Atención de enfermería en cuidado al paciente con derivación ventricular externa: scoping review

Sakamoto, Victoria Tiyoko Moraes; Vieira, Tainara Wink; Viegas, Karin; Blatt, Carine Raquel; Caregnato, Rita Catalina Aquino

Victoria Tiyoko Moraes Sakamoto

Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil.

https://orcid.org/0000-0002-4646-6848

Tainara Wink Vieira

Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil.

https://orcid.org/0000-0003-1404-1009

Karin Viegas

Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil.

https://orcid.org/0000-0002-2546-9281

Carine Raquel Blatt

Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil.

https://orcid.org/0000-0001-5935-1196

Rita Catalina Aquino Caregnato

Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil.

https://orcid.org/0000-0001-7929-7676

Corresponding author: Victoria Tiyoko Moraes Sakamoto E-mail: vic.sakamoto@gmail.com

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Ana Fátima Fernandes

Title	Year Country	Outlining	GRADE
Prolonged therapeutic external ventricular drainage: A prospective study	1988 China	Cohort study	Low
Continuous-pressure controlled, external ventricular drainage for treatment of acute hydrocephalus-evaluation of risk factors: clinical study	1992 Germany	Experience report	Low
Extraventricular drains: sterile versus aseptic technique	2002 Australia	Cohort study	Low
Benchmarking best practice for external ventricular drainage	2002 United kingdom	Qualitative systematic review	Moderate
Early diagnosis of external ventricular drainage infection: results of a prospective study	2003 Austria	Cohort study	Low
Efficacy of antimicrobial-impregnated external ventricular drain catheters: a prospective, randomized, controlled trial	2003 USA	Randomized clinical trial	High
Risk of infection with prolonged ventricular catheterization	2004 USA	Cohort study	Low
Prevention of external ventricular drain-related ventriculitis	2005 France	Cohort study	Low
External ventricular drain infection: The effect of a strict protocol on infection rates and a review of the literature	2006 United kingdom	Cohort study	Low
Nosocomial ventriculitis and meningitis in neurocritical care patients	2008 Austria	Integrative review	Low
Risk factors for infections related to external ventricular drainage	2008 Netherlands	Cohort study	Low
Paciente neurocrítico. Cuidados de enfermería	2009 Spain	Quasi-experimental study	Low
External ventricular drains in patients	2009 Canada	Cohort study	Low
External ventricular drains and mortality in patients with severe traumatic brain injury	2010 Canada	Cohort study	Moderate
Reducing the incidence of intraventricular catheter-related ventriculitis in the neurology-neurosurgical intensive care unit at a tertiary care center in St Louis, Missouri: An 8-year follow-up study	2010 USA	Quasi-experimental study	Low
A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections	2010 Netherlands	Cross-sectional study	Low
External ventricular and lumbar drainage-associated meningoventriculitis: prospective analysis of time-dependent infection rates and risk factor analysis	2010 Germany	Cohort study	Low
Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage	2011 USA	Clinical practice guideline	Moderate
Reduction in external ventricular drain infection rate. Impact of a minimal handling protocol and antibiotic-impregnated catheters	2011 Spain	Case study	Low
Cerebrospinal fluid collection: a comparison of different collection sites on the external ventricular drain	2011 Canada	Quasi-experimental study por convenience	Low
A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit	2012 USA	Experience report	Low
Intraparenchymal vs Extracranial Ventricular Drain Intracranial Pressure Monitors in Traumatic Brain Injury: Less Is More?	2012 USA	Cohort study	Moderate
Factors contributing to ventriculostomy infection	2012 USA	Cohort study	Low
External ventricular drain infections: Successful implementation of strategies to reduce infection rate	2012 Singapore	Cross-sectional study	Low
Impact of an educational intervention implanted in a neurological intensive care unit on rates of infection related to external ventricular drains	2013 Brazil	Quasi-experimental study	Low
A simple protocol to prevent external ventricular drain infections	2013 USA	Cohort study	Low
Ventriculitis of the Central Nervous System. Critical Care Nursing Clinics of North America	2013 USA	Technical note	Very low
Decreasing ventricular infections through the use of a ventriculostomy placement bundle: Experience at a single institution	2013 USA	Experience report	Very low
Bundle of measures for external cerebral ventricu/lar drainage-associated ventriculitis	2014 Greece	Case study	Low
Neuro-Intensive Treatment Targeting Intracranial Hypertension Improves Outcome in Severe Bacterial Meningitis: An Intervention-Control Study	2014 Sweden	Case-control study	Moderate
Are chlorhexidine-containing dressings safe for use with ventricular drainages?	2014 Germany	Quasi-experimental study by convenience	Low
Predictors of extraventricular drain-associated bacterial ventriculitis	2014 USA	Qualitative systematic review	Moderate
External Ventricular and Lumbar Drain Device Infections in ICU Patients: A Prospective Multicenter Italian Study	2015 Italy	Multicentric cohort study	Moderate
Impact of antibiotic- and silver-impregnated external ventricular drains on the risk of infections: A systematic review and meta-analysis	2015 China	Meta-analysis	High
Management of Intracranial Pressure	2015 USA	Narrative literature review	Low
External Ventricular Drains versus Intraparenchymal Intracranial Pressure Monitors in Traumatic Brain Injury: A Prospective Observational Study	2015 China	Cross-sectional study	Low
External ventricular drains: Management and complications	2015 USA	Narrative literature review	Low
Early monitoring of ventriculostomy-related infections with procalcitonin in patients with ventricular drains	2015 Egypt	Cohort study	Low
Evaluation of indication and outcome of external ventricular drainage in a tertiary ICU	2015 USA	Cohort study	Moderate
Gestion paramédicale de la dérivation ventriculaire externe en réanimation neurochirurgicale	2016 France	Technical note	Very low
Silver-impregnated external-ventricular-drain-related cerebrospinal fluid infections: a meta-analysis	2016 United kingdom	Meta-analysis	High
Current practice of external ventricular drainage: a survey among neurosurgical departments in Germany	2016 Germany	Quanti-qualitative research	Low
Critérios para banho de leito em unidade de terapia intensiva adulto: construção de um protocolo assistencial	2016 Brazil	Qualitative systematic review	Moderate
The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement	2016 USA	Systematic review	Moderate
Establishment of an External Ventricular Drain Best Practice Guideline: The Quest for a Comprehensive, Universal Standard for External Ventricular Drain Care	2016 USA	Qualitative systematic review	Moderate
Riesgo de ventriculitis asociado a cuidados del drenaje ventricular externo en pacientes neurocríticos	2016 Spain	Case-control study	Moderate
External Ventricular Catheters: Is It Appropriate to Use an Open/Monitor Position to Adequately Trend Intracranial Pressure in a Neuroscience Critical Care Environment?	2016 USA	Cohort study	Moderate
Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients	2017 USA	Cohort study	Low
The effects of ventricular drainage on the intracranial pressure signal and the pressure reactivity index	2017 Sweden	Cohort study	Very low
Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage	2017 USA	Case study	Very low
Implementation of an Early Mobility Pathway in Neurointensive Care Unit Patients With External Ventricular Devices	2017 USA	Case-control study	Moderate
Intracranial Pressure Values Are Highly Variable After Cerebral Spinal Fluid Drainage	2017 USA	Case study	Low
Caring for neurosurgical patients with external ventricular drains	2018 United kingdom	Narrative literature review	Low
Early Ambulation in Patients With External Ventricular Drains: Results of a Quality Improvement Project	2018 USA	Cohort study	Low

Category	Intervention	Justification	Degree of evidence
Patient positioning	Headboard angle between 15 and 30º	Leveling the headland angle between 15 and 30º in line with the system level ensures proper functioning and reliability of monitoring⁽¹⁸18 Flores GP. Critérios para banho de leito em unidade de terapia intensiva adulto: construção de um protocolo assistencial. [Dissertação] [Internet]. Universidade do Vale do Rio dos Sinos. 2016 [cited 2018 May 20]. Available from: http://www.repositorio.jesuita.org.br/handle/UNISINOS/5279 http://www.repositorio.jesuita.org.br/ha... ^-¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ⁾;	Moderate
	Keeping head in neutral position aligned to cervical	The aim is to facilitate venous return, reducing CSF without interfering with the EVD drainage system⁽¹⁸18 Flores GP. Critérios para banho de leito em unidade de terapia intensiva adulto: construção de um protocolo assistencial. [Dissertação] [Internet]. Universidade do Vale do Rio dos Sinos. 2016 [cited 2018 May 20]. Available from: http://www.repositorio.jesuita.org.br/handle/UNISINOS/5279 http://www.repositorio.jesuita.org.br/ha... ^-¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ⁾;	Moderate
	Repositioning at "zero point"	The system review must be carried out in order to avoid any change in the drain back pressure⁽⁵5 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620... ⁾. For example, if the transducer is above the interventricular foramen, a false CSF will be recorded as well as insufficient drainage of CSF, with an unnoticed ICH that may cause ventricular collapse or subdural collection⁽¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ⁾.	Low
EVD drainage system positioning	Flow level height	The height of the flow level of CSF by convention corresponds to a horizontal line that runs from the interventricular foramen to the counter pressure prescribed by the neurosurgeon, usually between 10 and 20 cmH₂O⁽⁵5 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620... ^,¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ^-²⁰20 Hill M, Baker G, Carter D, Henman LJ, Marshall K, Mohn K, et al. A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. J Neurosci Nurs. 2012;44(4):188-93. https://doi.org/10.1097/JNN.0b013e3182527672 https://doi.org/10.1097/JNN.0b013e318252... ⁾. This means that if it is 10 cmH₂O, EVD is 10 cm from foramen and, to drain CSF, pressure of ventricles must be at least 10 cmH₂O;	Low
EVD drainage system positioning	System clamping	The clamped system must be kept as short as possible. However, clamping of up to 30 minutes is considered safe, considered a sufficient period to perform intra-hospital transports, exams and changes in patient positioning⁽⁵5 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620... ⁾, unclamping and verifying the complete system in sequence⁽¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ^,²¹21 Chaikittisilpa N, Lele AV, Lyons VH, Nair BG, Newman SF, Blissitt PA, et al. Risks of routinely clamping external ventricular drains for intrahospital transport in neurocritically ill cerebrovascular patients. Neurocrit Care. 2017;26(2):196-204. https://doi.org/10.1007/s12028-016-0308-0 https://doi.org/10.1007/s12028-016-0308-... ⁾;	Low
Dressing change	Frequency of dressing assessment	To verify the appearance of the dressing every 6 hours, if there is moisture indicative of leakage of CSF or signs of inflammation when inserting the catheter⁽²⁰20 Hill M, Baker G, Carter D, Henman LJ, Marshall K, Mohn K, et al. A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. J Neurosci Nurs. 2012;44(4):188-93. https://doi.org/10.1097/JNN.0b013e3182527672 https://doi.org/10.1097/JNN.0b013e318252... ⁾;	Low
	Use of gauze dressing	Dressing should be performed with 0.9% saline and alcoholic chlorhexidine every 24 hours or earlier if necessary, paying attention to and recording the appearance of the insertion, covering with sterile gauze and bandage⁽²²22 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000... ⁾;	Moderate
	Use of transparent film dressing	When transparent film is impermeable, dressing should be applied weekly or earlier if necessary either by compromising the integrity of the dressing or detachment, in order to minimize direct contact between catheter and external environment⁽²⁰20 Hill M, Baker G, Carter D, Henman LJ, Marshall K, Mohn K, et al. A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. J Neurosci Nurs. 2012;44(4):188-93. https://doi.org/10.1097/JNN.0b013e3182527672 https://doi.org/10.1097/JNN.0b013e318252... ^,²²22 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000... ^-²³23 Flint AC, Rao VA, Renda NC, Faigeles BS, Lasman TE, Sheridan W. A simple protocol to prevent external ventricular drain infections. Neurosurgery. 2013;72(6):993-9. https://doi.org/10.1227/NEU.0b013e31828e8dfd https://doi.org/10.1227/NEU.0b013e31828e... ⁾.	Low
EVD drainage bag and catheter care	Aseptic technique for handling	Handling must be kept to a minimum in order to ensure that the risk of infection is minimized and the touch of the EVD components, whether in the cannula or in the bag, are considered aseptic procedures⁽²⁴24 Humphrey E. Caring for neurosurgical patients with external ventricular drains. Nurs Times [Internet]. 2018 [cited 2018 May 20];114(4):52-6. Available from: https://www.nursingtimes.net/clinical-archive/neurology/caring-for-neurosurgical-patients-with-external-ventricular-drains/7023833.article https://www.nursingtimes.net/clinical-ar... ⁾;	Low
	Limit capacity to despise the contents of the bag	The drainage bag must be emptied when it reaches 2/3 or 3/4 of its volume capacity. When very full, it can become heavy and may alter or even interrupt the operation of the CSF drainage system⁽²⁴24 Humphrey E. Caring for neurosurgical patients with external ventricular drains. Nurs Times [Internet]. 2018 [cited 2018 May 20];114(4):52-6. Available from: https://www.nursingtimes.net/clinical-archive/neurology/caring-for-neurosurgical-patients-with-external-ventricular-drains/7023833.article https://www.nursingtimes.net/clinical-ar... ⁾. This same care must be applied to the drip burette;	Low
	Watching for signs of catheter obstruction	It is important to note that the flow of the dropper from the system is well positioned. If there is minimal or no drainage, the system must be checked for folds, obstructions or any clamping. Drainage reduction can cause hydrocephalus remodeling or indicate other possible complications, including catheter traction or CSF leak⁽¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ⁾.	Moderate
	In cases of catheter traction	Do not try to reposition it, or even aspirate or administer solutions when it is obstructed, but communicate with the neurosurgery staff whenever there are any changes, due to high risk of infection and complications⁽¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ⁾.	Moderate
CSF care	Monitoring the level of consciousness	Careful assessments of the level of consciousness should be performed using the updated Glasgow Coma Scale, especially in cases of confused or cognitively impaired patients, in order to ensure that catheter remains properly fixed and is not accidentally pulled in cases of psychomotor agitation. Moreover, early neurological deterioration and signs of lowering of the sensorium due to excessive CSF drainage should be monitored and detected⁽²²22 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000... ⁾;	Low
	CSF drainage flow	Drainage flow varies according to the height of the collecting system in relation to "zero point" (usually 20 cmH₂O) and usually stays between 5 and 10 ml/h or, in some cases, up to 15 ml/h. The volume of CSF drained in ml should be recorded every 6-hour shift, calculating the total of 24 hours. Excess drainage can cause ventricular collapse, rupture of vessels and even subdural hematoma⁽¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ⁾;	Moderate
	Characteristics of drained CSF	The nursing staff must be aware of any changes in the color of the drained CSF, which can change according to patients' clinical pathologies. For instance, if there is blood in CSF, it can be indicative of cerebral hemorrhage or if it looks cloudy or with sediment it can indicate an infectious process. Therefore, it is important to communicate with the nurse and the neurosurgery staff whenever an atypical CSF stain is identified⁽¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ⁾.	Moderate
CSF measurement	Clamping the system to measure CSF	When the EVD system is open, the transducer may not represent the CSF wave correctly. Therefore, the system must be clamped for 1 minute so that the wave analysis is more accurate, taking care to unclamp the system immediately afterwards⁽¹⁹19 Woodward S, Addison C, Shah S, Brennan F, MacLeod A, Clements M. Benchmarking best practice for external ventricular drainage. Br J Nurs. 2002;11(1):47-53. https://doi.org/10.12968/bjon.2002.11.1.12217 https://doi.org/10.12968/bjon.2002.11.1.... ⁾.	Moderate
Administration of medication in the catheter	Clamping the system after administration	When drugs are introduced by the neurosurgery staff through the EVD catheter, such as tissue plasminogen activator for cases of intraventricular hemorrhage or antibiotics for ventriculitis, the system should be clamped for about 1 hour after administration so that it is not drained with excess CSF⁽⁵5 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620... ⁾.	Low
CSF collection	CSF collection periodicity	It should be performed only when necessary, especially in cases in which infection is suspected, which is why routine collection is not indicated⁽²²22 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000... ⁾;	Moderate
CSF collection	CSF collection site	It is recommended that the sample be collected at the distal port, as it minimizes the risk of infection of the system and can bring a more accurate diagnosis, in addition to being considered safe and easy for collection⁽²²22 Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65. https://doi.org/10.1097/JNN.000000000000017 https://doi.org/10.1097/JNN.000000000000... ⁾. However, when the sample is collected in this way, all CSF volume present in the drip chamber/burette must be collected and tested for an accurate leukocyte count. Collection in the bag should be avoided due to the rapid degradation of CSF components. It is also noteworthy that this procedure is performed by the neurosurgery staff⁽⁵5 Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(6):271-4. https://doi.org/10.4103/2152-7806.157620 https://doi.org/10.4103/2152-7806.157620... ⁾.	Low
Mobilization of patients with EVD	Early mobilization	Early mobilization is considered a viable and safe alternative when patients are stable. Such mobilization does not alter CSF and PPC parameters in patients with EVD⁽²⁵25 Kumble S, Zink EK, Burch M, Deluzio S, Stevens RD, Bahouth MN. Physiological effects of early incremental mobilization of a patient with acute intracerebral and intraventricular hemorrhage requiring dual external ventricular drainage. Neurocrit Care. 2017;27(1):115-9. https://doi.org/10.1007/s12028-017-0376-9 https://doi.org/10.1007/s12028-017-0376-... ⁾ and, when in favorable clinical conditions (MAP> 80 mmHg and CSF <20 mmHg), it can be safely tolerated and minimal risks to patients, which may decrease the time of hospitalization and adverse events⁽²⁶26 Shah SO, Kraft J, Ankam N, Bu P, Stout K, Melnyk S, et al. Early ambulation in patients with external ventricular drains: results of a quality improvement project. J Intensive Care Med. 2018;33(6):370-4. https://doi.org/10.1177/0885066616677507 https://doi.org/10.1177/0885066616677507... ⁾.	Low

[1] Corresponding author: Victoria Tiyoko Moraes Sakamoto E-mail: vic.sakamoto@gmail.com

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Atención de enfermería en cuidado al paciente con derivación ventricular externa: scoping review

RESUMEN

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