Long subcutaneous tunnelling reduces infection rates in paediatric external ventricular drains

External ventricular drainage in pediatric patients: indications, management, and shunt conversion rates

PURPOSE

Placement of an external ventricular drainage (EVD) is one of the most frequent procedures in neurosurgery, but it has specific challenges and risks in the pediatric population. We here investigate the indications, management, and shunt conversion rates of an EVD.

METHODS

We retrospectively analyzed the data of a consecutive series of pediatric patients who had an EVD placement in the Department of Neurosurgery at Hannover Medical School over a 12-year period. A bundle approach was introduced to reduce infections. Patients were categorized according to the underlying pathology in three groups: tumor, hemorrhage, and infection.

RESULTS

A total of 126 patients were included in this study. Seventy-two were male, and 54 were female. The mean age at the time of EVD placement was 5.2 ± 5.0 years (range 0-17 years). The largest subgroup was the tumor group (n = 54, 42.9%), followed by the infection group (n = 47, 37.3%), including shunt infection (n = 36), infected Rickham reservoir (n = 4), and bacterial or viral cerebral infection (n = 7), and the hemorrhage group (n = 25, 19.8%). The overall complication rate was 19.8% (n = 25/126), and the total number of complications was 30. Complications during EVD placement were noted in 5/126 (4%) instances. Complications during drainage time were infection in 9.5% (12 patients), dysfunction in 7.1% (9 patients), and EVD dislocation in 3.2% (4 patients). The highest rate of complications was seen in the hemorrhage group. There were no long-term complications. Conversion rates into a permanent shunt system were 100% in previously shunt-dependent patients. Conversion rates were comparable in the tumor group (27.7%) and in the hemorrhage group (32.0%).

CONCLUSION

EVD placement in children is an overall safe and effective option in children. In order to make further progress, carefully planned prospective and if possible randomized studies are needed controlling for multivariable aspects.

Long Tunneled External Ventricular Drains with Shunt Valves: A Technical Note

BACKGROUND

External ventricular drain (EVD) is a basic operation in neurosurgery. Due to the limitation of its safe duration, some patients need to receive multiple drainage operations. We describe the long tunneled EVD (LTEVD) with shunt valves that effectively avoid multiple operations as a technical note.

METHODS

The difference is that the middle part of the drainage tube is connected by an externalized shunt valve. The drainage tube is buried under the skin and the outlet is in the abdomen. The technique and more details are described.

RESULTS

The connection between the LTEVD and the shunt valve is simple and the required materials are easily accessible. Externalized valves allow the cerebrospinal fluid to be visualized and more controllable, making it easier for physicians to manage the cerebrospinal fluid. No drainage tube failure or secondary infection was observed. The indwelling time of the drainage tube was greatly extended.

CONCLUSIONS

LTEVD is effective and simple. It allows visual control of drainage flow, prolonging catheter indwelling time and eliminating the need for multiple surgeries.

Prevention of device-related infections in patients with cancer: Current practice and future horizons

Over the past several years, multifaceted advances in the management of cancer have led to a significant improvement in survival rates. Throughout patients' oncological journeys, they will likely receive one or more implantable devices for the administration of fluids and medications as well as management of various comorbidities and complications related to cancer therapy. Infections associated with these devices are frequent and complex, often necessitating device removal, increasing health care costs, negatively affecting quality of life, and complicating oncological care, usually leading to delays in further life-saving cancer therapy. Herein, the authors comprehensively review multiple evidence-based recommendations along with best practices, expert opinions, and novel approaches for the prevention of diverse device-related infections. The authors present many general principles for the prevention of these infections followed by specific device-related recommendations in a systematic manner. The continuous involvement and meaningful cooperation between regulatory entities, industry, specialty medical societies, hospitals, and infection control-targeted interventions, along with primary care and consulting health care providers, are all vital for the sustained reduction in the incidence of these preventable infections.

Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions

BACKGROUND

External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications.

METHODS

We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed.

RESULTS

There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies.

CONCLUSIONS

In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.

Risk factors and outcomes associated with external ventricular drain infections

BACKGROUND

Insertion of an external ventricular drain (EVD) is a common neurosurgical procedure which may lead to serious complications including infection. Some risk factors associated with EVD infection are well established. Others remain less certain, including specific indications for placement, prior neurosurgery, and prior EVD placement.

OBJECTIVE

To identify risk factors for EVD infections.

METHODS

We reviewed all EVD insertions at our institution from March 2015 through May 2019 following implementation of a standardized infection control protocol for EVD insertion and maintenance. Cox regression was used to identify risk factors for EVD infections.

RESULTS

479 EVDs placed in 409 patients met inclusion criteria, and 9 culture-positive infections were observed during the study period. The risk of infection within 30 days of EVD placement was 2.2% (2.3 infections/1,000 EVD days). Coagulase-negative staphylococci were identified in 6 of the 9 EVD infections). EVD infection led to prolonged length of stay post-EVD-placement (23 days vs 16 days; P = .045). Cox regression demonstrated increased infection risk in patients with prior brain surgery associated with cerebrospinal fluid (CSF) diversion (HR, 8.08; 95% CI, 1.7-39.4; P = .010), CSF leak around the catheter (HR, 21.0; 95% CI, 7.0-145.1; P = .0007), and insertion site dehiscence (HR, 7.53; 95% CI, 1.04-37.1; P = .0407). Duration of EVD use >7 days was not associated with infection risk (HR, 0.62; 95% CI, 0.07-5.45; P = .669).

CONCLUSION

Risk factors associated with EVD infection include prior brain surgery, CSF leak, and insertion site dehiscence. We found no significant association between infection risk and duration of EVD placement.

Technical description of a novel device for external ventricular drainage in neonatal and pediatric patients: Results from a single referral center experience

BACKGROUND

Since external ventricular drainage (EVD) related infections are usually due to skin flora, an extradural intra/extra-cranial accessory device, developed for pediatric patients under three years of age undergoing EVD positioning, is described. The aim of this paper is to provide technical description of this device, underlining the possibility to reduce infective risk and to prevent EVD dislocation.

METHODS

Patients undergoing A-D device EVD placement between 1990 and 2017 at authors' institution were retrospectively considered. The device was made of a fully MRI-compatible inert material (Ketron-Peek-1000), composed of two pieces securely fixable to the skull, bridging the catheter directly from the epidural space to the extracranial space without letting it come in contact with the skin.

RESULTS

A total number of 350 patients were considered. The mean age was 1.4 years, being the youngest patient a newborn of 25 weeks of gestational age. Mean time of EVD maintenance was 45 days, ranging from 21 to 81 days. 2 cases (0.6%) of EVD related infections were reported, while, pull-out of the ventricular catheter occurred in 3 cases (0.9%). No cases of bone fractures related to the clamp effect provided by A-D device were reported in the series CONCLUSIONS: This device could represent a safe and feasible option to reduce EVD related infections and catheter pull-out in pediatric patients. The encouraging results could strength the aim of the device to allow safer and longer length of CSF drainage. Moreover, the fully MRI-compatible nature and its non-magnetic properties allow to use it with neuronavigation systems.

Guideline for the management of long tunnelled external ventricular drains in chronic hydrocephalus

This article reports on the journey of a child with an inoperable hypothalamic-origin pilocytic astrocytoma causing hydrocephalus, which was refractory to treatment with shunts, and required a new approach. With multidisciplinary support, excellent nursing care and parental education, the child's hydrocephalus was managed long term in the community with bilateral long-tunnelled external ventricular drains (LTEVDs). This article describes the patient's journey and highlights the treatment protocols that were created to achieve this feat. Despite the difficulties in initially setting up these protocols, they proved successful and thus the team managing the patient proposed that LTEVDs are a viable treatment option for children with hydrocephalus in the context of inoperable tumours to help maximise quality of life.

The effect of external ventricular drain tunneling length on CSF infection rate in pediatric patients: a randomized, double-blind, 3-arm controlled trial

OBJECTIVE

The role of tunneling an external ventricular drain (EVD) more than the standard 5 cm for controlling device-related infections remains controversial.

METHODS

This is a randomized, double-blind, 3-arm controlled trial done in the Children's Medical Center in Tehran, Iran. Pediatric patients (< 18 years old) with temporary hydrocephalus requiring an EVD and no evidence of CSF infection or prior EVD insertion were enrolled. Patients were randomly assigned (1:1:1) into the following arms: 5-cm (standard; group A); 10-cm (group B); or 15-cm (group C) EVD tunnel lengths. The investigators, parents, and person performing the analysis were masked. The surgeon was informed of the length of the EVD by the monitoring board just before operation. Patients were followed until the EVD's fate was established. Infection rate and other complications related to EVDs were assessed.

RESULTS

A total of 105 patients were enrolled in three random groups (group A = 36, group B = 35, and group C = 34). The EVD was removed because there was no further need in most cases (67.6%), followed by conversion to a new EVD or ventriculoperitoneal shunt (15.2%), infection (11.4%), and spontaneous discharge without further CSF diversion requirement (5.7%). No statistical difference was found in infection rate (p = 0.47) or EVD duration (p = 0.81) between the three groups. No group reached the efficacy point sooner than the standard group (group B: hazard ratio 1.21, 95% CI 0.75-1.94, p = 0.429; group C: hazard ratio 1.03, 95% CI 0.64-1.65, p = 0.91).

CONCLUSIONS

EVD tunnel lengths of 5 cm and longer did not show a difference in the infection rate in pediatric patients. Indeed, tunneling lengths of 5 cm and greater seem to be equally effective in preventing EVD infection. Clinical trial registration no.: IRCT20160430027680N2 (IRCT.ir).

Decreasing External Ventricular Drain Infection Rates in the Neurocritical Care Unit: 12-Year Longitudinal Experience at a Single Institution

OBJECTIVE

External ventricular drain (EVD) placement is a common neurosurgical procedure, and EVD-related infection is a significant complication. We examined the effect of infection control protocol changes on EVD-related infection incidence.

METHODS

Changes in EVD placement protocol and incidence density of infections after implementation of protocol changes in the neurocritical care unit were tracked from 2007 to 2019. EVD infections were defined using a modified U.S. Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definition of meningitis/ventriculitis for patients with EVDs in situ for at least 2 days confirmed by positive culture. Contribution of protocol changes to EVD infection risk was assessed via multivariate regression.

RESULTS

Fifteen major changes in EVD protocol were associated with a reduction in infections from 6.7 to 2.0 per 1000 EVD days (95% confidence interval [CI], 4.1-5.3; P < 0.001). Gram-positive bacterial infection incidence decreased from 4.8 to 1.7 per 1000 EVD days (95% CI, 2.3-3.9; P = 0.00882) and gram-negative infection incidence decreased from 1.9 to 0.5 per 1000 EVD days (95% CI, 0.6-2.3; P = 0.0303). Of all protocol changes since 2007, the largest reduction in incidence was 3.9 infections per 1000 days (95% CI, 0.50-7.30; P = 0.011), associated with combined standardization of reduced EVD sampling frequency, cutaneous antisepsis with alcoholic chlorhexidine before EVD placement, and use of a subcutaneous tunneling technique during EVD insertion.

CONCLUSIONS

The most significant reduction in EVD infections may be achieved through the combination of reducing EVD sampling frequency and standardizing alcoholic chlorhexidine cutaneous antisepsis and subcutaneous tunneling of the EVD catheter.

Securing CSF catheters to the skin: from sutures and bolt system to subcutaneous anchoring device towards zero complications

INTRODUCTION

Securing the catheter to the skin either with sutures or staples and to the skull with bolt system still represents the most common options in the management of CSF external drainage. However, these options bear an unavoidable risk of complications. This problem is common to vascular accesses and has been successfully overcome with the introduction of device for subcutaneous anchoring (SecurAcath®, Interrad Medical, Inc., Plymouth, Minnesota), which has rapidly become the standard of care in this field.

METHODS

We report our experience with the use of SecurAcath® to secure CSF drainage, either ventricular or spinal. Results were compared with literature data.

RESULTS

Since 2015, SecurAcath® was used in 209 patients (mean age 7 years) to secure 195 external cranial catheters (either ventricular or subdural or intralesional) and 16 spinal drainages. Indwell time ranged from 5 to 30 days. No complication related to the use of the device was observed. In particular, there was no case of dislocation or accidental pullout of the catheter. Rate of infection, or superinfection in case of ventricular catheter implanted for CSF infection, was null.

CONCLUSIONS

SecurAcath® is a safe and effective device to secure CSF external catheters, with several relevant advantages, including easy placement and maintenance. Moreover, it may stay in place for the whole duration of the catheter without any skin tissue trauma and allows a complete antisepsis of the exit site, thus reducing local skin complications. This factor has significant impact on the reduction of infection rate of external CSF catheters.

Pulsatility Index Reflects Intracranial Pressure Better than Resistive Index in Patients with Clinical Features of Intracranial Hypertension

Background  The intracranial pressure (ICP) is measured through various noninvasive methods to overcome complications of invasive ICP monitoring. In this study, transcranial Doppler was used to measure pulsatility index (PI) and resistive index (RI) that were correlated with opening intraventricular ICP. The opening intraventricular ICP was measured with the placement of intraventricular catheter in lateral ventricle without loss of cerebrospinal fluid. Methods  The prospective, observational study was conducted on 40 patients with clinical and radiological features of raised ICP who underwent either endoscopic third ventriculostomy or ventriculoperitoneal shunt surgery. The PI and RI were measured simultaneously with opening ICP measurements under general anesthesia. Both PI and RI were correlated with ICP by using Pearson correlation coefficient. The receiver operating characteristic (ROC) curve was used to get the optimal values of PI ad RI for corresponding ICP values. Results  The mean PI was 1.01 ± 0.41 and mean RI was 0.59 ± 0.32. The mean opening ICP value was 21.81 ± 8.68 mm Hg. The correlation between PI and RI with ICP was a statistically significant with correlation coefficient of 0.697 and 0.503, respectively. The ROC curve shown statistically significant association between PI and ICP from 15 to 40 mm Hg, whereas the association between RI and ICP was from 15 to 25 mm Hg, with various sensitivity and specificity. Conclusion  The opening intraventricular ICP correlated better with PI than RI in patients with features of raised ICP.

The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.

Recurrent sampling and ventriculostomy-associated infections: a case-control study

BACKGROUND

External ventricular drain (EVD) insertion is a common neurosurgical procedure with a significant risk of ventriculostomy-associated infections (VAIs), other morbidities and mortality. Several risk factors have been identified but their effect is unclear.

OBJECTIVE

Our primary objective was to assess whether recurrent EVD sampling increased the risk of VAIs. The secondary objective was to explore the effect of sampling frequency, duration of EVD stay, presence of cerebrospinal fluid leak and concurrent infections.

METHODS

Ours was a retrospective, single-centre, age-matched, case control study of 83 patients and 249 controls who underwent EVD insertion between 1 January 2010 - 31 December 2016. Patients with primary CNS infections, age under 1 year and death within 5 days of EVD insertion were excluded. Blinded abstractors collected all patient data through the electronic patient record system and regression analysis was used to compare the two groups.

RESULTS

Sampling the EVD more than once did not increase the risk of infection (OR 0.47, 95% CI 0.27-0.83, p = 0.01). Risk factors significantly associated with VAI included CSF leak (OR 2.06, 95% CI 1.16-3.67, p = 0.01), concurrent infection (OR 1.85, 95% CI 1.09-3.16, p = 0.02), and an EVD duration of >10 days (OR 2.28, 95% CI 1.24-4.18, p = 0.01).

CONCLUSION

Our findings do not support the notion that increased sampling of EVDs is associated with a higher risk of VAI. CSF leaks, concurrent infection and long-term EVDs are also statistically significant risk factors for infection.

Rare case of a rapidly enlarging symptomatic arachnoid cyst of the posterior fossa in an infant: A case report and review of the literature

Background:

Intracranial arachnoid cysts are space-occupying lesions that typically remain stable or decrease in size over time. Cysts in infants younger than 1 year of age are remarkably different from those in older children and adults in terms of cyst localization and enlargement. Arachnoid cysts of the posterior fossa (PFACs) are very rare in infants and do not typically grow or present with clinical symptoms, such that surgical treatment is generally considered to be unnecessary. Here, we describe an extremely rare case of an infant with a rapidly enlarging symptomatic PFAC that was successfully treated with surgery.

Case Description:

A 4-month-old boy presented with increasing head circumference and a rapidly enlarging arachnoid cyst in the left posterior fossa with ventriculomegaly, which was documented using serial imaging over the preceding 2 months. We performed a microscopic resection of the cyst membrane to remove the mass effect as soon as possible and facilitate normal development. To confirm dural closure and prevent cerebrospinal fluid leakage, we also performed short-term (7 days) percutaneous long-tunneled external ventricle drainage after the surgery. Magnetic resonance imaging over a 4-year follow-up period revealed adequate reduction of the ventricle and cyst. The patient no longer exhibited progressive macrocrania and showed normal development.

Conclusion:

To our knowledge, this is the second successful case of surgical treatment of an enlarging symptomatic PFAC in an infant. Our surgical strategy for the treatment of this rare case can serve as a guide for surgeons in similar future cases.

Evaluation of a novel noninvasive ICP monitoring device in patients undergoing invasive ICP monitoring: preliminary results

OBJECTIVE There is no established method of noninvasive intracranial pressure (NI-ICP) monitoring that can serve as an alternative to the gold standards of invasive monitoring with external ventricular drainage or intraparenchymal monitoring. In this study a new method of NI-ICP monitoring performed using algorithms to determine ICP based on acoustic properties of the brain was applied in patients undergoing invasive ICP (I-ICP) monitoring, and the results were analyzed. METHODS In patients with traumatic brain injury and subarachnoid hemorrhage who were undergoing treatment in a neurocritical intensive care unit, the authors recorded ICP using the gold standard method of invasive external ventricular drainage or intraparenchymal monitoring. In addition, the authors simultaneously measured the ICP noninvasively with a device (the HS-1000) that uses advanced signal analysis algorithms for acoustic signals propagating through the cranium. To assess the accuracy of the NI-ICP method, data obtained using both I-ICP and NI-ICP monitoring methods were analyzed with MATLAB to determine the statistical significance of the differences between the ICP measurements obtained using NI-ICP and I-ICP monitoring. RESULTS Data were collected in 14 patients, yielding 2543 data points of continuous parallel ICP values in recordings obtained from I-ICP and NI-ICP. Each of the 2 methods yielded the same number of data points. For measurements at the ≥ 17-mm Hg cutoff, which was arbitrarily chosen for this preliminary analysis, the sensitivity and specificity for the NI-ICP monitoring were found to be 0.7541 and 0.8887, respectively. Linear regression analysis indicated that there was a strong positive relationship between the measurements. Differential pressure between NI-ICP and I-ICP was within ± 3 mm Hg in 63% of data-paired readings and within ± 5 mm Hg in 85% of data-paired readings. The receiver operating characteristic-area under the curve analysis revealed that the area under the curve was 0.895, corresponding to the overall performance of NI-ICP monitoring in comparison with I-ICP monitoring. CONCLUSIONS This study provides the first clinical data on the accuracy of the HS-1000 NI-ICP monitor, which uses advanced signal analysis algorithms to evaluate properties of acoustic signals traveling through the brain in patients undergoing I-ICP monitoring. The findings of this study highlight the capability of this NI-ICP device to accurately measure ICP noninvasively. Further studies should focus on clinical validation for elevated ICP values.

Long-tunnelled external ventricular drain as a long-term treatment option for hydrocephalus in a child with an unresectable low-grade supratentorial tumor: case report

The authors report a case of a child with hypothalamic-origin pilocytic astrocytoma and hydrocephalus, which was refractory to treatment with a ventriculoperitoneal shunt due to high CSF protein content. With parental education, the child's hydrocephalus was managed long-term in the community with a long-tunnelled external ventricular drain, which was maintained by his parents. To the authors' knowledge this is the first report of this management option as a long-term measure. No harm has come to the patient. The authors propose long-term, long-tunnelled external ventricular drain as a viable treatment option for such patients.

Introduction of percutaneous-tunneled transfontanellar external ventricular drainage in the management of hydrocephalus in extremely low-birth-weight infants

OBJECTIVE Hydrocephalus treatment in extremely low-birth-weight (ELBW) infants still represents a challenge for the pediatric neurosurgeon, particularly when the patient weighs far less than 1000 g. In such cases, the benefits in terms of neurological outcome following early treatment do not always outweigh the surgical risks, especially considering the great difference in the surgical risk before patient weight increases. To assess the efficacy and reliability of a percutaneous-tunneled, transfontanellar external ventricular drain (PTTEVD) in ELBW infants, the authors started a new protocol for the early surgical treatment of hydrocephalus. METHODS Ten cases of posthemorrhagic hydrocephalus (PHH) in ELBW infants (5 cases < 700 g, range for all cases 550-1000 g) were treated with a PTTEVD that was implanted at bedside as the first measure in a stepwise approach. RESULTS The average duration of the procedure was 7 minutes, and there was no blood loss. The drain remained in place for an average of 24 days (range 8-45 days). In all cases early control of the hydrocephalus was achieved. One patient had a single episode of CSF leakage (due to insufficient CSF removal). In another patient Enterococcus in the CSF sample was detected the day after abdominal surgery with ileostomy (infection resolved with intrathecal vancomycin). One patient died of Streptococcus sepsis, a systemic infection existing prior to drain placement that never resolved. One patient had Pseudomonas aeruginosa sepsis prior to drain insertion; a PTTEVD was implanted, the infection resolved, and the hydrocephalus was treated in the same way as with a traditional EVD, while the advantages of a quick, minimally invasive, bedside procedure were maintained. Once a patient reached 1 kg in weight, when necessary, a ventriculoperitoneal shunt was implanted and the PTTEVD was removed. CONCLUSIONS The introduction of PTTEVD placement in our standard protocol for the management of PHH has proved to be a wise option for small patients.

Infection prevention in breast implant surgery - A review of the surgical evidence, guidelines and a checklist

INTRODUCTION

As a result of increasing use of implant-based breast reconstruction, complications such as infection are being encountered more frequently. Surgical Site Infections (SSIs) cause morbidity for the patient, can lead to capsular contracture or implant loss and are costly to healthcare systems. National Guidelines suggesting methods to reduce SSI related complications have been produced, but are limited in the scope of interventions covered and underlying evidence presented.

METHODS

We performed a literature review encompassing a wide variety of possible SSI prevention strategies. We aimed to present summaries of the available evidence and give pragmatic recommendations as to their validity to use as guidelines for infection prevention strategies for implant-based breast reconstruction.

RESULTS

A lack of high quality data relating to the benefit of SSI prevention strategies in implant-based breast reconstruction exists. Many papers relate to orthopaedic implant surgery, or clean surgery in general. Following review of the evidence, sufficient data exists to support use of perioperative antibiotics at implant-based breast reconstruction, with continuation for an extended period in "high risk" patients. Alcohol containing skin preparations should be used over aqueous solutions. Laminar air flow use is suggested. Theatre traffic should be kept to a minimum, as should duration of operative procedure. The implant pocket should be washed prior to implantation. Double gloving and conductive warming are also endorsed.

CONCLUSIONS

We have produced a perioperative "Theatre Implant Checklist" for SSI prevention in implant-based breast surgery, with a set of pragmatic up to date guidelines, which allows the reader to evaluate the evidence upon which our recommendations are based.

Rapid Pore Cranial Drilling With External Ventricular Drainage for Treatment of Intraventricular Hemorrhage: A 36-Year Case Series

This study aimed to describe the technique details of rapid pore cranial drilling with external ventricular drainage and document its clinical outcomes by highlighting the advantages over the traditional and modified cranial drilling technique. Intraventricular hemorrhage is one of the most severe subtypes of hemorrhagic stroke with high mortality. The amount of blood in the ventricles is associated with severity of outcomes, and fast removal of the blood clot is the key to a good prognosis. Between 1977 and 2013, 3773 patients admitted for intraventricular hemorrhage underwent rapid pore cranial drilling drainage. The therapeutic effects and clinical outcomes were retrospectively analyzed. Of these patients, 1049 (27.8%) experienced complete remission, 1788 (47.4%) had improved condition, and 936 (24.8%) died. A total of 3229 (85.6%) patients gained immediate remission. One typical case was illustrated to demonstrate the efficacy of the rapid pore drilling technique. Rapid pore cranial drilling drainage in patients with intraventricular hemorrhage is fast, effective, and provides immediate relief in patients with severe conditions. It could be a better alternative to the conventional drilling approach for treatment of intraventricular hemorrhage. A randomized controlled trial for direct comparison between the rapid pore cranial drilling drainage and conventional drilling technique is in urgent need.