Surgical Coordinating Center for CLEAR III The University of Chicago Chicago, Illinois

Transcription

1 Surgical Protocol for External Ventricular Catheter (EVD) Placement for CLEAR III Trial Surgical Coordinating Center for CLEAR III The University of Chicago Chicago, Illinois June 17, 2009

2 General Principles full sterile technique most senior skilled surgeon (housestaff or attending) immediately available more than two passes additional stabilization at 24 hours optimize surgical technique consider image guided insertion

3 Emergent versus Image Guided Techniques of EVD Placement Emergent EVD Placement twist drill external landmarks ICU or Emergency Department setting first catheter placement ICP control Image guided EVD Placement second EVD (clot producing trapped ventricles, clinically important shifts, or panventricular enlargement with effacement/ischemia-- typically with larger IVH > 40 cc) elective catheter replacement (infection, obstruction, malposition, unplanned migration or withdrawal of previous EVD).

4 Emergent EVD Placement Supine position, i head in neutral position, bed elevated slightly (20-30 degrees) Frontal area is shaved

5 Emergent EVD Placement (cont.) EVD entry point is marked Head s i aped t Mark the direction of catheter t insertion

6 Emergent EVD Placement (cont.) Full sterile technique Entry point prepped

7 Emergent EVD Placement (cont.) The prepared field is sterilely draped The EVD entry point is re-measured and marked

8 Emergent EVD Placement (cont.) Local anesthetic Short incision

9 Emergent EVD Placement (cont.) Twist drill avoid plunging Durotomy

10 Emergent EVD Placement (cont.) EVD catheter with stylet is advanced A pop is gently felt indicating penetration of the ventricle

11 Emergent EVD Placement (cont.) The stylet is removed Ventricular drainage is verified

12 Emergent EVD Placement (cont.) The catheter is tunneled The catheter is temporarily The catheter is temporarily capped to prevent overdrainage

13 Emergent EVD Placement (cont.) The principal incision is closed The catheter is secured to the skin

14 Emergent EVD Placement (cont.) The EVD catheter is connected to the closed bag drainage system incorporating a three way stopcock Secure the catheter with suture to the skin

15 Emergent EVD Placement (cont.) The drapes are removed and the wound and catheter exit site are covered with a sterile dressing

16 Emergent EVD Placement (cont.) EVD drainage system The CSF collection chamber should remain upright

17 Image Guided EVD Placement Using Frameless Stereotaxy head is positioned neutral, fixed in three point Mayfield headrest Skull fixation is not necessary Fiducial markers are registered

18 Image Guided EVD Placement Using Frameless Stereotaxy Navigation is established and verified (cont.) Surgical lan p selected s i

19 Image Guided EVD Placement Using Frameless Stereotaxy (cont.) Entry point is marked, Surgical field is shaved, prepared, and draped d with full sterile technique Entry point and trajectory are verified

20 Image Guided EVD Placement Using Frameless Stereotaxy (cont.) Skin incision is made The EVD entry point is again verified

21 Image Guided EVD Placement Using Frameless Stereotaxy (cont.) Standard burr hole using power drill or Hudson brace Hole is curetted to expose the dura bone wax and bipolar coagulation as necessary

22 Image Guided EVD Placement Using Frameless Stereotaxy (cont.) Dura is coagulated and slit Dural edges are coagulated Pial surface is coagulated and slit, avoid cortical arteries and veins

23 Image Guided EVD Placement Using Frameless Stereotaxy (cont.) EVD is cut Catheter is marked PCI used as a stylet

24 Image Guided EVD Placement Using Frameless Stereotaxy (cont.) PCI is removed Flow of cerebrospinal fluid is verified Catheter is tunneled Incision is closed EVD is secured and connected to the closed bag drainage system

25 Alternative Image Guided Placement of EVD in CT Scanner previous burr or twist drill hole Supine position in CT scanner field is prepared wound is partially reopened EVD is advanced with a stylet under direct CT guidance Final complete postplacement CT scan of the brain is obtained

26 Questions? June 17, 2009