Neonatal Ventricular Taps

Supplies and Setup

• LP kit

• Gown/gloves

• 4x4 boat x 2

• betadine

• 10cc syringees

• largest guage butterfly needles x 2-3

• blue towels x 5-6

• marking pen (non-sterile)

• neonatal sunglasses

• blankets x 2-3 (for bumping)

• blue chuck

• morphine boluses x 2 (ask NICU to dose, usually reasonable to give one up front then have one ready PRN)

• You will need the help of at least one nurse holding baby at all times once positioned and prepped.

• May also consider asking a second nurse/provider to be available in room to give additional morphine boluses as needed or help with supplies otherwise.

Positioning / Prepping / Draping

1. Turn the baby around in their incubator (so that head is facing the side).

2. Place visors on baby’s eyes, then shine overhead light on your field.

3. Using blankets, bump the head so that baby is approximately 30 degrees up or whatever is comfortable and natural for your height

4. Place blue chuck above blankets once in final position

5. Mark out the mid-pupillary line (it will be covered by towels and also visors) with a marker. May also consider marking out mid-line.

6. Ask the nurse to give a morphine bolus now and swaddle baby’s body with a blanket to minimize movement of their trunk. The nurse will have to hold their head firmly on each side to minimize movement.

7. Prep widely with betadine.

8. Your markings will get washed out by the betadine, which is fine. The most important thing to maintain is an appreciation of midline, as SSS will be very close to where you are tapping just by virtue of working with a small brain.

Procedure

• Your entry point is approximately the intersection of anterior fontanelle border with mid-pupillary line.
• Once draped, make sure you re-establish where sinus. As the face will be draped at this point, simply feel outlines of the entire square of the fontanelle to make sure you are nowhere near midline.
• Your angle is just like that of an EVD, aim for ipsilateral nasal canthus in sagittal plane and around the tragus in the coronal plane. As always, go perpendicular if all else fails.

• Once ventriculostomy is proven, allow for spontaneous drainage or very gently aspirate
• The amount to aspirate is subjective, always just check with attending their preference but the following is a reasonable approach
• Aspirate at least 10 mL/kg (~20 cc for the typical baby) or until fontanelle becomes sunken
• Use one hand to aspirate gently and the other hand to fix the needle in place.