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External ventricular drains (EVDs) are vital in neurocritical care, enabling both the drainage of cerebrospinal fluid (CSF) and the monitoring of intracranial pressure (ICP). For nurses working in neuro ICUs, trauma centers, or stroke units, mastering EVD care is crucial for patient safety and improved outcomes.
This guide provides a step-by-step overview of bedside EVD management—from preparing for insertion and system setup to accurate leveling, zeroing, hourly assessments, and escalation protocols.
👉 To dive deeper into intracranial pressures, read Understanding Intracranial Pressures: What Nurses Need to Know About Monitoring and Management.
Preparing for Bedside EVD Insertion
When an EVD is inserted emergently in the ICU, the nurse must assist the provider with sterile technique, equipment, and patient safety.
Essential Supplies Checklist
Gather the following items before the procedure:
- Sterile gloves (ask provider for preferred size; grab extra pairs)
- Sterile surgical gown
- Hair clippers with a disposable head
- EVD insertion kit
- Sterile saline (a few vials or syringes)
- Mask and scrub cap/bouffant (for yourself and others present)
- Ordered sedation and monitoring setup
- Suction and oxygen setup at the bedside
🔎 Tip: Some providers may request help collecting supplies, so it’s best to be proactive.
Setting Up the External Ventricular Drain System
Every EVD system varies slightly. Always follow your hospital’s protocol and the manufacturer’s instructions.
Key Components of an EVD System
- EVD Catheter – Inserted into the ventricle by the provider
- Connection Tubing – Connects the catheter to the transducer
- Stopcocks – Allow direction of flow and isolation of tubing
- Transducer and Monitor – Measure and display ICP readings
- Leveling Manifold – Calibrated in cm H₂O or mmHg; follow the provider’s order
- Adjustable Burette/Drain – Controls the drainage threshold
- CSF Collection Reservoir – Collects drained CSF after hourly output measurement
🔗 Reference: Anatomy of an External Ventricular Drain (CriticalCareNow)
How to Prime and Assemble the Drainage System
- Secure all Luer lock connections.
- Prime tubing with sterile saline:
- Begin from the first stopcock and move slowly to avoid air bubbles.
- Prime the patient end, then the drainage chamber.
- Close off the tubing appropriately while priming each section.
- Prime the transducer:
- Close to the patient, open toward the burette, and flush.
- Replace sterile caps on all ports.
- Double-check tubing:
- No air bubbles.
- The stopcock nearest the patient is closed until connected.
⚠️ Always ensure the stopcock is closed to the patient before connecting to the EVD catheter.
- Secure the EVD system to an IV pole.
- Once connected to the patient, open the patient stopcock and proceed to leveling and zeroing.
How to Level and Zero the EVD
Anatomical Reference Point
- Level at the ear’s tragus (approximates Monro’s foramen).
- Patient should be at a 30-degree HOB elevation unless ordered otherwise.
- If the patient must lie flat, close the EVD during that time.
Using a Leveling Device
- Many systems include:
- Laser levels are attached to the transducer
- Bubble levels with string or adhesive markers
- Adjust the system height until the device is level at the tragus.
Zeroing the Transducer
- Ensure the drain is set to zero on the leveling scale.
- Close the stopcock to the patient.
- Open the stopcock to the transducer and remove the sterile cap.
- Press “Zero” on the monitor.
- Once complete, replace the cap and close the transducer stopcock.
- Raise EVD to the ordered drainage level on the manifold.
- Open the stopcock to the patient to resume drainage (if ordered “open to drain”).
Hourly Monitoring and Drain Management
If the EVD is ordered “open to drain,” perform the following steps every hour:
- Close the stopcock to the drain to take an accurate ICP reading.
- Record the ICP on the monitor.
- Measure the CSF output from the drip chamber.
- Open the stopcock to drain CSF into the reservoir.
- Close the stopcock to the reservoir after draining is complete.
- Re-open the system to the patient if ordered.
- Document hourly:
- ICP reading
- CSF volume output
- Drain status
When to Notify the Provider
Call the provider if:
- ICP > 22 mmHg for more than 5 minutes
- Sudden changes in ICP or drainage pattern
Before calling, assess:
- Recent suctioning or stimulation?
- Patient lying flat or recently clamped?
- Is the drain properly leveled and zeroed?
- Is the patient in pain or under-sedated?
🧠 If in doubt, escalate. Timely communication prevents secondary brain injury.
Conclusion
Proper management of an external ventricular drain demands strong clinical judgment, meticulous technique, and knowledge of ICP protocols. As the nurse at the bedside, you are a key player in preventing complications and recognizing early warning signs of deterioration.
Stay vigilant, stay level, and always follow your facility’s guidelines to ensure your patients with EVDs receive the highest standard of care. Adhere to your facility’s protocols and communicate significant changes promptly. Confidence and consistency in EVD care help ensure patient safety and neurological stability.
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