Lumbar Drains
By
Christine Carroll SDN GC Neuroscience candidate
What is a Lumbar Drain?
A Lumbar Drain is a closed, sterile system
that allows controlled drainage of
Cerebrospinal Fluid (CSF) from the lumbar
subarachnoid space
Aims of the session
Why do I need to know
this?
Reasons to insert a
lumbar drain
Goals of management
Complications
Review of CSF
Clear, colourless, odourless solution
Made by choroid plexus at approx 25ml/hr
Ependymal cells and blood vessels of the brain and spinal cord contribute a small amount of CSF
Continuously made and reabsorbed.
Total volume in circulation is approx 125-150mls with approx 30mls in the ventricles
Flow of CSF
Fluid flows from the two lateral ventricles via the two foramina of Monro into the third ventricle, then through the aqueduct of Sylvius into the fourth ventricle. It then exits via three small openings into the subarachnoid space where it circulates around the surface of the spinal cord and brain. CSF is reabsorbed by the arachnoid villi in the subarachnoid space into the cerebral venous system to maintain a constant volume and intracranial pressure within the brain
Absorption of CSF
Absorbed via the arachnoid villi into the dural sinuses
These are fingerlike projections that act as one way valves allowing CSF to leave the subarachnoid space and enter the venous sinuses
Function of CSF
Mechanical protection. Acts as a shock absorber by
cushioning the brain. CSF buoys the brain so that it
“floats” in the cranial cavity2
Chemical protection. “CSF provides an optimal
chemical environment for accurate neuronal
signaling”2
CSF flow allows exchange of nutrients and waste
products between the blood and nervous tissue2
Reasons for insertions of a Lumbar Drain
To assist with the repair of a CSF leak post
surgery or after a traumatic head injury
Diagnostic evaluation of idiopathic normal
pressure hydrocephalus
Treatment of shunt infections
Preoperatively in skull based surgery to
prevent CSF leaks
Considerations/Contraindications for insertion of a Lumbar Drain.
Clinical evidence of raised ICP e.g. papilledema, headache may result in brainstem compression, herniation through the formanen magnum resulting in death. Some patients may not have signs of ICP but still have raised ICP
Cutaneous infection at the proposed puncture site
Antiplatelet or anticoagulation therapy which may result in haemorrhage at the puncture site with possible intraspinal bleeding resulting in cord compression
Questions, questions, questions…
Who can insert?
Do we need consent?
How do we prepare the patient?
Where is the needle inserted and why
choose this site?
Prior to insertion
Review recent laboratory results, particularly coagulation profile
Complete a baseline neurological assessment.
Ensure adequate analgesia and assess Patient’s need for sedative. Doctor to obtain consent.
Prepare equipment as per protocol
Assist patient into lateral/foetal position on bed. This flexes the lower lumbar spine, opening the intra-laminar space. Place pillow between Patients legs for comfort
Fetal position
Drain Insertion
The spinal cord
terminates at Lumbar
vertebrae 1
The stylet is inserted
into the subarachnoid
space at L3-L4 or L4-L5
(usually)
Drain Insertion
A transparent dressing is
required at insertion site of
catheter, to facilitate
observation for leakage or
signs of infection. Loop
catheter near insertion site
and run catheter tubing up
patients back and over
shoulder securing firmly with
fixomull. NO KINKS
PLEASE.
Documentation
Document insertion;
time,
date,
by whom,
initial assessment of CSF,
condition of insertion site,
inserted with ease?
Amount of drainage
Drain at a specific level (CSF leak)
Drain to a specific amount (CSF leak)
Drain to a certain pressure (NPH and shunt)
Amount of Drainage
Refer to Doctors order regarding height/ amount of drainage required from drain
Ask if sampling is required?
The amount of fluid which drains depends upon the height of the drain and the position of the patient
The usual amount of drainage required for CSF leak, is 10-15mls/hr
Drainage of CSF
Connect lumbar drainage set. Checking all connections are tight
Ensure that all clamps are open
The “zero” reference point is the insertion site Patient lying supine
Drain Volume/hour: e.g. drain 10ml/hr.Manipulate the drainage bag height in order to achieve the target volume each hour. The lower the drainage bag the greater the amount of CSF drained. This may be difficult and requires some experience
Record amount of Drainage.
Empty the burette
hourly by turning the
three way tap off to the
sample port. This will
allow the burette to
empty in to the
drainage bag
Document drainage on
FBC
Excessive drainage
Adjust level of drain
Perform full neurological observation
Check for headache
Contact doctor
Nursing management
Education of patient. Bed rest, bed head position. Call for assistance
Constant reminders, if using cot sides obtain permission. (document as form of restraint)
Avoid sneezing, coughing or straining
Nursing management
15minutely observations of CSF drainage for first
hour until amount of CSF drainage achieved
Check insertion site 4/24 for leakage/redness
If no drainage, check for patency of drain
Strict aseptic technique when dealing with drain
4/24 Full neurological observations
4/24 temperature and vital signs
Nursing management
Refer to Dr’s instructions regarding height of
bed head, toilet privileges
Clamp drain for short periods only
Clamp drain when patient re-positioning
Keep patients head, neck and back in neutral
alignment
Keep dressing dry
Sampling.
Always sample from the most distal port
Prepare equipment needed
Follow protocol
Document of FBC that sample has been
taken
Sample at 0900hrs
Amount needed is 2-5mls
Changing drainage bag
Lumbar drains are kept insitu for up to 7 days
The Collection bag (distal to burette) should be
emptied only when ¾ full
Follow protocol to empty drainage bag
The Lumbar Drainage system should not be
changed, as breaking the closed system can
introduce bacteria into the system
Adhere to body fluid disposal
Removal of Catheter
Written medical instructions
Follow Lumbar drain protocol
Remove catheter slowly. If resistance and/or radicular pain is felt by patient, stop and seek medical advice. Once catheter is removed, check that catheter tip is intact
Send catheter tip for MC&S if requested by medical staff or if patient showed signs of infection
Document in patient’s notes
Monitor site 4/24 for signs of CSF leak or signs of infection
If CSF leak is observed contact medical staff, a stitch/blood patch may be required
Complications.
Infection
Pain due to nerve root
irritation
Low-pressure headache. If
the pressure of the CSF falls
to low levels, headache
normally results. Inform the
doctor
Complications.
Herniation
Subdural haematoma
Pneumocephalus. If the
pressure becomes very low
in the presence of a CSF
leak then air may be sucked
through the area of leakage
into the subarachnoid space
causing pneumocephalus
which may be diagnosed on
CT
Prevention/Complications of bed rest
Deep breathing exercises
Anti-embolic stocking
Flo-trons
? S/C heparin
Avoid constipation by increasing oral intake
of fluids, stool softeners
Questions?
For added support please contact senior staff
on ward G52 SCGH
Give me your e-mail address and I will send
you this power point presentation.
Thank You
Source of readings
1.Hickey, J.V. (2009). The Clinical practice of Neurological &
Neurosurgical Nursing (6th ed.). USA: Lippincott Williams & Wilkins.
2.Tortora, G. & Derrickson, B. (2006). Principles of Anatomy
and Physiology. (11th Ed) United States of America. John Wiley & Sons, Inc.
3. Beckett, L.J. (2008).Hydrocephalus and Extraventricular drainage workbook. WA: RPH
4.American Association of Neuroscience Nurses.(2007) Care of the patient with a lumbar drain (2nd ed.).