The High Cost of External Ventricular Drain Occlusions

Placing an external ventricular drain (EVD) is both a routine as well as critical procedure in neurocritical care. Even with many recent innovations in the procedure and tools, studies have shown that there’s a high likelihood that an EVD catheter will become occluded at some point with either a temporary or permanent obstruction that complicates intracranial pressure.

Not only do EVD occlusions put an extra burden of care on the patient’s team to address the clog in a timely manner – as short as 8 min with pediatric patients – but the necessary treatment options may also introduce new bleeding and infection risk to the patients. In addition, costs also significantly increase as more and more interventions are needed and possible complications arise.

For example, if the initial approach of flushing with saline doesn’t work, tissue plasminogen activator (tPA) can be administered to try to help break down the occlusion. Fibrinolytics, however, can cost anywhere from $20 to 130 for a standard dose, according to a 2020 article in World Neurosurgery by Aten et al.

If such irrigation or the introduction of active agents is unsuccessful, the catheter may need to be replaced. EVDs have a replacement rate of 1.26, as cited in the Aten et al study, with costs of EVD replacements ranging from $1,300 to $3,200 per replacement.

CT imaging may also be needed to determine possible shifts in the EVD catheter placement, but comes at a price. The typical cost of CT imaging is roughly $900 per case, according to a 2016 study by Fargen et al that examined occlusions in 98 patients undergoing frontal EVD placement.

In the end, total overall cost of EVD occlusions came to around $615 per patient in the Fargen study. Of the patients studied, 42% had a temporary occlusion and nearly 20% of patients developed a permanent occlusion.

Despite sterile techniques and use of antibiotics, EVDs carry a risk of infection with factors that include catheter irrigation and catheter placement duration, according to the Neurocritical Care Society’s evidence-based Consensus Statement.  Costs rise substantially when a patient acquires an EVD-related infection and must receive extended in-patient care in the ICU which can cost upwards of $4,300 a day on average. For patients with EVD infections, the length of extended hospital stay can range anywhere from 5 to 13 days with a EVD in place, which results in additional costs of $22,360 to $55,900 per patient.