TECHNICAL NOTE J Neurosurg 126:1003–1005, 2017 V entriculostomy, or external ventricular drainage, is among the most common procedures in neuro- surgery practice. However, it is not exempt from complications. 6,7 Since its frst description, it has been improved with several technical advances and safer pro- tocols. 5,8 Additionally, complications from the procedure have been addressed in several papers, including reports on infection 2,4 and misplacement 3,9 as the most important. Despite the better understanding we have about external ventricular drains (EVDs) and the technical advances, ac- cidental pullouts have been poorly described as a compli- cation. In our experience, this complication is not uncom- mon in busy neurosurgery units. Neither the morbidity nor the mortality specifcally associated with a pullout compli- cation has been addressed. External ventricular drains are often implanted in pedi- atric or newborn patients in a complex environment. This implies several situations that could increase the pullout risk. Furthermore, there are several techniques for secur- ing the EVD to the scalp, with a wide variability between hospitals and even between surgeons. 10 We describe the procedure used in our pediatric unit to secure an EVD to the scalp; this is a simple and reliable technique that minimizes the pullout complication risk. We retrospectively describe the single-center experience in a large consecutive patient series. Methods All EVDs were placed bedside under sedation in the ICU or, more often, under general anesthesia in the oper- ating room, depending on the patient’s clinical features. Freehand ventriculostomy was performed as traditionally described. 3,9 In some cases ultrasound and navigation aids were used. The frst step, after the EVD was placed and tunneled, was to secure it with 2 staples at the point where it emerged from the scalp (Fig. 1). Precautions must be taken to avoid damaging the EVD catheter while it is being stapled. This is the most delicate step of the procedure. Then, a thick hy- drocolloid dressing (Comfeel Plus, Coloplast [approximate cost €0.63]; Varihesive, ConvaTec Inc.; Hydrocoll, Hart - mann; and Tegaderm, 3M, among others) was placed on the skin where the EVD was to be fxed. A lateral section in the colloid allows exit of the catheter. Size was variable and adapted individually; usually a 4 × 8–cm rectangular dressing was enough. The EVD was then placed above the dressing and it was covered by a second, similar piece of ABBREVIATIONS EVD = external ventricular drain. SUBMITTED January 11, 2016. ACCEPTED February 19, 2016. INCLUDE WHEN CITING Published online May 6, 2016; DOI: 10.3171/2016.2.JNS1678. Avoiding pullout complications in external ventricular drains: technical note Carlos Velásquez, MD, 1 Mónica Rivero-Garvía, MD, PhD, 2 Maria Jose Mayorga-Buiza, MD, PhD, 3 María de los Ángeles Cañizares-Méndez, MD, 4 Manuel E. Jiménez-Mejías, MD, PhD, 5 and Javier Márquez-Rivas, MD, PhD 2 1 Department of Neurological Surgery and Spine Unit, Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander; 2 Department of Neurosurgery, 3 Department of Pediatric Anesthesia, and 5 Infectious Disease Unit, Hospitales Universitarios Virgen del Rocio, Seville; and 4 Department of Neurosurgery, Complejo Hospitalario de Toledo, Spain This report describes a reliable and simple technique for securing external ventricular drains (EVDs) to the scalp and avoiding pullout complications. The operative technique consists of fxing the drain between 2 hydrocolloid dressings and securing it with staples. A 10-year retrospective analysis of EVD pullout complications was performed in a series of 435 consecutive patients who were treated at a single institution. The EVD pullout complication rate was 0.4%. No complica- tions related to the fxation technique were found. The median operative time required to fx the drain was 60 seconds. The technique presented here is a simple and reliable procedure to fx the EVD to the scalp, preventing pullout complica- tions and thus reducing the morbidity of EVD reimplantation. https://thejns.org/doi/abs/10.3171/2016.2.JNS1678 KEY WORDS external ventricular drain; complications; infection; dislodgement; surgical technique ©AANS, 2017 J Neurosurg Volume 126 • March 2017 1003 Unauthenticated | Downloaded 12/05/22 11:57 PM UTC