Workflow Patterns and Clinical Consequences of External Ventricular Drain Timing: A 6-Year Analysis of 26 020 Cases From the American College of Surgeons National Trauma Data Bank
Neema Darabi, Alexa R. Lauinger, Wedam Nyaaba, Samuel Blake, Amogh Angadi, Christina Grannie, Gregory M. Polites, Paul M. ArnoldBACKGROUND AND OBJECTIVES:
External ventricular drains (EVDs) are critical for monitoring and managing intracranial pressure in acute traumatic brain injury patients. However, there is a lack of consensus on optimal EVD placement timing. Previous studies suggest benefits in early placement but are limited by smaller cohorts and lack of adjustment for illness severity. We sought to characterize EVD timing patterns and examine clinical characteristics and outcomes associated with early placement.
METHODS:
We performed a retrospective study of patients in the National Trauma Data Bank (2018-2023) who received EVD placement for traumatic brain injury. Early EVD was defined as placement ≤24 hours from admission. Multivariable regression models evaluated associations between EVD timing, patient characteristics (demographics, comorbidities, and injury severity), and in-hospital outcomes including mortality, severe sepsis, extended hospitalization (>14 days), ventilator duration, and secondary EVD placement.
RESULTS:
Of 26 020 patients, 77.3% received early placement. Patients receiving early EVD were independently more likely to be younger and to have lower Glasgow Coma Scale. Placement was delayed in patients with comorbidities such as hypertension, diabetes, smoking, and dementia. Early EVD was associated with higher in-hospital mortality (adjusted odds ratio [aOR] 1.39), with lower mortality odds for each 24-hour delay (aOR 0.96). However, early EVD was also associated with lower odds of severe sepsis (aOR 0.60) and prolonged hospitalization (>14 days) (aOR 0.44). Secondary EVD placement occurred in 8.2% of patients with less frequent and more delayed placement after early first EVD (aOR 0.84).
CONCLUSION:
Early EVD placement often identifies severe neurological compromise and is associated with higher mortality. However, early placement was also associated with lower complication rates, shorter hospitalization, and fewer and later EVD revisions. These findings suggest early EVD to be both a marker of severe injury and practice pattern reflecting efficient care, underscoring the need for distinguishing procedural benefit from confounding by indication.