28. Spivey WH. Comparison of intraosseous, central and peripheral

routes of sodium bicarbonate administration during CPR in pigs.

Ann Emerg Med. 1985;14:1135.

29. Cambray EJ, Donaldson JS, Shore RM. Intraosseous contrast

infusion: efficacy and associated findings. Pediatr Radiol.

1997;27:892.

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Secelela Malecela

Jayashree Ramasethu

51 Tapping a Ventricular Reservoir

The subcutaneous ventricular access device or ventricular

reservoir (Fig. 51.1) is used to drain cerebrospinal fluid

(CSF) in preterm infants with posthemorrhagic hydrocephalus and occasionally in term infants with obstructive hydrocephalus following intracranial hemorrhage (1–5).The ventricular reservoir is inserted in preterm infants who are too

small or too unstable to have a ventriculoperitoneal (VP)

shunt and may abrogate the need for a VP shunt in some

infants. It also allows drainage and clearing of CSF which

may be bloody and have a high protein content, thus decreasing the risk of blockage when a VP shunt is inserted (2,3,6).

The reservoir is usually tapped immediately following

insertion, by the neurosurgeon, to ensure proper placement

and to drain excess CSF. Subsequent taps are performed in

the neonatal intensive care unit (NICU), aiming to remove

enough CSF to prevent further ventriculomegaly and

maintain normal head growth (2,7).

A. Indications

1. Rapidly increasing head circumference, more than

2 mm/day (7)

2. Clinical signs of raised intracranial pressure, such as a

full or tense anterior fontanelle, separation of the sutures,

apnea and bradycardia, poor feeding or vomiting

3. Ultrasound or radiologic evidence of progressive ventriculomegaly

B. Contraindications

1. Low circulating blood volume

2. Cellulitis or abrasion over the reservoir site

3. Sunken fontanelle or overlapping sutures

4. Severe coagulopathy

C. Equipment (other than the cap and

mask, all equipment is sterile)

1. Mask, cap, gloves

2. Standard infant lumbar puncture set

3. Povidine–iodine surgical scrub and prep solution

4. An aperture drape

5. Scalp-vein needle (25- or 27-gauge)

6. 20-mL syringe

D. Precautions

1. Use strict aseptic technique.

2. Maintain continuous cardiorespiratory monitoring during the procedure.

3. Do not use local anesthetic.

4. Do not place IV lines on the same side of the scalp.

5. Do not shave the operative area.

6. Always use a fresh site for insertion of the needle with

every tap.

7. Insert needle just far enough into the reservoir to obtain

CSF; inserting the needle too deep may damage the

reservoir base.

E. Technique

1. Infant should be restrained and comfortable, with the

head in neutral position.

2. Clip any long hair, but do not shave the operative area.

3. Clean skin over the reservoir and a radius of at least

5 cm of the surrounding skin using surgical scrub for

2 to 5 minutes. Use light but firm contact.

4. Dry with blotting pads.

5. Don mask and cap.

6. Scrub hands and put on sterile gloves.

7. Paint area with povidone–iodine solution and allow

area to dry.

8. Drape area while maintaining patient visibility.

9. Insert scalp-vein needle at an angle of 30 to 45 degrees

through the skin into the reservoir bladder.

10.Aspirate fluid at a rate of 1 to 2 mL/min (Fig. 51.2). Remove

no more than 10 to 15 mL/kg. Some authors advocate letting the CSF drain spontaneously, rather than aspirating,

in order to reduce fresh bleeding into the ventricles (8).

11. Remove needle and hold firm pressure for 2 minutes,

until CSF leakage stops.

12. Clean area with sterile saline to remove the povidone–

iodine.

13. Remove the restraints.