Brains & Drains: The EVD survival guide for the PICU

Oct 26, 2025

Dr. Neal Laxpati, an assistant professor of neurosurgery and pediatric epilepsy expert, joins the discussion on intracranial pressure (ICP) monitoring in pediatric critical care. He shares insights on external ventricular drains (EVDs) and their setup, emphasizing the risks and challenges like infections and device complications. The conversation explores the significance of cerebrospinal fluid (CSF) in brain function and management strategies tailored for young patients. Listeners will also gain practical tips for optimal bedside care and waveform interpretation.

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ANECDOTE

Tumor Case Requiring Bedside EVD

A 10-year-old with a third ventricle DMG developed worsening headaches and bradycardia, then an EVD was placed at bedside.
The case illustrates acute hydrocephalus presentation, rapid deterioration, and emergent bedside EVD use.

ANECDOTE

AVM Case With Ventriculitis

A 16-year-old with ruptured AVM needed multiple EVDs, developed ventriculitis from Bacillus cereus, and required antibiotics.
This case highlights risks of infection, stepwise weaning, and close monitoring after EVD placement.

INSIGHT

CSF Production And Flow Basics

CSF is produced mainly by the choroid plexus and flows from lateral ventricles to subarachnoid spaces.
Adults produce ~500 mL/day with a total CSF volume around 125–150 mL and ~3 turnovers/day.

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In today’s episode, Dr. Monica Gray and Dr. Pradip Kamat sit down with neurosurgeon Dr. Neal Laxpati, MD, PhD, to chat about intracranial pressure (ICP) monitoring in pediatric critical care. Using real case studies, they dive into how and when to use external ventricular drains (EVDs) and ICP bolts, walking listeners through setup, potential risks, and everyday challenges. The group discusses device complications, ways to prevent infections, how to interpret waveforms, and shares practical bedside tips. It’s a must-listen for intensivists looking for hands-on advice and key insights to help optimize care for kids with brain injuries or hydrocephalus.

Show Highlights:

Pediatric critical care unit (PCU) case discussions
Intracranial pressure (ICP) monitoring in pediatric patients
Case studies involving a 10-year-old girl with diffuse midline glioma and a 16-year-old male with a ruptured arteriovenous malformation (AVM)
Cerebrospinal fluid (CSF) physiology and its role in ICP management
Types of ICP monitoring devices: external ventricular drains (EVDs) and intraparenchymal monitors
Indications and complications associated with ICP monitoring
Interpretation of ICP waveforms and their clinical significance
Management strategies for elevated ICP and CSF drainage
Risks and challenges of ICP monitoring, including infection and device malfunction
Importance of interdisciplinary communication and meticulous bedside care in pediatric critical care settings

References:

Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 118. Traumatic brain injury. Kochaneck et al. Page 1375 -1400
Rogers textbook:
Reference 1: Forsyth RJ, Parslow RC, Tasker RC, Hawley CA, Morris KP; UK Paediatric Traumatic Brain Injury Study Group; Paediatric Intensive Care Society Study Group (PICSSG). Prediction of raised intracranial pressure complicating severe traumatic brain injury in children: implications for trial design. Pediatr Crit Care Med. 2008 Jan;9(1):8-14. doi: 10.1097/01.PCC.0000298759.78616.3A. PMID: 18477907.
Reference 2: Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol. 2019 Nov 26;10:1261. doi: 10.3389/fneur.2019.01261. PMID: 32038449; PMCID: PMC6988791.