Significant reduction of shunt infection rate in children below 1 year of age after implementation of a perioperative protocol

Techniques to Reduce the Rate of Infection in Surgeries for Cerebrospinal Fluid Shunting in Adults

OBJECTIVE

Cerebrospinal fluid shunt placement is associated with high rates of infection. Multiple standardized protocols, particularly in pediatric populations, have been proposed to mitigate this infection rate. We sought to determine the effectiveness of a standardized shunt infection protocol in a large adult population.

METHODS

A retrospective cohort study of adults presenting for primary cerebrospinal fluid shunt placement from 2012 to 2022. The primary outcome of interest was shunt infection. The primary exposure of interest was implementation of the shunt protocol (began October 2015). Secondary exposures of interest included use and type of perioperative antibiotics and total operating room time.

RESULTS

In total, 820 patients were included, 140 before protocol implementation and 680 after protocol implementation. The overall number of infections over the study period was 15 (1.8% infection rate), with 8 infections preprotocol (5.7%) and 7 infections during the protocol period (1.0%). The infection protocol was associated with a decreased infection rate (odds rato [OR] 0.18, 95% confidence interval [CI] 0.05-0.58, P = 0.002). Total operating room time (OR 1.38 per 30-minute increase, 95% CI 1.05-1.81, P = 0.021) was associated with increased infection rate. Patients who received antibiotics with primarily gram-positive coverage (cefazolin or equivalent) did not have significantly different odds of shunt infection as patients who received broad-spectrum coverage (OR 2.10, 95% CI 0.56-7.88, P = 0.274).

CONCLUSIONS

The implementation of an evidence-based perioperative shunt infection protocol is an effective method to decrease shunt infections. Broad-spectrum perioperative antibiotics may not have greater efficacy than gram-positive only coverage, but more research is required.

Surgical instruments and catheter damage during ventriculoperitoneal shunt assembly

OBJECTIVE

Current surgical techniques use common surgical instruments for sterile shunt assembly. This study investigated the impact of using these techniques and surgical instruments on the mechanical integrity of the ventriculoperitoneal shunt system, specifically shunt catheters.

METHODS

The authors conducted failure testing on 85 rifampin-coated catheters and 85 barium-impregnated catheters using 5 different surgical instruments and 2 different surgical techniques. In technique A, the distal end of the catheter was pushed onto the shunt valve inlet connector with the surgical instrument. In technique B, the catheter was pulled over the inlet connector. One hundred sixty catheters underwent 10-repetition-maximum testing, in which the catheter either failed before completion of 10 consecutive assembly/disassembly repetitions or the catheter completed 10 consecutive repetitions. The authors also conducted 100-repetition-maximum tests on 5 barium-impregnated and 5 rifampin-coated catheters using technique A.

RESULTS

Catheter failure rates were significantly different among the different instruments used in assembly (p ≤ 0.001). Post hoc analysis showed that using mosquito forceps with shods resulted in a significantly lower catheter failure rate than the other instruments (p < 0.0005). The catheter failure rate of technique A was significantly lower than that of technique B (5% vs 81%, p < 0.001). There was no statistical difference between the failure rates of the barium and rifampin catheters (42% vs 44%, p = 0.9), but the barium catheters outperformed the rifampin catheters in the 100-repetition-maximum trials (p = 0.02). Instrument type (p = 0.0232) and catheter type (p = 0.0096) were both significant factors in determining the number of assembly/disassembly repetitions needed to cause catheter failure. It took an average of 2.79 repetitions of assembly/disassembly to cause catheter failure. DeBakey forceps had significantly lower mean repetitions to failure (mean 1.38) than the Gerald forceps without teeth (mean 2.73, p = 0.05) and bayonet (mean 3.25, p = 0.02).

CONCLUSIONS

This study was the first of its kind to analyze how physical manipulation affects the mechanical integrity of ventriculoperitoneal shunt components. The authors demonstrated a significantly lower shunt catheter failure rate when mosquito forceps with shods and technique A were used in assembly. Moreover, the authors established that use of DeBakey forceps resulted in failure with fewer assembly/disassembly repetitions than use of the Gerald and bayonet forceps, suggesting that DeBakey forceps are the most damaging instrument.

A Proposed Protective Protocol Predicting Reduction of Shunt Infection

OBJECTIVE

To identify the best protective interventions against shunt infection and, hence, to find an appropriate protocol assumed to be associated with reduction of infection rates.

METHODS

A combined prospective-retrospective cohort study was conducted over a period of 5 years in 3 referral hospitals. Twelve interventions against infection practiced by blinded surgeons during ventriculoperitoneal shunt operations were surveyed and their association with the outcome of interest (i.e., shunt infection) was tested. Interventions proved to be associated with the outcome entered a multivariate logistic regression to identify the protective interventions.

RESULTS

Among a total of 392 cases, shunt infection was diagnosed in 11.5% with a median onset of 55 days. Patients' demographics, etiology of hydrocephalus, shunt-related factors, and type of preoperative antibiotics were not associated with shunt infection. Two-thirds of infected shunts revealed Staphylococcus species. Among the tested interventions, double-gloving and device and wound irrigation using vancomycin solution and the use of incision adhesive drapes proved to exhibit a significant protective effect against shunt infection, whereas operative time <40 minutes revealed a marginal protective benefit.

CONCLUSIONS

Shunt infection is a significant complication that occurs early during the first 2 months after surgery. According to the study findings, an appropriate protocol against shunt infection is assumed to be composed of double-gloving, device and wound irrigation using vancomycin solution, and the use of incision adhesive drapes. Reduced operative time had a beneficial effect against shunt infection, although it was of marginal significance in the current study.

Risk factors for pediatric surgical site infection following neurosurgical procedures for hydrocephalus: a retrospective single-center cohort study

Background

Infection is a major complication following cerebral spinal fluid (CSF) diversion procedures for hydrocephalus. However, pediatric risk factors for surgical site infection (SSI) are currently not well defined. Because a SSI prevention bundle is increasingly introduced, the purpose of this study was to evaluate risk factors associated with SSIs following CSF diversion surgeries following a SSI bundle at a single quaternary care pediatric hospital.

Methods

We performed a retrospective cohort study of patients undergoing CSF diversion procedures from 2017 to 2019. SSIs were identified prospectively through continuous surveillance. We performed unadjusted logistic regression analyses and univariate analyses to determine an association between SSIs and patient demographics, comorbidities and perioperative factors to identify independent risk factors for SSI.

Results

We identified a total of 558 CSF diversion procedures with an overall SSI rate of 3.4%. The SSI rates for shunt, external ventricular drain (EVD) placement, and endoscopic third ventriculostomy (ETV) were 4.3, 6.9 and 0%, respectively. Among 323 shunt operations, receipt of clindamycin as perioperative prophylaxis and presence of cardiac disease were significantly associated with SSI (O.R. 4.99, 95% C.I. 1.27–19.70, p = 0.02 for the former, and O.R. 7.19, 95% C.I. 1.35–38.35, p = 0.02 for the latter). No risk factors for SSI were identified among 72 EVD procedures.

Conclusion

We identified receipt of clindamycin as perioperative prophylaxis and the presence of cardiac disease as risk factors for SSI in shunt procedures. Cefazolin is recommended as a standard antibiotic for perioperative prophylaxis. Knowing that unsubstantiated beta-lactam allergy label is a significant medical problem, efforts should be made to clarify beta-lactam allergy status to maximize the number of patients who can receive cefazolin for prophylaxis before shunt placement. Further research is needed to elucidate the mechanism by which cardiac disease may increase SSI risk after shunt procedures.

Implementation and adherence to a speciality-specific checklist for neurosurgery and its influence on patient safety

Background and Aims

Neurosurgery involves a high level of expertise coupled with enduring and long duration of working hours. There is a paucity of published literature about the experience with a speciality-specific checklist in neurosurgery. We conducted a cross-sectional observational study to identify the adherence to various elements of the Modified World Health Organization Surgical Safety Checklist (WHO SSC) for neurosurgery by the operating room (OR) team.

Methods

We implemented an intra-operative Modified WHO SSC consisting of 40 tools for neurosurgery, in 200 consecutive elective cases. Trained anaesthesiologists assumed the role of checklist co-ordinator. The checklist divided the surgery into 5 phases, each corresponding to a specific time-period. The adherence rates to various tools were evaluated and areas where the checklist prompted a corrective measure were analysed.

Results

A total of 131 cases undergoing craniotomy and 69 cases undergoing spine surgery were studied. With the 40-point modified SSC applied in 200 cases, we analysed a total of 8000 observations. The modified checklist prompted the OR team to adhere to speciality-specific safety practices about application of compression stockings (9.5%); airway precautions in unstable cervical spine (2.5%); precautions for treatment of raised intracranial pressure (10.5%); and intraoperative neuro-monitoring (5%).

Conclusion

The implementation of Modified WHO SSC for Neurosurgery, by a designated checklist co-ordinator, can rectify anaesthetic and surgical facets promptly, without increasing the OR time. The anaesthesiologist as SSC coordinator can effectively implement an intraoperative checklist ensuring excellent participation of operating room team members.

Manual Shunt Connector Tool to Aid in No-Touch Technique

BACKGROUND

Given the morbidity and cost associated with cerebrospinal fluid shunt infections, many neurosurgical protocols implement "no-touch" technique to minimize infection. However, current surgical tools are not designed specifically for this task and surgeons often resort to using their hands to connect the shunt catheter to the valve.

OBJECTIVE

To develop an efficient and effective shunt assembly tool.

METHODS

Prototypes were designed using computer assisted software and machined in stainless steel. The amount of time and number of attempts it took volunteers to connect a Bacticel shunt catheter to a Delta valve were recorded using the new tool and standard shodded mosquitos. Scanning electron microscopy (SEM) was done on manipulated catheters to assess potential damage. Practicing neurosurgeons provided feedback.

RESULTS

Nonsurgeon (n = 13) volunteers and neurosurgeons (n = 6) both completed the task faster and with fewer attempts with the new tool (mean 7.18 vs 15.72 s and 2.00 vs 6.36 attempts, P < .0001; mean 2.93 vs 5.96 s and 1.06 vs 2.94 attempts, P < .001, respectively). SEM of 24 manipulated catheters showed no microscopic damage. 100% of neurosurgeons surveyed (n = 10) would adapt the tool in their practice, 90% preferred use of the new tool compared to their existing method, and 100% rated it easier to use compared to existing instruments.

CONCLUSION

The new tool shortened the time and number of attempts to connect a shunt catheter to a valve. Neurosurgeons preferred the new tool to existing instruments. There was no evidence of catheter damage with the use of this tool.

The Need for Surgical Safety Checklists in Neurosurgery Now and in the Future-A Systematic Review

Safety checklists have been studied among various surgical patient groups, but evidence of their benefits in neurosurgery remains sparse. Since the implementation of the World Health Organization's Surgical Safety Checklist, their use has become widespread. The aim of this review was to systematically review the state of the literature on surgical safety checklists in neurosurgery. Also, in the new era of robotics and artificial intelligence, there is a need to re-evaluate patient safety procedures in neurosurgery. A systematic review was conducted on PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials, Embase, and MEDLINE for articles published between 2008 and 2016 using MeSH (medical subject heading) terms and keywords describing postoperative complications and surgical adverse events, and some additional searches were carried out until January 2019. Twenty-six original studies or reviews were eligible for this review. They were categorized into studies with patient-related outcomes, personnel-related outcomes, or previous reviews. Checklist use in neurosurgery was found to reduce hospital-acquired infectious complications and to enhance operating room safety culture. Checklists seem to improve patient safety in neurosurgery, although the amount of evidence is still limited. Despite their shortcomings, checklists are here to stay, and new research is required to update checklists to meet the requirements of the transforming working environment of the neurosurgery operating room.

Detailed standardized protocol to prevent cerebrospinal fluid shunt infection

OBJECTIVE

While cerebrospinal fluid (CSF) shunt surgery plays an essential role in the treatment of hydrocephalus, postoperative infection due to the implantation of foreign materials is still one of the most common and potentially serious complications of this procedure. Because no previously reported protocol has been proven to prevent postoperative infection after CSF shunt surgeries in adults, the authors investigated the effectiveness of a protocol introduced in their institution.

METHODS

A detailed standardized surgical protocol to prevent infection in patients undergoing CSF shunt surgeries was introduced in the authors' institution in December 2011. The protocol included a series of detailed rules regarding the surgical procedure, the surgical environment to minimize contamination from air, double gloving, local injection of antibiotics, and postoperative management. The rate of CSF shunt infection during the 3 years after surgery before and after implementation of the protocol was compared in patients undergoing their first CSF shunt surgeries. The inclusion periods were from January 2006 to November 2011 for the preprotocol group and from December 2011 to December 2014 for the postprotocol group.

RESULTS

The study included 124 preprotocol patients and 52 postprotocol patients. The mean patient age was 59 years in both groups, ranging from 40 days to 88 years. Comparison of patient background factors, including known risk factors for surgical site infections, showed no significant difference between the patient groups before and after implementation of the protocol. While 9 patients (7.3%) developed shunt infections before protocol implementation, no shunt infections (0%) were observed in patients who underwent surgery after protocol implementation. The difference was statistically significant (p = 0.047).

CONCLUSIONS

The authors' detailed protocol for CSF shunt surgeries was effective in preventing postoperative infection regardless of patient age.

Nursing Care of Infants With a Ventriculoperitoneal Shunt

BACKGROUND

Infants with congenital or posthemorrhagic hydrocephalus may require a ventriculoperitoneal (VP) shunt to divert the flow of cerebrospinal fluid, thus preventing increase in intracranial pressure. Knowledge on various aspects of caring for a child with a VP shunt will enable new and experienced nurses to better care for these infants and equip parents for ongoing care at home.

PURPOSE

To review the nurses' role in care of infants with hydrocephalus, care after VP shunt placement, prevention of complications, and parental preparation for home care.

METHODS/SEARCH STRATEGY

A literature review involving electronic databases, such as CINAHL and MEDLINE, Cochrane Database Systematic Reviews, and resources from the Web sites of the National Hydrocephalus Foundation and Hydrocephalus Association, was performed to gather evidence for current practice information.

FINDINGS AND IMPLICATIONS FOR PRACTICE AND RESEARCH

Vigilant care can help with early identification of potential complications. The younger the infant at VP shunt placement, the higher the occurrence of complications. All neonatal intensive care unit nurses must be equipped with knowledge and skills to care for infants with hydrocephalus and those who undergo VP shunt placement. Monitoring for early signs of increased intracranial pressure can facilitate timely diagnosis and prompt surgical intervention. Equipping families will be helpful in early identification and timely management of shunt failure. Research on infants with VP shunt placement is essential to develop appropriate guidelines and explore experiences of families to identify caregiver burden and improve parental preparation.

The Impact of a Pediatric Shunt Surgery Checklist on Infection Rate at a Single Institution

BACKGROUND

Shunt infections remain a significant challenge in pediatric neurosurgery. Numerous surgical checklists have been introduced to reduce infection rates.

OBJECTIVE

To introduce an evidence-based shunt surgery checklist and its impact on our shunt infection rate.

METHODS

Between January 1, 2008 and December 31, 2015, pediatric patients who underwent shunt surgery at our institution were indexed in a prospectively maintained database. All definitive shunt procedures were included. Shunt infection was defined according to the Center for Disease Control and Prevention's National Hospital Safety Network surveillance definition for surgical site infection. Clinical and procedural variables were abstracted per procedure. Infection data were compared for the 4 year before and 4 year after protocol implementation. Compliance was calculated from retrospective review of our checklists.

RESULTS

Over the 8-year study period, 1813 procedures met inclusion criteria with a total of 37 shunt infections (2%). Prechecklist (2008-2011) infection rate was 3.03% (28/924) and decreased to 1.01% (9/889; P = .003) postchecklist (2012-2015), representing an absolute risk reduction of 2.02% and relative risk reduction of 66.6%. One shunt infection was prevented for every 50 times the checklist was used. Those patients who developed an infection after protocol implementation were younger (0.95 years vs 3.40 years (P = .027)), but there were no other clinical or procedural variables, including time to infection, that were significantly different between the cohorts. Average compliance rate among required checklist components was 97% (range 85%-100%).

CONCLUSION

Shunt surgery checklist implementation correlated with lower infection rates that persisted in the 4 years after implementation.

Central Nervous System Device Infections

Nosocomial meningitis can occur in association with central nervous system (CNS) devices such as cerebrospinal shunts or drains, intrathecal pumps, and deep brain stimulators and carry substantial morbidity and mortality. Diagnosing and treating these infections may be challenging to physicians as cerebrospinal fluid cultures may be negative due to previous antibiotic therapy and cerebrospinal abnormalities may be secondary to the primary neurosurgical issue that prompted the placement of the CNS device (e.g., "chemical meningitis" due to intracranial hemorrhage). Besides antibiotic therapy given intravenously and sometimes intrathecally, removal of the device with repeat cultures prior to re-implantation is key in achieving successful outcomes.

Evaluation of intraoperative glove change in prevention of postoperative cerebrospinal fluid shunt infections, and the predictors of shunt infection

BACKGROUND

We have previously suggested that surgical gloves could be a possible means for transferring microorganisms from skin flora to shunt material during surgery. The objectives of this study were to examine (1) whether the rate of shunt infections was reduced after introducing intraoperative glove change before handling the shunt material; (2) clinical presentation of shunt infections, microbiological data, and treatment management; and (3) predictors of shunt infections.

METHODS

A retrospective study of 432 shunt operations in 295 adults was undertaken over a 7-year period. Study population consisted of two groups: Group A without intraoperative glove change (2003-2006), and Group B with change of the outer pair of the initial double gloves before handling the shunt material (2006-2009). The results were compared at 6- and 12-month postoperatively. A binary logistic regression was performed to determine predictors of shunt infections.

RESULTS

Overall, 46 (10.6%) infection episodes occurred in 40 (13.6%) patients. Main symptoms were fever, abdominal pain and altered mental status. Propionibacterium acnes was the frequently isolated microorganism, followed by Staphylococcus species. The infection rate was reduced only moderately from 11.8% in Group A to 9.8% in Group B (p = .472). Patients with subarachnoid haemorrhage were more likely to experience shunt infections (17.9%), compared to patients with normal pressure hydrocephalus (5.9%). An increased likelihood of shunt infections for the increased number of subsequent shunt revisions (p = .030) and a trend towards prior history of shunt infections (p = .118) was seen. After adjusting for various covariates, a decreased likelihood of shunt infections for intraoperative glove change was seen at 6-month follow-up for first-time shunt insertion (p = .050).

CONCLUSION

Intraoperative glove change does not significantly reduce the risk of shunt infection. However, it seems to reduce the infection rate within 6 months in patients undergoing first-time shunt insertion only.

Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study

OBJECT The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus management, the aim of which was to isolate specific risk factors for shunt failure. METHODS The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori-defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling. RESULTS A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 [95% CI 1.1-2.1]), a cardiac comorbidity (HR 1.4 [95% CI 1.0-2.1]), and endoscopic placement (HR 1.9 [95% CI 1.2-2.9]) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume. CONCLUSIONS This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor-an existing cardiac comorbidity-was also associated with shunt failure.

A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection

OBJECT In a previous report by the same research group (Kestle et al., 2011), compliance with an 11-step protocol was shown to reduce CSF shunt infection at Hydrocephalus Clinical Research Network (HCRN) centers (from 8.7% to 5.7%). Antibiotic-impregnated catheters (AICs) were not part of the protocol but were used off protocol by some surgeons. The authors therefore began using a new protocol that included AICs in an effort to reduce the infection rate further. METHODS The new protocol was implemented at HCRN centers on January 1, 2012, for all shunt procedures (excluding external ventricular drains [EVDs], ventricular reservoirs, and subgaleal shunts). Procedures performed up to September 30, 2013, were included (21 months). Compliance with the protocol and outcome events up to March 30, 2014, were recorded. The definition of infection was unchanged from the authors' previous report. RESULTS A total of 1935 procedures were performed on 1670 patients at 8 HCRN centers. The overall infection rate was 6.0% (95% CI 5.1%-7.2%). Procedure-specific infection rates varied (insertion 5.0%, revision 5.4%, insertion after EVD 8.3%, and insertion after treatment of infection 12.6%). Full compliance with the protocol occurred in 77% of procedures. The infection rate was 5.0% after compliant procedures and 8.7% after noncompliant procedures (p = 0.005). The infection rate when using this new protocol (6.0%, 95% CI 5.1%-7.2%) was similar to the infection rate observed using the authors' old protocol (5.7%, 95% CI 4.6%-7.0%). CONCLUSIONS CSF shunt procedures performed in compliance with a new infection prevention protocol at HCRN centers had a lower infection rate than noncompliant procedures. Implementation of the new protocol (including AICs) was associated with a 6.0% infection rate, similar to the infection rate of 5.7% from the authors' previously reported protocol. Based on the current data, the role of AICs compared with other infection prevention measures is unclear.

Prevention and management of internal cerebrospinal fluid shunt infections

Cerebrospinal fluid (CSF) shunt infection is a serious and potentially devastating complication of CSF shunt placement. Younger age, previous CSF shunt infection or revision, and the type of the shunt are important risk factors for shunt infection. More than half of the cases are caused by Staphylococcus aureus and coagulase-negative staphylococci. The biofilm plays a central role in its pathogenesis. CSF cultures remain the gold standard for diagnosis of CSF shunt infection. The most effective way to prevent CSF shunt infection is optimization of sterile protocols and use of proper and timely antibiotic prophylaxis. Management of CSF shunt infection frequently requires removal of all shunt components, placement of a temporary external device, and administration of intravenous antibiotics, followed by reshunting at a later time. This review summarizes and analyses the results of previous reports of CSF shunt infection and assesses the prevention and management of this important entity.

Autologous Skull Bone Flap Sterilization After Decompressive Craniectomy: An Update

OBJECTIVE

To report new results with ethylene oxide sterilization and new experiences with autogenous bone flaps autoclaved at a high or low temperature for preservation of a bone flap after decompressive craniectomy.

METHODS

In 45 patients who underwent a decompressive craniectomy, we determined bone flap preservation with ethylene oxide and with high- or low-temperature autoclave sterilization.

RESULTS

The bone flap was repositioned after a mean of 10 weeks in the ethylene oxide group and after 6 weeks in the other sterilization groups. A bone flap infection developed in 1 patient (2%), which required removal and subsequent methyl methacrylate cranioplasty. In 1 child, the bone flap had partially reabsorbed after 12 months. In all other patients, esthetic results were good after an average follow-up of 42 months. At follow-up, computed tomography or magnetic resonance imaging of the bone flap showed preservation of structural features with apparent fusion and revitalization at the bone flap margins.

CONCLUSIONS

Ethylene oxide and high- or low-temperature autoclave bone sterilization techniques for the preservation of autologous bone flaps after decompressive craniectomy were safe, rapid, and inexpensive.

Outcome of Surgery for Idiopathic Normal Pressure Hydrocephalus: Role of Preoperative Static and Pulsatile Intracranial Pressure

OBJECTIVES

To examine the outcome of surgery for idiopathic normal-pressure hydrocephalus (iNPH) and how outcome relates to the preoperative static and pulsatile intracranial pressure (ICP).

METHODS

An observational cohort study included all patients with iNPH managed at our department during the years 2002-2012 in whom overnight ICP monitoring was part of the preoperative work-up. Clinical data were retrieved from a quality registry and ICP scores from a pressure database.

RESULTS

The study included 472 patients, 316 in the surgery group and 156 in the nonsurgery group. Among those treated surgically, 278 (90%) showed clinical improvement (Responders) whereas 32 (10%) had no improvement (Nonresponders). Among Responders, only about one third reached the best clinical scores; moreover, the difference in clinical score between Responders and Nonresponders declined with time after surgery, particularly after 3-4 years. The surgery was accompanied by acute intracranial hematomas in 11 patients (3.5%), of whom 4 (1.3%) died. Survival (age at death) was significantly greater among the Responders than in Nonresponders. Although the static ICP was normal in all patients, the pulsatile ICP was significantly greater in Responders than in Non-responders.

CONCLUSIONS

The pulsatile ICP was greater in shunt Responders than Nonresponders. Although the clinical improvement declined over time and the majority did not experience complete relief of symptoms, shunt Responders lived significantly longer than Nonresponders. The present observations suggest that the current surgical treatment regimens for iNPH (primarily shunt surgery) address only some aspects of the disease process, in particular the aspect of brain water disturbance.

Characteristics of intracranial pressure (ICP) waves and ICP in children with treatment-responsive hydrocephalus

BACKGROUND

One important goal of modern treatment of pediatric hydrocephalus is to normalize the intracranial pressure (ICP) and ICP volume reserve capacity to optimize normal brain development. Better knowledge of the characteristics of ICP waves/ICP in pediatric hydrocephalus may provide new insight into the mechanisms behind modern hydrocephalus treatment. The aim of the present work was to characterize the ICP waves/ICP in children with either communicating or non-communicating hydrocephalus who improved clinically after surgery. The hydrocephalic children not treated surgically following ICP monitoring served as reference patients.

METHODS

The patient material includes all children with hydrocephalus and no previous surgical treatment who underwent diagnostic ICP wave/ICP monitoring during the period 2002-2011. We retrieved the information about the patients from the patient records and the digitally stored ICP waveforms. The ICP wave characteristics amplitude, rise time and rise time coefficient and the mean ICP were determined in the patients treated surgically for their hydrocephalus. The findings were compared with findings in children not treated surgically after ICP monitoring who served as reference patients.

RESULTS

The patient material includes 58 patients. Thirty-one (53%) were treated surgically after ICP monitoring, of whom all improved clinically. As compared to the reference patients, patients treated surgically presented with increased ICP wave amplitudes (MWA) and mean ICP. Alterations were comparable in communicating and non-communicating hydrocephalus. We found no apparent association between the ICP wave/ICP scores and presence of symptoms, indices of ventricular size or age.

CONCLUSIONS

Children with either communicating or non-communicating hydrocephalus improving clinically after surgery presented with elevated MWA and mean ICP. In particular, the levels of MWA were raised to a magnitude seen when intracranial compliance is impaired. Hence, the present observations may support the idea that improvement of intracranial compliance can be an important mechanism by which shunts work in pediatric hydrocephalus.

Evidence-based interventions to reduce shunt infections: a systematic review

PURPOSE

Cerebrospinal fluid shunt infection is associated with patient morbidity and high cost. We conducted a systematic review of the current evidence of comprehensive surgical protocols or individual interventions designed to reduce shunt infection incidence.

METHODS

A systematic review using PubMed and SCOPUS identified studies evaluating the effect of a particular intervention on shunt infection risk. Systemic prophylactic antibiotic or antibiotic-impregnated shunt efficacy studies were excluded. A total of 7429 articles were screened and 23 articles were included.

RESULTS

Eight studies evaluated the effect of comprehensive surgical protocols. Shunt infection was reduced in all studies (absolute risk reduction 2.2-12.3 %). Level of evidence was low (level 4 in seven studies) due to the use of historical controls. Compliance ranged from 24.6 to 74.5 %. Surgical scrub with antiseptic foam and omission of a 5 % chlorhexidine gluconate preoperative hair wash were both associated with increased shunt infection. Twelve studies evaluated the effect of a single intervention. Only antibiotic-impregnated suture, a no-shave policy, and double gloving with glove change prior to shunt handling, were associated with a significant reduction in shunt infection. In a hospital with high methicillin-resistant staphylococcus aureus (MRSA) prevalence, a randomized controlled trial found that perioperative vancomycin rather than cefazolin significantly reduced shunt infection rates.

CONCLUSION

Despite wide variation in compliance rates, the implementation of comprehensive surgical protocols reduced shunt infection in all published studies. Antibiotic-impregnated suture, a no-shave policy, double gloving with glove change prior to device manipulation, and 5 % chlorhexidine hair wash were associated with significant reductions in shunt infection.

Intracranial pressure monitoring in pediatric and adult patients with hydrocephalus and tentative shunt failure: a single-center experience over 10 years in 146 patients

OBJECT In patients with hydrocephalus and shunts, lasting symptoms such as headache and dizziness may be indicative of shunt failure, which may necessitate shunt revision. In cases of doubt, the authors monitor intracranial pressure (ICP) to determine the presence of over- or underdrainage of CSF to tailor management. In this study, the authors reviewed their experience of ICP monitoring in shunt failure. The aims of the study were to identify the complications and impact of ICP monitoring, as well as to determine the mean ICP and characteristics of the cardiac-induced ICP waves in pediatric versus adult over- and underdrainage. METHODS The study population included all pediatric and adult patients with hydrocephalus and shunts undergoing diagnostic ICP monitoring for tentative shunt failure during the 10-year period from 2002 to 2011. The patients were allocated into 3 groups depending on how they were managed following ICP monitoring: no drainage failure, overdrainage, or underdrainage. While patients with no drainage failure were managed conservatively without further actions, over- or underdrainage cases were managed with shunt revision or shunt valve adjustment. The ICP and ICP wave scores were determined from the continuous ICP waveforms. RESULTS The study population included 71 pediatric and 75 adult patients. There were no major complications related to ICP monitoring, but 1 patient was treated for a postoperative superficial wound infection and another experienced a minor bleed at the tip of the ICP sensor. Following ICP monitoring, shunt revision was performed in 74 (51%) of 146 patients, while valve adjustment was conducted in 17 (12%) and conservative measures without any actions in 55 (38%). Overdrainage was characterized by a higher percentage of episodes with negative mean ICP less than -5 to -10 mm Hg. The ICP wave scores, in particular the mean ICP wave amplitude (MWA), best differentiated underdrainage. Neither mean ICP nor MWA levels showed any significant association with age. CONCLUSIONS In this cohort of pediatric and adult patients with hydrocephalus and tentative shunt failure, the risk of ICP monitoring was very low, and helped the authors avoid shunt revision in 49% of the patients. Mean ICP best differentiated overdrainage, which was characterized by a higher percentage of episodes with negative mean ICP less than -5 to -10 mm Hg. Underdrainage was best characterized by elevated MWA values, indicative of impaired intracranial compliance.

Congenital hydrocephalus in the northeast of Brazil: epidemiological aspects, prenatal diagnosis, and treatment

PURPOSE

Congenital hydrocephalus (CH) has higher proportions in developing countries such as Brazil, reaching rates of 3.16:1,000 newborns. Early diagnosis is essential and can be done during the second trimester of pregnancy, highlighting the importance of regular prenatal care. Our objective is to describe the epidemiological profile of children with CH in the state of Bahia.

METHODS

Consecutive medical records of patients with CH, aged less than 2 years and operated at a pediatric reference hospital between September 2009 and September 2012, were reviewed.

RESULTS

One hundred twenty-one children underwent ventricular peritoneal shunt (VP shunt) due to CH. As for prenatal care, 38% of pregnant women did it regularly. Males predominated with 56% of cases with a median age of 3 months, and 68% were from the countryside area. The most frequent clinical manifestations were bulging fontanelle (37%) and increased head circumference (30%). There were 13 (11%) reports of complications associated with VP shunts. There were nine deaths (7%), and respiratory complications were the main cause.

CONCLUSIONS

Public health measures are the key to increase mothers' knowledge about the importance of regular prenatal monitoring. There was a predominance of male children, with a median age of 3 months, with the majority coming from the countryside.