Effect of Implementing External Ventricular Drain Guidelines on Nurses' Practice and Traumatic Brain Injury Patients' Outcomes

Traumatic brain injury (TBI) remains a global public health challenge. It is a major cause of death and disability across all ages worldwide (World Health Organisation, 2018; American Association for Surgery of Trauma, 2018), with substantial socio-economic consequences (Kolias, Rubiano, Figaji, Servadei \& Hutchinson, 2019). The rising global incidence of TBI is attributable to the increase in road traffic collisions and trauma-related violence in low and middle-income countries. It causes death in more than five million people annually, representing approximately 10% of the global death toll (WHO, 2014). Major trauma is a main cause of admissions to intensive care units (ICU) and consumes a significant share of ICU resources (Menon, \& Ercole, 2017).

Traumatic brain injury can be divided into primary and secondary brain injury. The primary injury occurs because of the initial physical insult. The pattern and extent of damage will depend on the nature, intensity, and duration of the impact (Carlson et al., 2024). Following a primary injury, brain oedema, disturbed cerebrospinal fluid (CSF) dynamics, and the presence of mass lesions exhaust the volume buffering compensatory mechanism mediated by CSF drainage from brain cisterns to the spinal subarachnoid space and can lead to a rise in intracranial pressure (ICP) (Chau et al., 2019).

The subsequent increase in ICP and impaired autoregulation result in reduced cerebral perfusion, exacerbating cerebral ischemia, secondary brain injury, brain tissue compression, distortion, and herniation can ultimately lead to death (Alali et al., 2013). Therefore, control of ICP is an important factor in the medical and surgical management of TBI (Winkler, Minter, Yue, \& Manley, 2016).

External ventricular drainage is a lifesaving procedure experienced in neurocritical care units (Muralidharan, 2015). It is consisting of placing a catheter into the lateral ventricles of the brain to a collection system outside of the body with the purpose of diverting the CSF flow extra-cranially or to monitor ICP (Patil et al., 2013). After insertion, the EVD monitoring, maintenance and troubleshooting essentially become a nursing responsibility. Accurate and accountable nursing care may have the ability to portend better outcomes in patients requiring CSF drainage ( Mohamed Maarouf, \& Faltas Marzouk Faltas, 2020) .

The external ventricular drain (EVD) is a medical and health technology that serves both diagnostic and therapeutic purposes (Jamjoom et al., 2018). It is widely recognized as the preferred method and is considered the gold standard for treating certain neurological conditions such as hydrocephalus, intracranial hemorrhage, tumors, meningitis. By facilitating continuous monitoring and effectively reducing ICP. Although the EVD enables drug delivery, blood or CSF drainage, and CSF collection samples when required (Carney et al., 2017).

The utilization of EVD catheters combined with ICP monitoring has seen a notable rise. This monitoring technique enables the recording of ICP values and waveform patterns while maintaining continuous CSF drainage (Chau et al., 2019). External ventricular drain is contraindicated in patients who have a coagulation disorder, receive anticoagulant medication, or have a disease on their scalp or localized abscesses. This precaution is due to the significant risk of central nervous system infections, such as meningitis and ventriculitis (Sweet \& Foley, 2019).

The EVD system must be correctly levelled and closed to CSF drainage for an appropriate amount of time to provide a precise ICP reading, which is required to assess the brain's health (Liu et al, 2020). Adjusting the height of the collection chamber regulates the flow by increasing or decreasing the amount of pressure required for the CSF to drain . The CSF drainage is dependent on the balance between ICP and the height of the reservoir. Ventricular drainage can be used to assist with controlling increased ICP by providing a temporary exit for the CSF flow (Camacho et al, 2013).

Patients undergoing EVD may encounter various complications that can impact their wellbeing. These include the possibility of infection, which can be recognized by symptoms such as elevated body temperature, redness, or the discharge of fluid or secretion. System obstruction may be observed when the drainage of CSF falls below the expected minimum level or when the CSF waveform appears flat on the monitoring device. Another potential complication is excessive CSF drainage. Furthermore, EVD can result in bleeding, problems with the ventricles, or unintentional catheter removal, requiring neurosurgical interference (Aslam, Afzal, Sarwar, \& Khan, 2022).

Nurses who are competent in the assessment and care of patients with both neurological and drain conditions should keep a close eye on patients who need an EVD. Monitoring for symptoms and signs connected to changing ICP should be part of the patient assessment process. The registered nurse should conduct and record neurological examinations on an hourly basis. This includes measuring the mean ICP, CSF drainage, color, and clarity (Kumar, Malhotra, \& Bhatia, 2021).