove dressing at site or along catheter unless discontinuing the catheter. This is to avoid accidentally pulling out catheter. Only reinforce site as necessary. If there is drainage on the dressing, notify the prescriber immediately of potential CSF leak at the insertion site. 2. WITHDRAWAL OF CSF FOR DIAGNOSTIC TESTING a. Perform hand hygiene. Don mask. b. Turn stopcock off to the patient (stopcock closest to the patient). Remove closed end cap. c. Cleanse injection port on the stopcock with three (3) povidone iodine wipes and let dry for at least one (1) minute. Allow drying. d. Don sterile gloves. e. Insert syringe into injection port on the stopcock. f. Allow CSF pressure to push the plunger to the amount of fluid needed. Two (2) ml is sufficient for culture and gram stain. (May have to aspirate.) Additional volume may be necessary if other lab tests ordered. Remove syringe. g. Cleanse port with betadine wipe after removing the syringe and place a new sterile closed end cap on the stopcock injection port. h. Return stopcock to original position. i. Print label and place on specimen. Obtain computer requisition for the ordered tests and send specimen to the laboratory within 30 minutes. j. DO NOT draw specimens from the resealable port in line at the drainage system. 3. TROUBLE SHOOTING (If there is a question as to the catheter draining) *It is expected that there will be no, or minimal, CSF drainage for up to eight hours after initial placement of the intrathecal catheter. This is because the CSF pressure may be too low to allow drainage since the patient had a prior leak and must replenish the body s normal amount of CSF. Normal pressure = 0-15 mm Hg.

6 a. To determine if catheter is patent: 1) Check that tubing is not kinked. 2) Make sure stopcock is open to drain and that there are no system disconnections. 3) May have to tap small collection chamber with your fingers as the valve may be occluded. 4) Clamp off to patient and slowly lower the chamber (pressure level) approximately onehalf to one inch. Assess for presence of drainage of CSF and return chamber pressure level to ordered level. 5) Lastly, using the same steps in procedure #2 Withdrawal of CSF for Diagnostic Testing. For withdrawing a CSF sample, aspirate ½ ml to check for patency of catheter. 6) Assess for C/O drainage in back of throat or presence of CSF from ear, nose or around catheter site. Notify MD if this occurs as it is indicative of the intrathecal catheter not draining appropriately. 7) Notify MD if patient complains of headache as chamber level may need to be readjusted (too low). 4. DISCONTINUING THE INTRATHECAL CATHETER a. The catheter is removed by the practitioner (physician, physician assistant or nurse practitioner); nurse will assist. b. Nursing will prepare equipment: sterile gloves, suture removal kit, and dressing supplies. c. Explain the procedure to the patient. d. The practitioner will clamp the catheter drainage system, perform hand hygiene and don sterile gloves. e. Place the patient in the lateral decubitus position (*LP position). f. The practitioner will remove the dressing, adhesive tape, and suture (if applicable). g. The practitioner will pull the catheter gently towards the patient s feet (caudal). If increased resistance is felt, reposition the patient and try again. h. Make sure the drain is intact and then culture the tip of the catheter if ordered by the practitioner. i. Apply a sterile occlusive dressing. j. Assess for neurological changes in patient. k. Notify MD of any drainage at site (may be CSF). l. Assess site and document every shift.

7 DOCUMENTATION: Assessment/Reassessment or ICU Assessment flowsheets: Document the condition of dressings, amount and description of drainage, position of set up. Document the amount of CSF sent to the lab and tests to be done. Also document the patient s response to the procedure and any other pertinent information. Document complaints of headache, dizziness, or nuchal rigidity. REFERENCE: 1. Lynn-McHale Wiegand, D., and Carlson, K. (2011). AACN Procedure Manual for Critical Care. (6 th Edition). St. Louis: Missouri: Elsevier Saunders. 2. Codman & Shurtleff, Inc. (2006). Codman EDS3 CSF External Drainage System with Ventricular Catheter; Codman CSF External Drainage System without Ventricular Catheter. 3. American Association of Neuroscience Nurses (2011). AANN Clinical Practice Guideline Series: Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage. 4. American Association of Critical Care Nurses (2011). AACN Procedure Manual for Critical Care: Lumbar subarachnoid catheter insertion (assist) for cerebrospinal fluid drainage and pressure monitoring. REVIEWING AUTHOR(S): Benny Kruger, MSN, RN, CCRN, CNN, NPD Specialist, Critical Care Kelly Comingore, BSN, RN, CCRN, NPD, Critical Care