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Introduction: The perioperative management of patients with external ventricular drains (EVDs) is not well defined, and adherence to published management guidelines unknown. This study investigates practice, patterns, and variability in the perioperative management of patients with EVDs., Methods: A 31-question survey was sent to 1830 anesthesiologists from 27 institutions in North America, Europe, and Asia. A perioperative EVD Guideline Adherence Score was calculated for the preoperative, transport and intraoperative periods. Differences in management practices between neuroanesthesiologists and non-neuroanesthesiologists, and factors affecting EVD guideline adherence, were examined using bivariate significance tests and linear regression., Results: Among a sample of 599 anesthesiologists (survey response rate, 32.7%), compared with non-neuroanesthesiologists, neuroanesthesiologists were more likely to include baseline neurological examination (P=0.023), hourly cerebrospinal fluid output (P=0.006) and color (P<0.001), intracranial pressure trends (P<0.001), and EVD clamp trial (P<0.001) data in their routine preanesthetic assessment of patients with EVDs. There was a low prevalence of routine intracranial pressure monitoring during patient transport of patients with EVDs (14.4%). Overall, 25.9% of respondents were aware of EVD guidelines, and 21% reported receiving formal training in EVD management. The EVD Guideline Adherence Score was highest among anesthesiologists who reported being very comfortable in managing patients with EVDs compared with those who reported being uncomfortable (9.93 vs. 6.93, P<0.001)., Conclusions: The EVD Aware study identifies opportunities for improvement in the perioperative management of patients with EVDS, including global awareness, formal EVD training, and dissemination of educational tools.

What We Already Know About This Topic: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Ketamine is an N-methyl-D-aspartate receptor antagonist that reduces temporal summation of pain and modulates antinociception. Ketamine infusions can produce significant relief of neuropathic pain, but the treatment is resource intensive and can be associated with adverse effects. Thus, it is crucial to select patients who might benefit from this treatment. The authors tested the hypothesis that patients with enhanced temporal summation of pain and the capacity to modulate pain via the descending antinociceptive brain pathway are predisposed to obtain pain relief from ketamine., Methods: Patients with refractory neuropathic pain (n = 30) and healthy controls underwent quantitative sensory testing and resting-state functional magnetic resonance imaging and then completed validated questionnaires. Patients then received outpatient intravenous ketamine (0.5 to 2 mg · kg · h; mean dose 1.1 mg · kg · h) for 6 h/day for 5 consecutive days. Pain was assessed 1 month later. Treatment response was defined as greater than or equal to 30% pain relief (i.e., reduction in pain scores). We determined the relationship between our primary outcome measure of pain relief with pretreatment temporal summation of pain and with brain imaging measures of dynamic functional connectivity between the default mode network and the descending antinociceptive brain pathway., Results: Approximately 50% of patients achieved pain relief (mean ± SD; Responders, 61 ± 35%; Nonresponders, 7 ± 14%). Pretreatment temporal summation was associated with the effect of ketamine (ρ = -0.52, P = 0.003) and was significantly higher in Responders (median [25th, 75th] = 200 [100, 345]) compared with Nonresponders (44 [9, 92]; P = 0.001). Pretreatment dynamic connectivity was also associated with the clinical effect of ketamine (ρ = 0.51, P = 0.004) and was significantly higher in Responders (mean ± SD, 0.55 ± 0.05) compared with Nonresponders (0.51 ± 0.03; P = 0.006). Finally, the dynamic engagement of the descending antinociceptive system significantly mediated the relationship between pretreatment pain facilitation and pain relief (95% CI, 0.005 to 0.065)., Conclusions: These findings suggest that brain and behavioral measures have the potential to prognosticate and develop ketamine-based personalized pain therapy.

External ventricular drains and lumbar drains are commonly used to divert cerebrospinal fluid and to measure cerebrospinal fluid pressure. Although commonly encountered in the perioperative setting and critical for the care of neurosurgical patients, there are no guidelines regarding their management in the perioperative period. To address this gap in the literature, The Society for Neuroscience in Anesthesiology & Critical Care tasked an expert group to generate evidence-based guidelines. The document generated targets clinicians involved in perioperative care of patients with indwelling external ventricular and lumbar drains.