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Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study

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Abstract

Background

Survivors of aneurysmal subarachnoid hemorrhage (SAH) face a protracted intensive care unit (ICU) course and are at risk for developing refractory hydrocephalus with the need for a permanent ventriculoperitoneal shunt (VPS). Management of the external ventricular drain (EVD) used to provide temporary cerebrospinal fluid diversion may influence the need for a VPS, ICU length of stay (LOS), and drain complications, but the optimal EVD management approach is unknown. Therefore, we sought to determine the effect of EVD discontinuation strategy on VPS rate.

Methods

This was a prospective multicenter observational study at six neurocritical care units in the United States. The target population included adults with suspected aneurysmal SAH who required an EVD. Patients were preassigned to rapid or gradual EVD weans based on their treating center. The primary outcome was the rate of VPS placement. Secondary outcomes were EVD duration, ICU LOS, hospital LOS, and drain complications.

Results

A rapid EVD wean protocol was associated with a lower rate of VPS placement, including a delayed posthospitalization shunt, in an adjusted Cox proportional analysis (hazard ratio 0.52 [p = 0.041]) and adjusted logistic regression model (odds ratio 0.43 [95% confidence interval 0.18–1.03], p = 0.057). A rapid wean was also associated with 2.1 fewer EVD days (p = 0.007) and saved an estimated 2.5 ICU days (p = 0.049), as compared with a gradual wean protocol. There were fewer nonfunctioning EVDs in the rapid group (odds ratio 0.32 [95% confidence interval 0.11–0.92]). Furthermore, we found that the time to first wean and the number of weaning attempts were important independent covariates that affected the likelihood of receiving a VPS and the duration of ICU admission.

Conclusions

A rapid EVD wean was associated with decreased rates of VPS placement, decreased ICU LOS, and decreased drain complications in survivors of aneurysmal SAH. These findings suggest that a randomized multicentered controlled study comparing rapid vs. gradual EVD weaning protocols is justified.

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Acknowledgements

The authors thank Alexa Collins and Sara Gray (UTSW) for assistance with data collection and Matthew Cobler-Lichter, Joanna Yang, and Mabel Chung for helpful comments. Special thanks to Marek Mirski for helpful comments on the manuscript.

Funding

Dr. Chung and Dr. Locascio have received support from the National Institutes of Health (R25NS065743, KL2TR002542, and K08NS112601 to DYC and UL1TR001102 to JJL). This work was conducted with support from Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UL1TR002541) and financial contributions from Harvard University and its affiliated academic health care centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health. Dr. Chung has also received support from the American Heart Association and American Stroke Association (18POST34030369), the Andrew David Heitman Foundation, the Aneurysm and AVM Foundation, and the Brain Aneurysm Foundation’s Timothy P. Susco and Andrew David Heitman Foundation Chairs of Research.

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Authors and Affiliations

  1. Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA

    David Y. Chung, James H. Lai & Guy A. Rordorf

  2. Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA

    David Y. Chung & James H. Lai

  3. Departments of Neurology and Neurosurgery, Alpert Medical School, Rhode Island Hospital, Brown University, Providence, RI, USA

    Bradford B. Thompson, Ali Mahta & Shyam S. Rao

  4. Department of Neurology, Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA

    Monisha A. Kumar, Aleksey Tadevosyan & Kathryn Kessler

  5. Biostatistics Center, Division of Clinical Research, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Joseph J. Locascio

  6. Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Aman B. Patel

  7. Department of Neurology, Detroit Medical Center, Wayne State University, Detroit, MI, USA

    Wazim Mohamed

  8. Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA

    DaiWai M. Olson

  9. Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA

    Sayona John

Authors
  1. David Y. Chung
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  2. Bradford B. Thompson
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  14. Guy A. Rordorf
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Contributions

DYC, BBT, MAK, AM, SSR, JJL, ABP, WM, DMO, SJ, and GAR conceptualized and designed the study. DYC, BBT, MAK, AM, SSR, AT, KK, WM, DMO, SJ, and GAR collected the data. DYC, AM, JHL, and JJL performed statistical analysis. DYC and JHL made the figures. DYC prepared the first draft of the article. All authors revised the article and gave approval of the final manuscript.

Corresponding author

Correspondence to David Y. Chung.

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The authors declare no conflicts of interest.

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We adhered to ethical guidelines. Ethical approvals (institutional review board) were obtained. Use of informed consent was not applicable. Prospective observational studies require a statement regarding institutional review board approval, which we have obtained, as stated in the article.

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Chung, D.Y., Thompson, B.B., Kumar, M.A. et al. Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study. Neurocrit Care 36, 536–545 (2022). https://doi.org/10.1007/s12028-021-01343-9

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  • DOI: https://doi.org/10.1007/s12028-021-01343-9

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