A composite healthcare team comprised of [6]:

• A neurosurgeon
• A qualified assistant
• An attending nurse
• An anesthetist
• A general duty assistant (GDA)

The patient and next of kin/relatives should receive a thorough explanation regarding the indication for the procedure and the risks involved before the procedure, and written consent obtained.[6]

Strict adherence to aseptic guidelines is a cornerstone in preventing the risk of infection and prophylactic antibiotic needs to be administered just at the beginning of the procedure.[7]

The meticulous technique is pivotal in minimizing procedure-related complications. The patient should be well sedated, assuring patency of his airway, and local anesthetic administered at the allocated point of ventriculostomy.

The insertion of the device is aided with the placement of either a burr hole or a twist drill technique. Kocher's point is the choice for the ventriculostomy. Other points of ventricular puncture include.[3]

1. Keen’s point: -2.5 to 3 cm posterior and 2.5 to 3 cm above the pinna of the ear.
2. Kocher’s point: This point is 1 to 2 cm anterior to the coronal suture in the mid pupillary line, or 11 cm posterior from the glabella and 3 to 4 cm lateral from midline ipsilateral medial canthus and a line extending coronally from the ipsilateral tragus.
3. Dandy’s point: 3 cm above and 2 cm lateral to the inion
4. Frazier’s point: 6 cm above and 4 cm lateral to the inion
5. Paine’s point-  the apex of an isosceles triangle, whose base is 3.5 cm and lies along the Sylvian veins, and each of the two limbs is 2.5 cm.
6. Tubbs’ point: is a point just medial to the midpapillary point through the roof of the orbit. The trajectory aims 45 degrees from a horizontal line and 15 to 20 degrees medial to a vertical line.

 Computed tomogram based grading system has been developed to assess the accuracy of the placement of ventricular catheters.[8]

1. Grade 1 - the tip within the ipsilateral lateral ventricle nearing foramen of Monro.
2. Grade 2 - the medial deviation into a contralateral frontal horn or a lateral ventricle.
3. Grade 3 - the lateral deviation through the caudate nucleus along the lateral corner and wall of the frontal horn.
4. Grade 4 - extraventricular catheterization.

Ghajar first introduced a ventricular catheter guide for optimizing trajectory during ventriculostomy. He advocated a perpendicular trajectory relative to the skull surface.[9]

However, the calvarial slope obviates this trajectory, especially in the coronal plane.[10][8] The accuracy for the ideal placement of the ventricular tip is around 86%. Furthermore, only 3.1% of the catheters were found to be nonfunctional and requiring a replacement or reposition.[11] The accuracy can undergo further improvement along with the application of ultrasonogram,[12] endoscopy, neuronavigation,[10] and adjustable Ghajar guide technique.[8]

The complications include [4]:

1. Intracranial and tract hemorrhage (10%) However, this hemorrhage is usually insignificant and rarely needs surgical intervention.[13]
2. Ventriculitis (20%)Infection is the most common complication of external ventricular drainage (EVD), with rates ranging from 0 to 45%. Multiple attempts to insertion of EVD is associated with an increased risk of infection. The duration of the drain was paradoxically not related to predicting increased odds for infection.[3] Antibiotic-impregnated catheters and provision of tunneling methods have shown to minimize EVD infection. There was no relation to the difference in infection rate comparing its placement either at OR or at the bedside.[1]
3. Technical failure (failure to tap ventricle or misplacement) (5%) One study revealed that 22.4% of catheter tips were in extraventricular spaces during a freehand placement,  showing ample room for improvement.[14] There is also an association between malpositioned tips with the subsequent risk of shunt occlusion.[10] 
4. The cost for placing an external ventricular drain (EVD) amounting to around $200 with transducers costing an extra $400 to 600.
5. Over-drainage can lead to aneurysmal rebleed and in cases of hydrocephalus complicate the upward transtentorial herniation.
6. Kinks and blockage by air, blood, and debris are also frequent, leading to the poor and false recording of the ICP.
7. Inadvertent vascular injury.
8. Pneumocephalus and pneumoventriculi.
9. CSF leak.
10. Accidental fracture
11. Accidental pull
12. Obstruction by choroid plexus, blood clot or proteinous plug. The anterior entry site lowered the risk of shunt failure compared with the posterior entry site by approximately one-third due to the chandelier effect.[15] Overdrainage can also lead to obstruction of the catheter due to the formation of ependymal bands.[16]

Ventricular catheters represent a “global” ICP with minimal chances of drift and influence from pressure gradients between parenchyma and ventricular system.

It is the most reliable method of achieving maximum accuracy at minimal expense. There are added therapeutic benefits of CSF drainage, instilling medications like antibiotics and thrombolytic agents.

The advantage of the ventricular monitoring device is the facility for egress of CSF in cases of a sustained rise in ICP (greater than or equal to 20 mm Hg for 5 minutes or longer), but the disadvantage is that simultaneous monitoring, as well as CSF drainage, is not possible. The amount of CSF to be drained can be guided as per the recommended target ICP (commonly set as 10 mm Hg) or can be aided with the visual guidance in the improvement in the ICP waveform analysis obtained from the concurrent application of intraparenchymal monitors or through clinical neurological examination. Care always needs to be taken in preventing paradoxical upward transtentorial herniation due to overzealous drainage of CSF.

EVD can be removed once the ICP is normalized with sustained or improved clinical neurology (motor score at least 5) for at least 48 to 72 hours without the use of any interventions by clamping, or more ideally gradual increment in its height (training of the EVD) is attained to watch for any clinical deterioration in the patient for at least 48 hours.[6]

Strict aseptic precautions and care also need to be implemented during its removal as well. The head end should be lowered down to prevent the risk of pneumocephalus and pneumoventriculi. The tip of the catheter can be sent for bacteriological analysis in cases of persisting fever with features of meningitis. The wound is closed in layers to minimize the risk of CSF leak and infection. The patient should receive close monitoring for any signs of clinical deterioration for at least 24 hours with all preparations made for the emergency placement of a new EVD set.[6]

To ensure better clinical outcome and to prioritize patient safety by minimizing complications, there need to be mandatory patient safety checklists to be implemented by the interprofessional team involved in the process. Following guidelines has to be adhered to [6]:

1. Valid treatment order sheet which has to be signed and dated by the surgeon
2. All reportable limits clearly specified by the clinician
3. Nurses need to be educated in the management of patients with a ventriculostomy and understand the tracing waveform so that they can report abnormalities to the team.
4. EVD drainage point at a prescribed level with the transducer leveled to the tragus of the ear
5. The EVD column is oscillating
6. Monitoring for normal ICP waveform
7. ICP waveform is pulsatile on the monitor
8. No soakage in the wound site or any junctions within the monitor set
9. Judicious assessment of drained CSF volume
10. Stringent evaluation of the neurological status of the patient
11. Strict maintenance of an aseptic environment.

Monitoring of intracranial pressure requires an interprofessional team approach, including physicians, specialists, and specialty-trained nurses, all collaborating across disciplines to achieve optimal patient results. Obviously, surgically-trained nurses will play a significant role in the procedure, assisting and monitoring for the surgeon performing the procedure. Deviation from these standards can result in life-threatening complications. Open communication between the interprofessional team is necessary so that the procedure achieves optimal outcomes safely. [Level V]

• Draw CSF for culture
• Assist the surgeon administer medications
• Monitoring for signs of intracranial hypertension
• Checking for CSF leak
• Ensuring aseptic techniques when manipulating the catheter
• Monitoring the tracing for dampening or lack of pulsation

The nurses involved in patient care should monitor the following: [4]

• Monitor hourly CSF drainage
• Ensure CSF oscillation inside the tubes
• Confer no soakage of the wound
• Ensure the correct height of EVD
• Zeroing of the EVD height at the level of the foramen of Monro or tragus of the ear
• Stringent neurological monitoring of the patient
• Monitor hourly ICP

There needs to be a strict provision of following checklists.[4]

Maintaining a sterile environment, and stringent monitoring for foreseeing and timely troubleshooting of complications are the cornerstones in the care bundle approach in managing these patients.[17]