HEALTH SERVICES CODE L.4 NURSING PROCEDURE TITLE: LUMBAR … · Lumbar drains are indicated for...

Approved: June 7, 2017 of 17

HEALTH SERVICES

CODE: L.4

NURSING PROCEDURE

TITLE: LUMBAR DRAIN

A. Preparing the System

B. Connecting to a Patient

C. Draining CSF

D. Maintenance

E. Obtaining a CSF Sample

F. Replacing Drainage Bag

G. Removal

H. Transducing a CSF Pressure (ICU Only)

CATEGORY:

Sections A-G : RN- Special Nursing Procedure

Sections A-G: LPN- Advanced Practice

Section H: RN – Special Nursing Procedure (ICU only)

PURPOSE

To provide drainage of cerebrospinal fluid (CSF) from ventricles of brain or lumbar subarachnoid space to an external closed drainage system.

Lumbar drains are indicated for patients with a dural fistula or tear, shunt infections or malfunctions, or for patients undergoing thoracoabdominal aortic aneurysm repairs.

To provide safe care to patient with a lumbar drain.

To safely and accurately monitor CSF pressures through lumbar drain.

NURSING ALERT:

Physician orders must be obtained for: level of zero reference, set pressure level, continuous/intermittent drainage, and activity.

When draining CSF from lumbar subarachnoid space, preventing over drainage is critical.

Not to be used on patients on anticoagulants/antiplatelet drugs or with an anticoagulation disorder.

Volume limiting external CSF drainage and monitoring system (LimiTorr™) is MRI compatible, evolution pole mount is NOT.

LimiTorr™ has a volume limiting valve which stops drainage at 20 mL.

Aseptic technique MUST be used when setting up, priming, accessing, and replacing drainage bag.

Stopcock must be “OFF” to patient line for all position changes or for any patient transport to prevent over drainage. Once patient is in desired position drain should be re-levelled and stopcock can be reopened.

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CODE L.4

A. Preparing the System

EQUIPMENT

1. Rolling IV pole 2. Evolution pole mount 3. (LimiTorr™) 4. Personal protective equipment (PPE) 5. Sterile gloves 6. Procedure mask 7. 2 - 12 mL prefilled sterile normal saline syringe (SPD # 314190) 8. White cap (dead ender) PROCEDURE NOTE: In addition to procedure diagrams, also refer to Appendix A for reference.

NURSING ALERT:

System must be primed prior to attaching tubing to lumbar subarachnoid catheter.

1. Perform hand hygiene. 2. Attach evolution pole mount to the rolling IV pole.

3. Open LimiTorr™ package.

NOTE: Ensure that packaging is opened carefully so that sterility is maintained as much as possible (this can be utilized as sterile field).

4. Add white cap and 12 mL prefilled sterile NS syringes and place onto sterile field using

aseptic technique. 5. Perform hand hygiene, don sterile gloves and procedure mask.

Evolution pole mount

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6. Attach sliding bracket to main drainage system. 7. Tighten all connections, mount LimiTorr™ to evolution pole mount and tighten thumb

screw. 8. Insert transducer manifold into slot of evolution pole mount and tighten thumb screw.

NURSING ALERT:

System must be primed under aseptic conditions.

Permission granted by Integra LifeSciences Corporation, Plainsboro, New Jersey, USA.

Transducer manifold

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CODE L.4

9. Turn pressure transducer stopcock “OFF” to burette, remove sterile red end cap and place onto sterile field.

10. Attach 12 mL prefilled sterile NS syringe to transducer mount stopcock port, remove cap

on distal end of catheter and prime patient line to catheter connection. Keep 12 mL syringe in place.

11. Attach a white cap (dead ender) to the patient end of tubing.

12. Turn distal patient line stopcock “OFF” to the patient end of tubing.

Sterile end cap

Permission granted by Integra LifeSciences Corporation, Plainsboro, New Jersey, USA.

Patient Line

“Off” to patient end of tubing

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13. Turn pressure transducer stopcock to “OFF” to patient line. Prime tubing allowing 2-3 mL

of saline to collect into collection bag.

14. Turn stopcock beneath burette “OFF” to burette. NOTE: Leave appropriate amount of saline in burette if a volume per hour order

is present. e.g. Physician orders 10 mL/hour to drain from patient – 10 mL CSF must remain in burette to ensure maximum that can be drained from patient in next hour would be 10 mL.

NURSING ALERT:

Ensure stopcock between burette and drainage bag is “OFF” to burette to ensure volume limiting feature is engaged.

15. Turn transducer mount stopcock port “OFF” to syringe. 16. Remove 12 mL syringe and replace with red sterile end cap.

B. Connecting to a Patient

NURSING ALERT:

Patient line stopcock must be “OFF” to distal/patient end of tubing prior to connecting lumbar catheter to external drainage system.

Strict aseptic technique must be used when connecting lumbar catheter to external drainage system.

Off to Patient Line

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EQUIPMENT

1. Appropriate PPE 2. 2 – alcohol swabs 3. Procedure mask 4. Sterile gloves 5. Primed LimiTorr™ PROCEDURE 1. Perform hand hygiene and don appropriate PPE.

2. Scrub catheter port to be connected with alcohol swab for 15 seconds and allow to dry

for 1 minute. Do not allow connections to touch anything until system is connected (assistant may be required).

3. Perform hand hygiene, don mask and sterile gloves. 4. Remove sterile end cap from LimiTorr™ and from lumbar catheter using aseptic

technique; connect lumbar catheter to LimiTorr™.

NURSING ALERT:

If stopcock present on lumbar catheter, ensure it is turned “OFF” to patient prior to removing sterile end cap.

5. Ensure patient line stopcock remains “OFF” to patient until system is levelled

appropriately, ordered pressure parameters are set, and physician order to drain CSF has been obtained (See section C).

C. Draining CSF

EQUIPMENT

1. Personal protective equipment (PPE) 2. Laser Level 3. LimiTorr™

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PROCEDURE

NURSING ALERT:

Physician orders must be obtained for: level of zero reference, set pressure level, continuous/intermittent drainage, and activity.

Amount of drainage is controlled by height of pressure level of burette chamber and can affect ICP.

System must be properly aligned relative to the patient for accurate drainage.

Use of lockouts on bed MUST be used when drain open to ensure patient remains in correct position as ordered by physician.

Stopcock must be “OFF” to patient line for all position changes or for any patient transport to prevent over drainage. Once patient is in desired position drain should be re-levelled and stopcock can be reopened as ordered.

1. Confirm physician orders for intermittent or continuous drainage. This must include: zero

reference level, set pressure level in cm H20, amount of CSF to be drained per hour, and activity.

2. Perform hand hygiene. 3. Don appropriate PPE.

4. Set zero reference level.

4.1 Place laser level into bracket on back of evolution pole mount. 4.2 Turn red laser level power button on. 4.3 Ensure bubble level is within markings to position system correctly. 4.4 Use laser level to align zero reference to external landmark of patient as ordered by

physician.

NOTE: Zero reference point varies with lumbar drains. Common landmarks are point of insertion or phlebostatic axis.

Bubble level

Zero Reference level on patient

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NOTE: Laser level will remain on for 60 seconds. Use caution to ensure laser

level light does not shine into patient’s eyes.

5. Set pressure level. 5.1 Align yellow indicator with drainage level as ordered by physician (in cm H20) by

moving sliding bracket on right side of Evolution Pole Mount. 5.2 Secure with thumb screw.

NOTE: A set pressure level of 0 cm H20 is most commonly ordered when physicians are ordering a specific volume of CSF to be drained per hour.

6. Ensure stopcock between burette and drainage bag is “OFF” to burette.

7. Turn patient line stopcock “OFF” to sampling port and open to patient allowing CSF to

drain into burette.

Continuous Drainage

NOTE: Drain will remain open to patient at prescribed settings.

7.1 Observe amount of CSF collected in burette hourly.

NURSING ALERT:

If order is to drain less than 20 mL/hour, a specific volume of CSF must remain in burette to prevent over drainage. i.e. physician orders 10 mL/hour to drain from patient – 10 mL CSF must remain in burette to ensure maximum that can be drained from patient in next hour would be 10 mL.

Intermittent Drainage

7.2 Open drain at prescribed settings. 7.3 Observe and record prescribed amount of CSF has collected in burette. 7.4 Remain with drain to prevent over drainage. 7.5 Turn patient line stopcock “OFF” to patient.

Set Pressure in cm H2O

Thumb screw

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NURSING ALERT:

If CSF does not empty into graduated burette, system may be blocked. If this happens, system may need to be flushed. This MUST be done by physician.

8. Empty CSF in burette into drainage bag hourly.

8.1 Turn patient line stopcock “OFF” to patient. 8.2 Turn stopcock between burette and drainage bag “OFF” to sampling port to allow

CSF to empty from burette. 8.3 Turn stopcock between burette and drainage bag “OFF” to burette to ensure that

volume limiting feature is re-established.

NURSING ALERT:

In case of accidental overdrainage of burette to drainage bag, nurse must drain ordered volume for next hour under direct supervision and then turn patient line stopcock “OFF” to patient until appropriate time has elapsed.

9. Turn patient line stopcock “OFF” to sampling port allowing the CSF to drain into burette

as ordered. 10. Document hourly CSF drainage on appropriate RQHR approved form.

D. Maintenance

NURSING ALERT:

If system becomes disconnected, place sterile dead end cap on catheters. Immediate replacement of LimiTorr™ is required to minimize risk for serious infection.

If catheter has become contaminated, ordering physician must be notified so that appropriate decision regarding continued catheter use can be made.

Use of lockouts on bed MUST be used to ensure patient remains in correct position as ordered by physician.

Stopcock must be “OFF” to patient line for all position changes or for any patient transport to prevent over drainage. Once patient is in desired position drain should be re-levelled and stopcock can be reopened as ordered.

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PROCEDURE 1. Perform hand hygiene and don appropriate PPE prior to handling any part of lumbar

drainage device.

2. Ensure use of lockouts on bed.

NOTE: Patient positioning is crucial to prevent complications from lumbar drainage.

3. Assess system setup and record zero reference level, set pressure level, amount, clarity and colour of CSF drainage hourly and prn.

4. Perform neurological assessment as ordered by physician. 5. Assess insertion site every shift and prn for CSF leakage or infection.

NOTE: Lumbar drain dressing is to be kept dry and intact. If drainage is noted

on the dressing the physician should be notified as it could mean a possible CSF leak. Dressing changes are to be done by physician if required.

6. Ensure patient and family have understanding of importance of positioning restrictions.

7. Instruct patient to notify nurse with any neurological changes including headaches.

8. Notify physician for:

Change in level of consciousness.

Change in cranial nerve function.

Change in sensation of upper/lower extremities.

Change in motor function.

Change in vital signs.

Worsening headache. E. Obtaining a CSF Sample EQUIPMENT

1. Personal protective equipment (PPE) 2. Sterile gloves 3. Alcohol swabs 4. 6 mL syringe 5. Sterile specimen container(s) 6. Lab requisition 7. Procedure mask

NOTE: Do NOT insert a needle directly into the needleless sampling site or it will be damaged.

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1. Confirm physician’s order for CSF sample. 2. Perform hand hygiene and don appropriate PPE including sterile gloves and mask.

NOTE: There must be at least 3 mL of CSF in the graduated burette before taking a CSF sample.

3. Turn patient line stopcock “OFF” to patient. 4. Cleanse needleless sampling site beneath graduated burette vigorously with alcohol

swab using a 15 second scrub (let dry). 5. Attach 6 mL syringe to sampling site beneath burette. 6. Ensure stopcock is “OFF” to collection bag. 7. Aspirate required volume of CSF.

NOTE: Only a small amount of CSF is required for testing. For general chemistry (glucose, LDH, protein, lactate) a minimum 1 mL is required. Recommended volume for routine bacterial Gram stain and C&S is 2 mL; an additional 2 mL for fungal stains and culture; an additional 2 mL for AFB stain and culture; an additional 1 mL for each viral test. If additional specialty/send out testing is ordered please refer to the lab compendium for volumes required/test. If both culture and sensitivity and chemistry are ordered they may both be put in same sterile specimen container.

8. Transfer CSF to sterile specimen container(s) using caution to maintain sterility of

sample.

9. Label sample with patient’s name, MRN, date and time sample collected. 10. Send specimen immediately to lab with appropriate requisitions.

11. Reopen patient line stopcock to drainage system after confirming ordered settings to

continue with CSF drainage.

Sterile Specimen Container

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F. Replacing Drainage Bag EQUIPMENT

1. Personal protective equipment (PPE) 2. Sterile gloves 3. Procedure mask 4. Sterile replacement drainage bag 5. Alcohol wipes

NOTE: Replace drainage bag when drainage bag is ¾ full.

PROCEDURE 1. Perform hand hygiene. 2. Don appropriate PPE including sterile gloves and procedure mask. 3. Ensure stopcock beneath burette is “OFF” to burette. 4. Cleanse bag disconnection site vigorously with alcohol swab using a 15 second scrub

(let dry). 5. Disconnect drainage bag using aseptic technique. 6. Cap drainage bag using blue cap that is attached to drainage bag. 7. Connect new sterile replacement drainage bag using aseptic technique.

8. Dispose old drainage bag in biohazard bin.

NOTE: Do not attempt to empty CSF out of drainage bag.

9. Document. G. Removal

NURSING ALERT:

Before removal check when last anticoagulants were administered – see same as recommended in nursing procedure E.2.

NOTE: Removal of lumbar catheter is responsibility of physician.

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1. Perform hand hygiene and don appropriate PPE.

2. Assist physician as needed with removal. 3. Apply a sterile occlusive dressing.

4. Ensure appropriate disposal of catheter and drainage system in biohazard bin.

5. Instruct patient to remain in supine position x 4 hours post removal.

6. Perform and document neuro assessment and assess insertion site dressing q1hx4,

then q4h post removal or as ordered by physician.

H. Transducing a CSF Pressure (ICU Only)

NOTE: Normal CSF pressure is 0-15 mm Hg and usually corresponds with intracranial pressure. Maintenance of intraspinal pressure of less than 10 mmHg after thoracic abdominal aortic resection may be ordered.

EQUIPMENT 1. Single transducer pressure tubing 2. Sterile pre-filled NS syringe 3. Sterile dead end cap 4. Pressure module and cable 5. Sterile gloves 6. Procedure mask

NOTE: Strict asepsis is required when setting up or accessing system.

PROCEDURE 1. Perform hand hygiene and don appropriate PPE including mask

2. Open transducer package, add NS syringe and sterile dead end cap while maintaining

sterility of package contents. 3. Don sterile gloves

4. Disconnect soft and hard tubing from transducer.

NOTE: Transducer will be only piece remaining.

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5. Attach pre-filled NS syringe to transducer and flush entire system by activating the fast flush

device.

6. Replace vented cap with non-vented cap and add dead end cap to distal end of transducer.

7. Detach syringe and apply sterile dead end cap.

8. Connect transducer to pressure cable and module.

9. Attach transducer to transducer mount stopcock of lumbar drain.

NOTE: Transducer will always correspond to zero reference landmark with Limitorr Lumbar Drain.

9.1 Remove sterile cap from transducer mount stopcock of lumbar drain. 9.2 Remove sterile cap from end of transducer. 9.3 Attach transducer directly to transducer mount stopcock. 9.4 Ensure drain levelled to appropriate anatomical landmark as ordered.

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10. Zero transducer with Philips monitoring system by turning transducer stopcock “OFF” to patient and opening transducer to air.

NOTE: Zeroing of transducer is required q shift and prn.

11. Turn transducer mount stopcock “OFF” to burette and open to patient to obtain accurate CSF pressure waveform and reading.

12. Print and mount CSF pressure waveforms once per shift and prn.

NOTE: CSF pressure waveform should resemble an ICP waveform.

NURSING ALERT:

Notify physician if unable to obtain CSF pressure waveform as this may indicate blockage or dislodgement of catheter.

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REFERENCES Caple, C. (2014). Thoracoabdominal Aortic Aneurysm Repai: Managing Lumbar Drains.

Cinahl Information Systems, Glendale, CA. Fedorow, C., Moon, M., Mutch, A., Grocott, H. (2010). Lumbar Cerebrospinal Fluid

Drainage for Thoracoabdominal Aortic Surgery: Rationale and Practical Considerations for Management. Anesthesia & Analgesia July 2010, 11(1). 46-58.

Hickey, J. (2009). The Clinical Practice of Neurological and Neurosurgical Nursing. (6th Ed.).

Philadelphia, PA: Lippincott-Williams & Wilkins Integra. (2013) LimiTorr™ volume limiting external CSF drainage and monitoring system

operator’s manual. Integra Neurosciences. Integra. (2009) LimiTorr™ volume limiting external CSF drainage and monitoring system

chart. Integra Neurosciences. Lynn, S.J. (2016). Caring for patients with lumbar drains. American Nurse Today, 7-10. Schraeder, N., Wiegand, D. (2017). AACN Procedure Manual for High Acuity,

Progressive, and Critical Care. (7th Ed.). St. Louis: Elsevier Saunders. Slazinski, T., Anderson, T., Cattell, E., Eigsti, J., Heimsoth, S., Holleman, J., et al. (2011).

Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage. Glenview: American Association of Neuroscience Nurses.

Tymianski, D., Sarro,A. & Green, T. (2012).Navigating Neuroscience Nursing: A Canadian

Perspective. Pembroke, Ontario: Pappin Communications Tymianski, D., (2013). Neuroanatomy and physiology. Canadian Journal of Neuroscience

Nursing. (35)3, 6-22. Revised by: Stacey Mittermayr, CNE; Lindsay Dusselier, CNE; Angela Kubiak, CNE Date: November 2014 Revised by: Lindsay Dusselier, CNE & Sarah Harder, CNE Date: May 2017

Approved by RQHR Procedure Committee: Date:

Regina Qu’Appelle Health Region Health Services

Nursing Procedure Committee

June 7/17

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APPENDIX A

Volume Limiting External CSF Drainage and Monitoring System

Permission granted by Integra LifeSciences Corporation, Plainsboro, New Jersey, USA. Code: L.4 November 2014

HEALTH SERVICES CODE L.4 NURSING PROCEDURE TITLE: LUMBAR … · Lumbar drains are indicated for...

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