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Care of the Patient with a Lumbar Drain (6.16)

Care of the Patient with a Lumbar Drain (6.16) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Neurologic

6.16

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
September 30, 2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 6.16 AP


Original
Revision

Page
1
of 5

Title: Care of the Patient with a Lumbar
Drain (Adult and Pediatric)

I. PURPOSE
A. To provide guidance for the safe use and management of lumbar drains.
B. A lumbar drain is a sterile system which drains CSF from the subarachnoid space
in the lower lumbar intervertebral space.
II. POLICY
A. The provider is responsible for the insertion and discontinuation of the catheter,
instillation of medications into the system, and irrigation and aspiration of the
system.
B. Use of a closed lumbar drain system (stopcock open for hourly drainage only
according to provider order) can be instituted on any unit where the RN has
completed training.
C. CAUTION: Use of an open lumbar drain system (stopcock open at all times
according to provider order) is uncommon and generally limited to adult and
neuro critical care areas, operating room, emergency department and the pediatric
ICU, where RN is at the bedside and able to perform neuro/safety checks at least
every hour or more for subdural or epidural hematoma, herniation,
pneumocephalus, overdrainage of CSF, and paraplegia.
III. EQUIPMENT
A. Lumbar Drain Kit (Central Service [CS] Item Number 5632318)
1. Lumbar drainage catheter: Hermetic Lumbar Catheter Closed Tip
2. Sterile CSF drainage system that contains the collection tubing, bag,
buretrol (LimiTorr Volume Limiting EVD 20 mL is latex-free and MRI
compatible)
B. Lumbar Puncture Kit (CS Item Number 1212300)
1. Spinal needle
2. Specimen vials
3. Towel and fenestrated drape
4. 1% Lidocaine
5. Manometer
C. Evolution Pole Mount Assembly Kit: UWHC has limited numbers of these black
pole mounts in special areas including the OR, Neuro ICU, D6/4 and TLC
D. Personal protective equipment (mask, gloves, gown, eye protection)
E. Antimicrobial disc (Biopatch®)

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F. Sterile transparent adhesive dressing Chlorhexidene swabs (alternative antiseptic
cleansing solution for neonates)
G. Sterile 4x4 gauze
H. Hair clippers
I. Saline syringes

IV. PROCEDURE
A. Set Up and Insertion if performed at bedside
1. RN will perform baseline neurological exam and document prior to
lumbar drain insertion.
2. There should be a review of recent lab data, especially CBC and
coagulation labs, prior to insertion.
3. Immediately prior to the lumbar drain insertion, hospital policies regarding
the Universal Protocol should be followed, including:
a. Pre-procedure verification;
b. Site marking;
c. Taking an active "Time Out" to verify the five elements: Correct
patient, procedure and site, position and equipment. The Universal
Protocol is documented in the appropriate progress note in the
clinical record. Refer to UWHC Hospital Administrative Policy
8.48 Operative, Invasive and Other Procedures.
4. Provide sedation/pain medication according to physician order, as needed,
for patient safety and comfort. Follow UWHC Hospital Administrative
Policies 8.38, UWHC Adult Sedation or 8.56 Pediatric Sedation, when
applicable.
5. Assist the physician to assemble the above equipment. The lumbar drain
unit can be placed in the OR or at the bedside.
6. Position patient in one of two ways: (1) in side-lying position, with chin
tucked into the chest, or (2) sitting up in bed and leaning over the bed-side
table, in order to round out the lower back.
7. Assist the physician as necessary. Physician will clip hair in lumbar area
as needed, prep area with chlorhexidine or appropriate skin prep
depending on patient, drape area, and make standard needle insertion
through which catheter will be placed. The physician may take CSF
samples from the stopcock at this point, if needed. Label tubes at bedside.
The catheter is then attached to the buretrol tubing and drainage bag
system.
8. The physician will apply a sterile antimicrobial disc (Biopatch®) or 3M
CHG Tegaderm dressing around the catheter (if age appropriate), near the
insertion site. The lumbar drain catheter will be taped in place by the
provider and should be covered with a large transparent adhesive dressing
(TegadermTM). Dressings should only be changed, as needed, by the
physician. Include date, time, and initials on the dressing.
B. Assessment
1. Drain the ordered amount of CSF into the collection system per provider
order. Typical amount drained is 5-10 mL per hour.
a. Open the catheter stopcock to drain ordered amount.

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b. Once the ordered amount of CSF is in the buretrol, close the
catheter stopcock off toward the patient and drain the buretrol
contents into the drain bag.
c. Ensure drain bag clamps and catheter stopcock are closed after
hourly drainage is complete. System will remain clamped when not
draining.
d. Open lumbar drains should NOT be left unattended. See
“CAUTION” note in II.C. above.
e. If drainage takes more than 20 minutes, notify physician. If
drainage changes color, quality, or clarity, notify physician
immediately.
2. Perform comprehensive neurological exam every four (4) hours or more
often as indicated or ordered by physician. Include assessment for signs of
meningeal irritation (i.e., headache, stiff neck, nausea, vomiting,
photophobia or decreased level of consciousness), pain, changes in
sensory-motor function of the lower extremities, and bowel/bladder
dysfunction. Notify physician immediately if any changes in
neurological exam.
3. Assess insertion site every four (4) hours or more frequently as
appropriate for signs and symptoms of infection, signs of CSF leakage at
the site, tubing is not kinked and that the dressing remains intact. Notify
physician of any abnormal findings.
4. Assess integrity and sterility of drainage system every four (4) hours.
Notify physician immediately if the unit dislodges/disconnects, is not
functioning properly, or if you are unable to drain desired hourly
amount.
5. Ensure drainage system lower than insertion site unless otherwise
indicated by provider order.
C. Documentation in the Clinical Record
1. Document insertion time, any medications given, and patient response to
insertion.
2. Add Lumbar Drain as a LDA to I/O/Drains Flowsheet.
3. Document neurological exams in the patient’s clinical record.
4. Document each drainage event on the I/O/Drains Flowsheet. Record
amount drained, color and characteristics of CSF, dressing condition and
any comments.
5. Document any changes in patient's condition including headache and/or
any events where the physician was notified.
6. Document patient and family teaching in Patient Education.
D. System Maintenance
1. If the system disconnects, or otherwise malfunctions/becomes
contaminated, the physician must be notified and the entire system
must be replaced.
2. If there is a break in the system, turn the stopcock closest to the patient
OFF or clamp the catheter to close off the system and notify physician
immediately.
3. If dressing loosens, the RN may reinforce it with additional occlusive
dressing(s) using aseptic technique. Dressings should only be changed,
as needed, by the physician.

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4. CSF specimens can be drawn, by the provider only.
5. Maintain the drainage system upright on the mounting pole. The drain bag
(or any part of the drain system) should not be placed directly on the floor.
6. The collection bag is never emptied; if it becomes filled, a new bag is
attached using aseptic technique. Order replacement bags from Central
Services (CS Item Number 2201558).
7. Use caution in the mobile patient, so as not to cause an accidental
dislocation of the drainage system.
a. Lumbar drain unit should always be lower than the patient's
insertion site when open. The drain should never be raised above
the lateral ventricles when open.
b. Avoid dependent loops and kinks in the drainage tubing.
E. Discontinuation and Removal
1. Catheter removal from patient's lumbar area is the physician's
responsibility. Assist as needed.
2. When a lumbar drain is discontinued by the physician, cover site with a
sterile occlusive dressing. Monitor dressing and document any drainage.
Notify physician of drainage, if appropriate.
3. When disposing of full or discontinued drainage system, place the system
in a red bag and dispose of as biohazardous waste.
V. UWHC CROSS REFERENCES

A. Health Facts For You 6817, Lumbar Drain
B. Hospital Administrative Policy 8.38, UWHC Adult Sedation
C. Hospital Administrative Policy 8.48, Operative, Invasive & Other Procedures
D. Hospital Administrative Policy 8.56, Pediatric Sedation

VI. REFERENCES

A. Al-Tamimi, Y., Bhargava, D., Feltbower, R., Hall, G., Goddard, A., Quinn, A., &
Ross, S. (2012). Lumbar drainage of cerebrospinal fluid after aneurysmal
subarachnoid hemorrhage: a prospective, randomized, controlled trial (LUMAS).
Stroke, 43(3), 677-682.
B. American Association of Neuroscience Nurses (2011). Care of the Patient
Undergoing Intracranial Pressure Monitoring/External Ventricular Drainage or
Lumbar Drainage- AANN Reference Series for Clinical Practice. Available online
at: http://www.aann.org/pubs/content/guidelines.html
C. Borkar, S. (2013). Spinal cerebrospinal fluid drainage for prevention of
vasospasm in aneurysmal subarachnoid haemorrhage: a prospective randomized
controlled study. Neurosurgery, 60 Suppl, 1180-1181.
D. Lynn-McHale, D. J., & Carlson, K. K. (Eds.) (2011). AACN Procedure Manual
for Critical Care (6th Ed.). Philadelphia, PA: WB Saunders Company.

VII. REVIEWED BY

Clinical Nurse Manager, Neurosciences ICU
Clinical Nurse Manager, Pediatric ICU
Clinical Nurse Specialist, Neurosciences

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Clinical Nurse Specialist, Pediatric ICU
Nursing Patient Care Policy and Procedure Committee, September 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer