Acta Neurochir DOI 10.1007/s00701-016-2747-y

REVIEW ARTICLE - NEUROSURGICAL TECHNIQUES

Current practice of external ventricular drainage: a survey among neurosurgical departments in Germany Zafer Cinibulak 1,2 & Alfred Aschoff 2,3 & Anani Apedjinou 1 & Jan Kaminsky 2,4 & Hans A. Trost 2,5 & Joachim K. Krauss 1,2

Received: 30 June 2015 / Accepted: 16 February 2016 # Springer-Verlag Wien 2016

Abstract Background There are various recommendations, but no generally accepted guidelines, to reduce the risk of external ventricular drainage (EVD)-associated infections. The primary objective of the present study was to evaluate the current practice of EVD in a European country and to set the results in perspective to published data. Method A standardised questionnaire prepared by the Commission of Technical Standards and Norms of the German Society of Neurosurgery was sent to 127 neurosurgical units in Germany. Results Data were analysed from 99 out of 127 neurosurgical units which had been contacted. Overall, more than 10,000 EVD procedures appear to be performed in Germany annually. There is disagreement about the location where the EVD is inserted, and most EVDs are still inserted in the operation theatre. Most units apply subcutaneous tunnelling.

Impregnated EVD catheters are used regularly in only about 20 % of units. Single-shot antibiotic prophylaxis is given in more than half of the units, while continued antibiotic prophylaxis is installed in only 15/99 units at a regular basis. There are discrepancies in the management of prolonged EVD use with regard to replacement policies. Regular cerebrospinal fluid (CSF) sampling is still performed widely. There were no statistical differences in policies with regard to academic versus non-academic units. Conclusions This survey clearly shows that some newer recommendations drawn from published studies penetrate much slower into clinical routine, such as the use of impregnated catheters, for example. It remains unclear how different policies actually impact quality and outcome in daily routine.

Electronic supplementary material The online version of this article (doi:10.1007/s00701-016-2747-y) contains supplementary material, which is available to authorised users.

Introduction

* Zafer Cinibulak [email protected]

1

Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Str. 1, 30625 Hannover, Germany

2

Commission of Technical Standards and Norms, German Society of Neurosurgery, Messe-Allee 1, 04356 Leipzig, Germany

3

Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany

4

Department of Neurosurgery, Sankt Gertrauden Hospital, Berlin, Germany

5

Department of Neurosurgery, Bayreuth Hospital, Bayreuth, Germany

Keywords Infection . Neurosurgery . Survey . Technique . Ventricular drainage

The placement of an external ventricular drainage (EVD) is one of the most elementary and most common neurosurgical procedures worldwide [15, 24, 31]. It is used as an emergency treatment for acute hydrocephalus and increased intracranial pressure (ICP), and for temporary cerebrospinal fluid (CSF) diversion in patients with craniocerebral infections [16, 23, 38, 41]. From a methodological and practical point of view, it allows continuous measurement and monitoring of ICP, investigation of CSF dynamics, controlled release of CSF and treatment and prevention of CSF leaks after neurosurgical operations [8, 16, 20, 29]. Thus far, no commonly accepted guidelines have been developed for how to perform EVD and how to handle the various issues associated with its daily use. Undoubtedly, one of

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the most important aspects of EVD is the risk of secondary bacterial infection occurring after 1–18 % of procedures, resulting in ventriculitis or meningitis and imposing a tremendous burden on healthcare [10, 17, 20, 21, 23, 36, 38]. Several measures have been suggested to reduce EVDrelated infection rates, including bundle approaches covering a variety of aspects [7, 12, 20, 21, 23, 28]. Nevertheless, there have been partially contradictory statements. Little is known about opinions on best practice and on the performance and management of EVDs in neurosurgical routine. Here, we aimed to provide a contemporary survey on current practice in neurosurgical departments in Germany, and to discuss the results with regard to published studies and recommendations.

Methods A standardised questionnaire was prepared by the Commission of Technical Standards and Norms of the German Society of Neurosurgery to obtain information on the frequency of EVD implantation, the patient population, the location where EVDs were inserted, the technique of insertion, the use of antibiotics and the postoperative handling of inserted EVDs. The questionnaire was structured within seven main sections, including subsections on five pages. Most questions asked for numerical values or estimates in percentage, sometimes with multiple choices. Few questions allowed open answers or comments. Time needed to complete the questionnaire was 15–20 min. The questionnaire and an accompanying letter were sent to the head of the department (for English translation of the original questionnaire see Supplementary table). From a total of 180 neurosurgical departments or sections listed in the directory of the German Society of Neurosurgery, 127 were selected to qualify for the survey and to be included in the mailing of the questionnaire. Those 53 units which were not contacted focused on neurosurgical subspecialties such as functional neurosurgery or spine surgery only, or there was a transition in leadership in the department. After the initial mailing of the questionnaires, a first reminder was sent 6 months later, and the second and last reminder another 12 months later. The last completed questionnaire was received 24 months after the initial mailing. Statistical analysis of the data was performed with SigmaStat 3.5 for Windows (Systat Software, Point Richmond, USA) using descriptive analysis and the chi-squared test. The significance level was set at p = 0.05.

Results Responses were received from 103/127 neurosurgical units (81 %). Four units indicated that they could not answer the

questionnaire because of low caseload or other reasons. Thus, the analysis was based on the responses from 99 units (78 %). Few questionnaires were incomplete, but provided information on the crucial aspects of the study. There were 29 university hospitals (29 %), 64 academic teaching hospitals (64 %) and 6 other institutions (6 %). Frequency of EVD insertion and patient population (Section 1 and 2) The 99 neurosurgical units indicated that a total of 9,893 patients were treated with EVDs per year. While 429 patients were 3 years old or younger (4.3 %), the majority was older than 3 years totalling 9,474 patients (95.7 %). The number of patients seen per unit ranged from 12 to 416 per year, with an average of 100 patients per year. Location for EVD insertion (Section 3) There was a distinct variability regarding the practice in which location in the hospital the EVD was inserted (Table 1). While the majority of units indicated that EVDs were inserted always or most often in the operating room (64 %), a subset of units used the intensive care unit for that purpose (24 %). Only exceptionally, EVDs were inserted in general wards. Use of impregnated EVD catheters (Section 4) Impregnated EVD catheters were not used at all in 46 units, while they were regularly or almost regularly used in 21 units, and from time to time in the other 32 units. Those units which used regularly or almost regularly impregnated catheters preferred silver-coated EVDs and used less often EVD catheters coated with antibiotics. The frequency of the use of impregnated EVD catheters is shown in Table 2. The following antibiotics were used for impregnation of EVDs in 32 units: clindamycin combined with rifampicin (24), clindamycin only (2), rifampicin only (5) and gentamycin (1). Techniques for EVD insertion (Section 5) Craniostomy was achieved by using an electric or compressed-air burr hole trephine exclusively in 51 units, and a twist–drill gimlet exclusively in 24 units. The other 24 units used either a trephine or a twist–drill gimlet, or occasionally a rechargeable power drill. Subcutaneous tunnelling of the EVD was performed regularly in 72 units, sometimes in 8 units, while it was not established in the other 19 units. The EVD was externalised at a distance of less than 3 cm from the craniostomy in 20 units (25 %), while the distance for subcutaneous tunnelling was more than 3 cm in the other 60 units (75 %). The EVD was fixed to the skin by a suture in 46 units, while a fixation bracket plus suture was used exclusively in 22 units. Practice varied in the remainder. One unit applied occasionally a plaster for fixation of the drainage.

Acta Neurochir Table 1 Location for EVD insertion

Always

Most often

In 50 % of the cases

Seldom

Never

Operating room

46 %

18 %

6%

21 %

9%

Intensive care unit

9%

15 %

9%

27 %

40 %

General ward

0%

0%

1%

10 %

89 %

Prophylaxis of EVD associated infection (Section 6) At the time of insertion of the EVD, CSF samples were obtained and sent for further analysis regularly in 42 units and occasionally in 34 units, while no sampling was performed in 23 units. Analysis of CSF most frequently included CSF cell count and differentiation, evaluation of CSF protein and microbiological examination (66 units). There was a wide variability in the other units. Single-shot antibiotic prophylaxis at the time of craniostomy was administered regularly in 55 units, from time to time in 10 units and never in 34 units. For single shot prophylaxis the following antibiotics were used: cefazolin (24 units), cefuroxim (20 units), ceftriaxon (8 units) and other cephalosporins (12 units). Antibiotics were administered regularly while the EVD was in place in 15 units and from time to time in 18 units, while 66 units (i.e. the majority of units) did not use antibiotic prophylaxis during that period. The following antibiotics were used for prophylaxis: cefuroxim (22 units), ceftriaxon (2 units) and other cephalosporins (9 units). Post–explantation prophylaxis was continued also after removal of the EVD regularly in 2 units and occasionally in 16 units. There were remarkable differences in the practice of EVD replacement in cases in which long-term drainage was needed. While regular replacement was performed in 31 units, EVDs were replaced from time to time in 12 units and never in 56 units. No replacements were achieved when the drainage was in place for less than 4 days, while 11 units indicated that they replaced the EVD within 5–9 days, and 32 units performed replacements after a period of 10 days. Those units which replaced EVDs after 5 or 10 days most frequently used the same craniostomy site (25/43), while the other units (18/43) inserted the new EVD via a new craniotomy on the same side as the previous one (4/18) or on the contralateral side (14/18).

Table 2

Use of impregnated EVD catheters Always Most often

Silver 5% Antibiotics 2 %

9% 7%

In 50 % of the cases Seldom Never

5% 1%

15 % 22 %

66 % 68 %

Impregnated EVD catheters were used in a total of 53/99 neurosurgical units

Overall, it was estimated that the average time the EVD was in place ranged between 5 and 14 days in the majority, i.e. 90 %, of patients. Wound dressings were changed on a regular basis in 88 units, but no regular regimen was installed in 11 units. Wound dressings were changed daily in 50 units and every 2 days in 38 units. Desinfectants were used regularly in 82 units upon change of wound dressing. Desinfectants used included: combination of propanol, biphenyl-2-ol and hydrogen peroxide (Kodan) in 36 units, octenidine hydrochloride (Octanisept) in 29 units, providone iodine (Braunol) in 9 units and various others in the remainder. There was a wide variability with regard to the method used to restore patency of the EVD in case it was blocked. Most frequently, a combination of aspiration and flushing of the drainage was applied (61/99), while 13 units used aspiration only and avoided flushing, and 25 units used flushing but did not use aspiration. The tip of the EVD after its removal was regularly sent for microbiological analysis in 36 units, from time to time in 48 units and never in 15 units. Postoperative CSF sampling (Section 7) During drainage, CSF samples were collected routinely in 74 units, from time to time in 22 units and never in 3 units. Samples were collected daily in 35/96 units, weekly in 27/96 units and at other or irregular intervals in the other 34/96 units. Complete CSF analysis (cell count, protein, microbiology) was obtained in 86 units, while CSF samples were not sent for microbiological analysis in 10 units. CSF samples were collected by various healthcare professionals in different units, sometimes with variable practices in the same unit (Table 3). CSF was collected by neurosurgeons only in 53 units, and by neurosurgeons and other healthcare professionals in 33 units. In 10 units, neurosurgeons were not primarily involved. Comments by the respondents In two university hospitals and in six teaching hospitals, the BDuisburger needle^ was used regularly for EVD [33]. In one teaching hospital, the BDuisburger needle^ was preferred for drainage when EVD remained for more than 4 weeks. In another unit, EVD was replaced by a lumbar drain when prolonged drainage was needed. Comparative analysis Statistical analysis did not reveal significant differences in the practice of EVD among university

Acta Neurochir Table 3 EVD

Healthcare professionals involved in CSF sampling from the

Healthcare professional

Number of units 53

Neurosurgeon Anaesthesiologist Other MD Nurse

3

7

x x

18

2

6

x

x

x

x x x

2

4

x

x

x

x

x

x

x

x x

x x

1

hospitals and other hospitals. There was a marked trend to use impregnated EVD catheters more often and to perform elective EVD revisions less frequently in university hospitals.

Discussion The present survey demonstrates the variability of current practice in techniques for inserting and handling EVDs in a European country with widespread access to neurosurgical treatment and with most neurosurgeons being organised under the umbrella of a national neurosurgical society. According to the relatively high number of respondents, it may be considered representative for what actually is being done in daily practice rather than what should be done considering results from published data including meta-analyses, reviews and randomised clinical trials. Of course, any survey like this will provide valid data only for a limited time period, and it does not demonstrate only current practice but it reflects also periods of transition between different practices. Interestingly, as we have experienced earlier, a survey like this might even induce by itself changes in practice and alter what is considered to be daily routine [22]. While during the first two decades after the introduction of EVD practice was mainly governed by personal opinions and judgements, there has been a plethora of studies on several issues associated with its use in more recent years, which unfortunately, however, came to partially contradictory results [1–4, 7, 8, 10, 18, 19, 21, 24, 30, 32, 36–38, 42, 44, 47, 48, 51, 52]. One of the main reasons for this is, of course, the inherent possible bias in non-randomised, single-centre, or retrospective studies which were used in many instances to clarify problems of EVD treatment [5, 11–14, 16, 20, 23, 25–28, 40, 41, 43]. However, also larger randomised studies and meta-analyses on several aspects of EVD practice did not yield a uniform picture. Therefore, it is not surprising that there is a paucity of commonly accepted guidelines which would be followed by the majority of neurosurgeons [49]. Our survey confirms that EVD is one of the most common neurosurgical procedures. Extrapolation of the results on frequency of EVD indicates that more than 10,000 EVDs are

being inserted annually in Germany and that, based on the assumption that a standard neurosurgical department would perform about 2,000 thousand operations a year, EVD would account for 5 % of all neurosurgical procedures. Interestingly, EVDs appear to be inserted about 20 times more often in older children or adults than in the very young age group. Unfortunately, there is no national database which would provide exact numbers. Nevertheless, this relatively high estimate stresses also the importance of optimising practice to reduce side effects in a procedure which would be considered the most simple neurosurgical operation at all. A recent systematic review showed an overall rate of EVRrelated infection of 7.9 % according to published studies, with a wide variability ranging from 1 to 28.2 % [8]. Undoubtedly, the most serious problem of EVD is infection and it is, therefore, not surprising that most of the reviews and meta-analyses concentrated on this subject [10, 21, 32], while several other areas—such as where and how the EVD is inserted—received relatively less attention. An important step to reduce infection rates, covering several aspects, was the introduction of bundle approaches more recently, which often, however, did not allow to separate more important measures from the possibly less relevant changes in technique [7, 23, 28, 45]. In a study from The Netherlands, for example, implementation of a bundle approach based on five pillars including increased awareness, adherence to standard operating procedures and given algorithms, antibiotic prophylaxis and improvement of hardware, resulted in the reduction of drain-related meningitis within a period of 5 years from 37 to 9 % [28]. In a more recent study encompassing 2,928 ventriculostomies over a period of 6 years, the infection rate decreased from 9.2 to 0 % after introduction of a bundle approach consisting of a best-practice protocol including specific instructions for hand hygiene, antibiotic prophylaxis, hair removal, skin preparation, draping and use of an impregnated catheter [23]. Our survey reflects the uncertainty about where the EVD should be inserted. This issue has been already discussed by Clark and colleagues in 1989 [6], who noted no significant difference in the incidence of infection depending on whether ICP monitoring devices were implanted in the intensive care unit or in the operating theatre. While some studies support the notion that EVD placement in the operating theatre would reduce infection rates [7], many other studies have shown either no benefit when patients are brought to the operating room or even higher infection rates subsequently [34, 40, 44]. When Schödel et al. [41], for example, compared the number of CSF infections retrospectively in a series of 312 consecutive patients who underwent insertion of the ventricular drain either in the operating room (190 patients) or in the intensive care unit (122 patients), they noted a significantly lower infection rate in the second group. While the majority of neurosurgical units used subcutaneous tunnelling in our survey, still one-third did not use it

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consistently. Although this issue has been studied less frequently than other related topics, there is rather solid data to support the beneficial effect of subcutaneous tunnelling in the prevention of infection [13, 19, 27]. The ideal length for tunnelling, however, still remains unclear, with most studies reporting no additional effect for extended tunnelling that is more than 10 cm away from the burr hole [27]. One of the most important questions is whether or not and for how long antibiotic prophylaxis should be administered in patients with EVD. According to the World Health Organisation (WHO) guidelines for safe surgery, administration of routine prophylactic antibiosis is recommended within 1 h of skin incision in all surgical procedures [50]. According to our survey, however, there is still a wide variety of opinion regarding the necessity to administer single-shot antibiosis before insertion of an EVD. While more than half of the neurosurgical units gave single-shot antibiotic prophylactics regularly, less than half did not consider this a requirement to be followed always. This discrepancy deserves particular attention and it is difficult to explain why many surgeons would not follow the WHO guidelines. One possible explanation would be that many neurosurgeons would not consider EVD as a surgical procedure proper. Also, sometimes EVDs might be placed rather in an emergency context without a standard setting for a neurosurgical procedure. Also, despite there being several studies out now which support the use of preoperative antibiotic prophylaxis, in general [2, 3, 18, 51], one might argue whether the evidence is good enough for its use in EVD. Nevertheless, there are several studies which clearly support the use of preoperative antibiotic prophylaxis [2, 3, 18, 51]. In particular, antibiotic prophylaxis at the time of EVD insertion may result in disappearance of early postoperative Staphylococcus aureus infections, as shown in a prospective study on 467 patients [28]. According to our survey, only a minority of neurosurgical units in Germany administered antibiotics regularly, while the EVD is in place. Indeed, there is less evidence for prolonged systemic antibiotic therapy than for preoperative prophylaxis. Several cohort studies and two randomised controlled trials came to conflicting conclusions [2, 4, 36, 37, 43, 51]. The more recent study by Murphy et al. [36] showed that the rate of ventriculitis did not increase when antibiotics were discontinued in a series of patients in whom antibioticcoated EVDs were used. However, in that study there was a significant increase in the rate of systemic nosocomial infections in the group who had prolonged antibiotic prophylaxis. This was thought to be possibly related to biofilm formation. Overall, the issue of whether prolonged prophylaxis is necessary or not needs further study. One of the most promising advances over the past few years has been the development of impregnated EVD catheters [21]. Basically, three different types have become available: antibioticimpregnated catheters, silver-coated catheters and hydrogel-

coated catheters [1, 11, 14, 25, 26, 42, 47, 52]. Our survey shows that the use of such catheters is probably less common than it has been estimated. While only about one-fifth of units used impregnated catheters regularly, less than about one-half of the units never used such catheters. Konstantelias et al. [21] recently showed that based on data which were derived mainly from non-randomised studies, antibiotic-impregnated and silvercoated catheters reduced the risk for infections. According to their meta–analysis on 36 studies including 16,796 procedures on both patients with EVDs and CSF shunts, impregnated ventricular catheters had a lower risk for infection at a risk ratio of 0.44, although publication bias was detected [21]. However, this was counterbalanced by an increased risk for methicillin-resistant Staphylococcus aureus, non-staphylococcal and Gram–negative bacterial infections when anti-microbial catheters were used [21]. Concerns that have been forwarded using impregnated catheters include also the question of cost–effectiveness and the probability of a shift to more virulent bacterial strains [21]. At the present time, the choice of using impregnated catheters or not remains open and may depend on logistic, medical and financial considerations. It is of interest to note that the BDuisburger needle^, which was more commonly applied for EVD in the 1990s in Germany, was still used in eight hospitals. The metallic needle had been introduced initially as an alternative to the plastic EVD with intention to reduce EVD-associated infections [33]. An unsolved issue is the question of whether or not CSF samples should be collected regularly. Our study indicates that it is actually current practice to collect samples routinely in most units, and in about one-third this is even being done daily. The rationales for this practice have been challenged, and one study even indicated a lack of value both for prediction and diagnosis of EVD-related meningitis [39]. A more recent study on 449 EVD patients, on the other hand, demonstrated that dynamic changes in clinical and laboratory parameters as determined by daily CSF sampling could be used to decide that specific treatment was necessary in only 9/32 patients with positive CSF cultures [35]. Remarkably, in our survey there was considerable variance with regard to who was responsible for obtaining CSF samples from the drainages. It would be of interest to know whether this would have an impact on infection rates or not. Another area of controversy in our survey was the topic of replacement of EVD in patients who needed prolonged drainage. While regular replacements were performed in about one third of units, the majority never replaced EVDs. While some respondents indicated that their rationales were based on the length of the need for drainage, others clearly would not see a necessity for any replacement procedure. Notably, EVD exchange was strongly recommended in the 1980s [32] to reduce infections. Subsequent studies over the years, however, indicated that infection rates would even be increased with routine EVD replacements [30, 48]. Lo et al. [30], for instance, demonstrated in a retrospective study on 199 patients with 269

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EVDs that multiple insertions were a significant risk factor for CSF infection, while the duration of drainage by itself was not. Careful attention to the surgical wound and regular control with change of drapings are being considered elementary in wound care after any surgical procedure. Nevertheless, it appears that in particular this issue has been somehow neglected in patients with EVD for many decades. Only more recently, wound management has been identified as one of the major measures to prevent infection in patients with chronic drainage [5, 9, 12, 46]. Again, there were remarkable differences in practice according to our survey, although subtleties could not be reliably interrogated by the questionnaires. There is no doubt, however, that the introduction of simple infection control protocols may result in a dramatic reduction in the risk of EVD infection [8]. It has to be stressed also that wound control protocols are important and inherent elements of all published bundle approaches [23, 28]. Hopefully, our report will stimulate the formulation of new guidelines on the practice of EVD management. When the last AWMF (Arbeitsgemeinschaft Wissenschaftlich-Medizinische Fachgesellschaften) guidelines on procedures for access to the CSF space including EVD were published in 2011, several statements were made which need revision to consider daily practice but without ignoring recommendations from current publications [49]. For example, in these guidelines it was still recommended that EVDs should be placed in the operating theatre and that routine CSF samples should be taken. Meanwhile, after presentation of the current survey at local and national conferences and during board meetings, the Commission of Technical Standards and Norms has been charged to coalesce with the Commission of Quality Control to produce a new guideline based on both evidence and best practice. In conclusion, our survey clearly demonstrates a wide variability in the practice of EVD placement and handling. This variability is much greater than would be expected according to results from published literature. Interestingly, while some changes apparently are accepted and implemented easily, other new developments such as the use of impregnated drains penetrate much slower into clinical practice.

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Compliance with ethical standards Conflicts of interest None.

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Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

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Informed patient consent Informed consent was obtained from all individual participants included in the study.

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Funding None.

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Current practice of external ventricular drainage: a survey among neurosurgical departments in Germany.

There are various recommendations, but no generally accepted guidelines, to reduce the risk of external ventricular drainage (EVD)-associated infectio...
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