The effects of prolonged immobilization in the critical patient have been well described.
Patients on mechanical ventilation and patients receiving extracorporeal membrane
oxygenation therapy have been presented as evidence of the feasibility of implementation
of early mobilization protocols. Prolonged immobilization of critically ill patients
has been associated with intensive care unit-acquired weakness syndrome, increased
mortality, at the cognitive level, impact on quality, and cost increase among other
considerations. Early mobilization emphasizes strategies to stimulate motor, sensory,
and proprioceptive levels in the context of critically ill patients. Early mobility
intervention in critically ill patients begins in the first days of stay in the unit
and requires a scheduled combination of passive and active activities. The presence
of an external ventriculostomy device is not a contraindication for mobilization.[1]
[2] It helps as above with the progression and improvement in the outcome. The dislodgement
and risk of fracture of external ventricular drainage (EVD) are major concerns. Here,
we briefly go over the technical aspect of EVD placement and how to safely mobilize
the patient.
Most of the EVDs are placed in the operating rooms, while some are in the intensive
care. While placement is a closely controlled procedure, certain features help with
the security of the device and hence early mobilization. After all, incisions are
closed, and stitches with 3-0 nylon stitches are used. The ventriculostomy catheter
itself should be tunneled at least 4 to 5cm from the entry site to decrease infection
risk. The exiting ventriculostomy catheter is best secured with a U stitch. Then coil the catheter and place a figure of eight stitch around the connection
of the ventriculostomy catheter to its most proximal port. Care should be taken to
not suture this hub too close to the skin, as this could lead to skin necrosis. One
technique to avoid skin necrosis is to secure this proximal hub with an air knot around
with enough room to place a biopatch underneath the hub. Then one to four staples
can be used to secure the coiled catheter segments. The staples will not harm the
ventriculostomy tubing. At this point, a wet and dry sponge is used to clean your
wound and a chloraprep can also be used. Two biopatches are used. One is underneath
the exit site, and the second is underneath the proximal hub. Sterile dressings can
be applied ([Fig. 1 A–D]).
Fig. 1 Neurosurgical secure anchoring to help with activity planning in the intensive care.
(A) Incision shown with a roman saddle wrapped around the external ventricular drainage
(EVD); the knot for U stitch is under the exit site of the EVD. (B) Staples to secure the loop, U stitch secured at the end of EVD to pressure tube
side, the silk tie is applied to secure EVD end over the proximal hub of pressure
tubing. (C) Bipatches placed underneath the exit side of EVD and under the hub. (D) Dressing to cover the full system.
The proper selection of patients with a checklist-type tool has shown the benefits
of the implementation for patients with EVD to receive early rehabilitation. Nurses-driven
protocol has shown an effective methodology.[3]
[4] The activity positions that can be used are head of the bed elevation, upright in
the bed, seat position inside the bed with legs down for the patient to move these
against the gravity, sitting on the side of the bed for legs activity, full assistance
to the bedside chair, standing with the full assist on the side of the bed, gentle
ambulation inside the room, and finally ambulating around the intensive care unit.
During all these activities, full assistance is required, and a protocol is in place
for intensive care with neurological stability is noted. During any activity and ambulation,
a close neurological and general examination is kept. The patient assessment is done
after the activity and changes are documented. During the activity, the EVD is clamped
especially during ambulation.
The limitation of ambulation and activity with EVD is related to the device, the patient's
condition, and the limitation of resources. The biggest limitation is the device itself.
There are multiple connections in EVD and any one of these can be loose or get disconnected.
A disconnected EVD leads to infection risk and requires another procedure to replace
the EVD. Patient condition, especially related to high output EVD and unstable neurological
status, leads to delay or difficult situation to increasing the activity. EVD cannot
be clamped during these changes and a close watch is required if any activity is done
while keeping EVD opening. A system like LiquoGuard (MollerMedical GmbH Wasserku ppenstraß e 29–31 36043 Fulda, Germany), with continuous
control of CSF drainage rather the gravity, can help in this matter. A protocol implementation
requires resources and some intensive care units do not have all the key functional
elements like a daily physical therapist, nursing staff, and respiratory therapist
to proceed with ambulation and activity.
In conclusion, early and protocol-driven ambulation in intensive care with an EVD
is a safe and effective therapy. A team effort is required including proper surgical
placed EVD, early consultation with the physical therapy, nurse-driven oversite, and
physician directed supervision. A daily review of activity in patients with EVD should
be part of the bedside communication tool. There are limitations with early ambulation
of stable intensive care patients with EVD. The risk of disconnection or dislodgement
can set back the progress and the patient can go from stable to unstable status.
