OT notes · Neurosurgery

External ventricular drain insertion

Usual anaesthesia
Local infiltration with lignocaine and adrenaline, with sedation, in ICU or OT; general anaesthesia if the patient is already intubated or cannot keep still
Position
Supine, head neutral, head end raised (20 to 45 degrees), head slightly over the top end of the bed
Setting
emergency

Operative note template for insertion of an external ventricular drain through Kocher's point, with a filled example for acute hydrocephalus from a hypertensive thalamic bleed with intraventricular extension.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding along the catheter track or in the ventricle
  • infection: meningitis or ventriculitis
  • catheter in the wrong place or blocked, needing another pass or reinsertion
  • catheter falling out or being pulled out
  • too much CSF drainage, with subdural bleeding or, rarely, upward herniation
  • re-bleeding of an untreated aneurysm
  • injury to the brain, motor area or sagittal sinus
  • need for a permanent shunt later

Pre-operative details for this operation

  1. IndicationAcute hydrocephalusICP monitoringIntraventricular haemorrhageCSF diversion for leakIntrathecal accesscause, e.g. IVH, SAH, posterior fossa lesion
  2. GCS and pupilsE V M, pupil size and reaction, time
  3. CT findingsventricle size, IVH, mass lesion in the path, fracture or previous burr hole at the entry site; periventricular abscess or neurocysticercosis cyst in the path
  4. CT measurementsscalp and skull thickness, depth from skin to the lateral ventricle (coronal)
  5. CoagulationINR, platelets, antiplatelet / anticoagulant / thrombolytic given, reversal
  6. Side chosenRightLeft (reason)left if a right craniotomy is likely
  7. Blood pressure controltarget systolic under 140 mmHg; drug used
  8. Antibioticsingle dose covering skin flora, time given before incision

Anaesthesia and position

  1. PlaceOTICU bedside
  2. AnaesthesiaLocal + sedationGeneral (already intubated)local: lignocaine with adrenaline, volume
  3. Positionsupine, head neutral, head end raised (degrees)
  4. Landmarks markedKocher's point: 10 cm behind glabella, 2.75 cm off midlineKocher's point: 11 cm behind nasion, 3 cm off midline (mid-pupillary line)Frazier's pointKeen's pointDandy's pointmidline marked; at least 2.5 cm off midline and about 3 cm in front of coronal suture
  5. Skin preparationshaved area, antiseptic

Operative findings

  1. Ependymal pop feltdepth in cm
  2. Number of passes1 / 2 / more
  3. Opening pressureheight of CSF column in cm H2O, or transducer reading in mmHg
  4. CSFClearBlood stainedFrank bloodTurbid
  5. FlowBriskSlowStopped after a few ml

Procedure (steps)

  1. Drainage system and catheter flushed with sterile saline
  2. Incision1 to 2 cm longitudinal stab over the entry point; blade
  3. Periosteum strippedmosquito / No. 15 blade; retractor
  4. Burr holeTwist drill with guardHand drill with depth guardguard set to scalp plus skull thickness (cm); direction in line with ipsilateral medial canthus and 1 cm in front of tragus
  5. Hole irrigated, BP checkedsystolic under 140 mmHg before dural puncture
  6. Dura puncturedwith trocar, not more than 1 cm beyond the dura
  7. Catheter passed with styletStandardAntibiotic-impregnateddirection; depth at skin in cm, as measured on CT (Jallo: 6.5 to 7 cm at the skin in most adults; Ganti: 5 to 6 cm from the outer table)
  8. Stylet removed, CSF flow confirmedopening pressure; CSF drained (ml) if ICP high; samples sent
  9. Catheter tunnelledlength in cm (Jallo: at least 5 cm; Ganti: 3 to 5 cm), direction, separate exit stab; catheter held at the skull while tunnelling
  10. Flow rechecked after tunnelling
  11. Catheter securedCap tied with 2-0 silk, catheter anchored with 2-0 silk (Roman sandal) and strain-relief loopStopcock sutured, catheter stapled to scalpnot so tight that it blocks the catheter
  12. Connected to closed drainage systemstopcock closed until system is levelled

Closure, drains and dressing

  1. Incision closedMonocryl 3-0 interruptedNylon 3-0Staplesnumber of stitches; skin glue
  2. DressingChlorhexidine-impregnated transparent dressingTransparent dressing
  3. Tubing securedto scalp, neck and shoulder
  4. Drain level setzero at the tragus; chamber height in cm H2O above the tragus, as ordered (for example 15 to 20)

Specimens and implants

  1. CSF sentcell count, protein, sugar, Gram stain, culture
  2. Ventricular cathetertype (plain / antibiotic-impregnated), make, lot number; sticker pasted
  3. Drainage systemmake, lot number

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. CT headto confirm catheter position and look for track bleed
  2. Drain levelzero at tragus; chamber at ___ cm H2O above tragus; re-level every time the patient or head end is moved
  3. Drain open or clampedstate which; stopcock closed until the chamber is set at the ordered height, for example after a move
  4. Hourly output and neuro checksCSF volume and colour, GCS, pupils; ICP if transduced
  5. System checkat least every 4 hours: insertion site to chamber, leaks, kinks, chamber upright
  6. BP targetas ordered, e.g. systolic under 140 mmHg
  7. Antibioticno further prophylactic doses after the single peri-procedure dose
  8. Handlingkeep manipulation of the system to a minimum; CSF samples only by trained staff
  9. Planremove as early as the condition allows; weaning plan

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. V.K., 58 years, known hypertensive, with a left thalamic bleed and intraventricular extension. GCS fell from 11 to 8 over 4 hours. Repeat CT showed acute hydrocephalus.

Case details

Date: 21/06/2026. Emergency. OT 3.

Decision 16:40. In OT 17:05. Incision 17:25. Procedure ended 17:50.

Surgeon: Dr A. (1st-year resident, MCh Neurosurgery). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

GCS at 12:30 E3 V3 M5 = 11. At 16:30 E1 VT M5 (intubated in ICU at 16:10), pupils 2 mm equal, reacting.

CT 16:20: left thalamic bleed about 12 ml with blood in both lateral, third and fourth ventricles. Both lateral ventricles and temporal horns dilated. No mass in the right frontal path. No fracture.

Coronal CT: scalp plus skull 1.4 cm at the right Kocher's point. Skin to right frontal horn 5.0 cm.

Indication: acute obstructive hydrocephalus from intraventricular haemorrhage.

No antiplatelet or anticoagulant. INR 1.0, platelets 2.2 lakh/cumm. BP controlled to 134/80 mmHg with an infusion in ICU.

Consent: taken from wife, Mrs. S.K., in Marathi, including infection, bleeding, blockage, reinsertion and need for a shunt later. Right side marked.

WHO checklist sign in and time out done. Inj cefazolin IV push 5 min before incision (dose on the anaesthesia chart).

Anaesthesia and position

General anaesthesia (already intubated). Supine, head neutral, head end up 20 degrees, head just over the top of the table.

Scalp shaved widely. Midline marked. Right Kocher's point marked 10 cm behind the glabella and 2.75 cm to the right of midline. Lines drawn to the right medial canthus and to 1 cm in front of the right tragus.

Painted with povidone-iodine and draped. 5 ml lignocaine 1% with adrenaline infiltrated at the incision and tunnel track.

Procedure

Drainage system and catheter flushed with sterile saline.

1 cm longitudinal stab incision at Kocher's point. Periosteum stripped with a mosquito.

Twist drill with guard set at 1.5 cm. Hole drilled in line with the two marked lines, roughly perpendicular to the scalp. Bone dust washed out. Systolic BP 128 mmHg.

Dura punctured with the trocar, not more than 1 cm deep.

Plain ventricular catheter passed with stylet towards the right medial canthus and 1 cm in front of the right tragus. Ependymal pop at 4.5 cm. Catheter advanced to 6.5 cm at the skin. One pass.

Findings: stylet removed, brisk flow of blood-stained CSF. Opening pressure about 30 cm H2O by column height. 10 ml drained slowly. CSF sent for cell count, protein, sugar and culture.

Catheter tunnelled posteriorly under the scalp for 6 cm and brought out through a separate stab, held at the burr hole while tunnelling. Flow rechecked: good.

Cap tied with 2-0 silk. Catheter anchored at the exit with a 2-0 silk Roman-sandal stitch and a strain-relief loop.

Closure

Incision closed with two interrupted poliglecaprone 25 (Monocryl) 3-0 sutures. Chlorhexidine-impregnated transparent dressing. Tubing taped to scalp, neck and shoulder.

Connected to a closed drainage system. Zero at the tragus. Chamber set at 15 cm H2O above the tragus, then stopcock opened. CSF dripping.

Specimens and implants

CSF sent for cell count, protein, sugar, Gram stain and culture.

Implant: plain ventricular catheter and drainage set, make and lot number as per sticker; stickers pasted in the case sheet and OT implant register.

End of procedure

Blood loss minimal, about 10 ml. No complications.

Mop, needle and instrument count correct.

Shifted back to neuro-ICU on ventilator with the stopcock closed for transfer; re-levelled at the tragus and opened on arrival. Pupils 2 mm equal, reacting. BP 130/78 mmHg.

Post-op orders

CT head to check catheter position and look for track bleed.

Drain open at 15 cm H2O above tragus. Re-level every time the patient or head end is moved. Close the stopcock after any move until the drain is re-levelled.

Hourly CSF output and colour, GCS and pupils. System check at least every 4 hours.

Systolic BP under 140 mmHg as charted.

No further prophylactic antibiotic doses. Minimum handling of the system.

Review daily for weaning and removal as early as possible.

Signature

Dr A., MCh resident (year 1), Neurosurgery. Reg. no. ________. 21/06/2026, 18:05.

Must document for this operation

  • Entry point by measurement, side and trajectory. If the catheter is misplaced or a second drain is needed, the next surgeon needs the landmarks that were used.
  • Depth at the skin and number of passes. More passes mean more risk of track bleeding, and the depth tells the ICU team if the catheter has moved.
  • Opening pressure and the colour of the CSF. This is the baseline for intracranial pressure (ICP) management and for spotting new bleeding or infection.
  • Tunnel length and how the catheter was secured. A tunnel of at least 5 cm lowers infection risk, and the fixing method helps if the drain falls out.
  • Drain level and whether it was left open or clamped. Wrong height or an unclear order causes over-drainage or blocked drainage on the ward.
  • Antibiotic given before the procedure and the catheter type. EVD infection is the commonest serious complication, and audits look at prophylaxis and antibiotic-impregnated catheters.
  • Catheter and drainage set with lot numbers. Needed for a device recall or an infection cluster review.

Common mistakes in these notes

  • Writing 'EVD inserted' without side, entry point, depth or number of passes.
  • Not recording the drain height and zero point.
  • Not recording CSF colour and opening pressure.
  • Not ordering a CT to confirm position.
  • Leaving out the tunnel length and the fixing method.
  • Not recording the coagulation status and BP at insertion.

Indian practice and paperwork

  • When the patient cannot consent, record who gave consent and their relationship. Consent must be in a language they understand and taken by the person doing the procedure. (NABH 5th ed., PRE.4(c) and (e))
  • Record the batch and serial number of the ventricular catheter and drainage set in the patient's record, the OT master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • Write the name of every anaesthetist in the note. A hospital was held negligent when the operation notes did not name the anaesthetist. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • The operative note must be written before the patient leaves recovery or the procedure area, and post-procedure care must follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Jallo JI, Slottje DF, eds. Neuro ICU Procedure Atlas. Thieme; 2021, Ch 1, External ventricular drain (Slottje DF, Patel NV, Goldstein I), e-book PDF pp. 23-44.
  • Ganti L, ed. Atlas of Emergency Medicine Procedures. 2nd ed. Springer Nature Switzerland; 2022, Ch 43, External ventricular drain placement (Ganti L), pp. 223-228.
  • Neuro ICU Procedure Atlas (Thieme 2021), Ch 1: cefazolin as IV push 5 minutes before incision, single dose only (citing Fried HI et al., Neurocrit Care 2016;24:61-81); systolic BP under 140 mmHg; tunnel at least 5 cm.
  • Atlas of Emergency Medicine Procedures 2e, Ch 43: lidocaine 1-2% with epinephrine; zero at tragus, chamber 15-20 cm H2O as set; system checks at least every 4 hours; CT to verify placement.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

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