Lumbar Subarachnoid Catheter Insertion (Assist) for Cerebrospinal Fluid Drainage and Pressure Monitoring
Patients with a variety of central nervous system conditions and thoracoabdominal aneurysms may benefit from monitoring of intraspinal pressure and maintenance of therapeutic levels of cerebrospinal fluid drainage. Lumbar subarachnoid catheters are used for cerebrospinal fluid pressure monitoring and drainage.23,40
PREREQUISITE NURSING KNOWLEDGE
• Knowledge of the anatomy and physiology of the vertebral column, spinal meninges, spinal cord, nerve roots, and cerebrospinal fluid (CSF) circulation and intracranial and intraspinal dynamics is needed.
• Knowledge of aseptic technique is necessary.
• Normal intraspinal pressure in the adult is 0 to 20 cm H2O (0 to 15 mm Hg or 50 to 150 mm H2O) and usually corresponds with intracranial pressure.24 Intraspinal pressure may be influenced by a number of factors. Further research is needed to ascertain therapeutic levels after various surgical interventions.21
• Lumbar subarachnoid catheters, also referred to as lumbar drains or intrathecal catheters, require lumbar puncture (LP) for insertion.16 Lumbar subarachnoid catheters permit monitoring of CSF pressure. CSF pressure may be monitored intermittently or continuously, and CSF drainage may be performed intermittently or continuously.23,40
• Lumbar subarachnoid catheters may be used in the prevention or management of spontaneous, traumatic, or surgical CSF fistulas to allow any tears in the dura mater to heal.37,41–44 The catheter reduces moisture and pressure at the tear and may be placed before, during, or after surgery.4,8,11,37,41
• Lumbar subarachnoid catheters may be used in the diagnostic workup and management of normal pressure hydrocephalus instead of serial lumbar punctures.12,27,28
• Lumbar subarachnoid catheters may be used in the perioperative management of intraspinal pressure during and after thoracoabdominal aortic aneurysmal repair to provide adequate room in the intraspinal space to accommodate spinal cord edema and to improve impaired spinal cord perfusion related to spinal cord edema.
• Lumbar subarachnoid catheters may be used instead of or with an external ventricular drain to decrease intracranial pressure and remove blood from the subarachnoid space, which may lessen aneurysmal subarachnoid hemorrhage vasospasm.13,16,22,26,36 When ventricular and lumbar drainage are used simultaneously, the ventricular drainage output should exceed the lumbar drainage output to lessen the risk of herniation.12,16,22,38
• Lumbar subarachnoid catheters may be use in the management of communicating hydrocephalus related to intraventricular, intracerebral hemorrhage.18,19
• Complications related to the use of lumbar subarachnoid catheters include infection, headache, nerve root irritation, retained fragments of broken catheters, paraplegia, and neurologic deterioration related to overdrainage, including subdural hematomas, pneumocephalus, and herniation.1,30,31,33
• Lumbar subarachnoid catheters have been used, with extreme caution, in the management of patients with meningitis.26
• Lumbar subarachnoid catheter drainage is contraindicated with midline mass effect. A computed tomographic (CT) scan before lumbar subarachnoid catheter insertion to confirm discernible basal cisterns and absence of a mass lesion may lessen the risk of herniation.1,16,21,22
• A variety of products are available for lumbar subarachnoid catheter drainage systems, making it essential to follow the manufacturer’s guidelines for management of the patient23 to include the type of pressure measurement unit used for patient monitoring (e.g. monitoring pressures in units mm Hg, cm H2O).
EQUIPMENT
• Caps, masks with face shields, sterile gowns, and sterile gloves
• Sterile towels, half-sheets, and drapes
• Local anesthetic (lidocaine 1% or 2% without epinephrine)
• 5- or 10-mL Luer-Lok syringe with 18-gauge needle for drawing of lidocaine and 23-gauge needle for administration of lidocaine
• Sutures (2-0 nylon, 3-0 silk)
• Preservative-free sterile normal saline solution (vial, bag, or prefilled syringe)
• External transducer with three-way stopcock
PATIENT AND FAMILY EDUCATION
• Assess the patient and family understanding of the lumbar subarachnoid catheter system. 
Rationale: Any necessary clarification may limit anxiety for the patient and family.
• Explain insertion, patient monitoring, and care involving the lumbar subarachnoid catheter. 
Rationale: Knowledge of expectations can minimize anxiety and encourage questions regarding goals, duration, and expected outcomes of the lumbar subarachnoid catheter.
PATIENT ASSESSMENT AND PREPARATION
Patient Assessment
• Assess the patient’s neurologic status, including level of consciousness, cranial nerves, sensory and motor function in the upper and lower extremities, vital signs, and bowel and bladder function. 
Rationale: Baseline data are provided.
• Assess the patient’s current laboratory profile, including complete blood count (CBC), with platelets, partial thromboplastin time (PTT), prothrombin time (PT), and international normalized ratio (INR). 
Rationale: Baseline coagulation study results determine the risk for bleeding during and after lumbar subarachnoid catheter insertion.16,26,36
• Assess the patient’s medication profile. 
Rationale: Recent anticoagulants or antiplatelet agents may increase the risk of bleeding during and after lumbar subarachnoid catheter insertion.
• Assess known allergies. 
Rationale: Usual medications used during the procedure may be contraindicated by allergy.
Patient Preparation
• Verify correct patient with two identifiers. 
Rationale: Prior to performing a procedure, the nurse should ensure the correct identification of the patient for the intended intervention.
• Ensure that informed consent is obtained. 
Rationale: Informed consent protects the rights of the patient and makes competent decision-making possible for the patient; however, in emergency circumstances, time may not allow for the consent form to be signed.
• Administer preprocedural analgesia or sedation as prescribed. 
Rationale: The patient must be correctly positioned and immobile during lumbar subarachnoid catheter insertion and monitoring and therefore may need sedation or analgesia to tolerate the procedure.
• Administer preprocedural antibiotics as prescribed. 
Rationale: Prophylactic intravenous antibiotics may reduce the risk of infection.
• Perform a pre-procedure verification and time out, if non-emergent. 
Rationale: Ensures patient safety.
Figure 91-2 Top of the drip chamber with reference line.
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