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.).