Severe Dehydration and Acute Renal Failure Associated with External Ventricular Drainage of Cerebrospinal Fluid in Children

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.

Predictors of catheter-associated meningitis in pediatric patients after brain tumor surgery: A 10-year single center experience

OBJECTIVE

To evaluate the incidence of catheter-associated meningitis (CAM) in a pediatric population receiving brain tumor surgery, and to identify the major risk factors involved.

METHODS

We retrospectively analyzed the medical and radiological records of 205 pediatric patients who received 251 external ventricular drains (EVDs) between January 2008 and December 2017. All patients less than 18 years old who underwent cerebrospinal fluid (CSF) diversion in the course of brain tumor surgery were included. Patients with central nervous system infection (CNS) at the time of EVD insertion were excluded.

RESULTS

A total of 99 patients receiving 107 EVDs met the study selection criteria. Among this population, the incidence of CAM was 19.2%. Median time-to-infection was 5 days. CAM prolonged the period of drainage in 57.9% of the cases. An extended ICU stay (>3 days) was statistically significantly associated with the occurrence of CAM. In the multivariate analysis, the presence of a high-grade CNS tumor was a predictor of an extended intensive care unit (ICU) stay. Furthermore, CSF leakage along the catheter tunnel was an independent predictor of CAM.

CONCLUSION

Our data confirms CAM as a significant complication in the acute treatment of hydrocephalus associated with pediatric brain tumors. To limit the incidence of CAM, measures must be taken to prevent CSF leakage, particularly among patients with high-grade CNS tumors that are likely to stay longer in the ICU and need prompt postoperative radiotherapy and oncological treatment.

Collection and Analyses of Cerebrospinal Fluid for Pediatric Translational Research

Cerebrospinal fluid sample collection and analysis is imperative to better elucidate central nervous system injury and disease in children. Sample collection methods are varied and carry with them certain ethical and biologic considerations, complications, and contraindications. Establishing best practices for sample collection, processing, storage, and transport will ensure optimal sample quality. Cerebrospinal fluid samples can be affected by a number of factors including subject age, sampling method, sampling location, volume extracted, fraction, blood contamination, storage methods, and freeze-thaw cycles. Indicators of sample quality can be assessed by matrix-associated laser desorption/ionization time-of-flight mass spectrometry and include cystatin C fragments, oxidized proteins, prostaglandin D synthase, and evidence of blood contamination. Precise documentation of sample collection processes and the establishment of meticulous handling procedures are essential for the creation of clinically relevant biospecimen repositories. In this review we discuss the ethical considerations and best practices for cerebrospinal fluid collection, as well as the influence of preanalytical factors on cerebrospinal fluid analyses. Cerebrospinal fluid biomarkers in highly researched pediatric diseases or disorders are discussed.

Development of severe hyponatremia due to cerebrospinal fluid leakage following meningomyelocele surgery in a newborn

Cerebrospinal fluid leakage following meningomyelocele surgery is a frequent complication in the wound-healing period and is associated with wound dehiscence. CSF loss can cause severe hyponatremia, especially in the newborn and early infancy periods when dietary sodium content is relatively low. Hyponatremia in the newborn period can result in adverse neurodevelopmental outcomes. In addition, hyponatremia's cerebral effects can increase complications in neurosurgery patients. The authors present the case of a newborn in whom CSF leakage from the operative site and severe hyponatremia developed following meningomyelocele surgery. To the best of their knowledge, severe hyponatremia caused by CSF leakage after meningomyelocele surgery has not been previously reported in the literature.

Incidence of hemorrhage in the pediatric population with placement and removal of external ventricular drains

OBJECT

External ventricular drains (EVDs) are regularly used in pediatric neurosurgery for diagnostic and therapeutic purposes. Hemorrhage caused by placing an EVD is a common complication noted in the adult literature. In the pediatric literature, on the other hand, only a few articles have assessed the risk of hemorrhage with placement, and none have reported the occurrence of hemorrhage with removal of an EVD. The authors investigated the incidence of hemorrhage with both placement and removal of the EVD in a pediatric population.

METHODS

After obtaining institutional review board approval, a comprehensive database was created to include all pediatric patients who required EVD placement between March 2008 and June 2014 at the authors' institution. A retrospective chart review was completed, and all imaging was reviewed for evidence of hemorrhage with placement and removal of the EVD.

RESULTS

During the designated time period, 73 EVDs were placed in 63 patients (ages 2 weeks-17 years). Indications for EVD placement were as follows: shunt infection/malfunction (21), tumor (12), hydrocephalus (18), hemorrhage (12), edema (4), trauma (1), and other (5). Hemorrhage with placement was noted in 5 of the 50 patients who underwent imaging, with a volume ranging from 0.48 cm3 to 7.7 cm3. Thirty-two patients had imaging after EVD removal, and 7 of these patients were noted to have hemorrhage (volume range 0.012 cm3 to 81.5 cm3).

CONCLUSIONS

The authors found the incidence of hemorrhage at EVD placement to be 10%, and the incidence of hemorrhage on EVD removal to be 21.9% in those patients who underwent imaging after each event. Although none of the hemorrhages were of obvious clinical significance, these data can be useful in decision making, and in discussing the risks of EVDs with the patient's family.

Greater fluctuations in serum sodium levels are associated with increased mortality in children with externalized ventriculostomy drains in a PICU

OBJECTIVES

Dysnatremia is common in critically ill children due to disruption of hormonal homeostasis. Children with brain injury are at risk for syndrome of inappropriate antidiuretic hormone, cerebral salt wasting, and sodium losses due to externalized ventricular drain placement. We hypothesized that among PICU patients managed with an externalized ventricular drain, hyponatremia is common, hyponatremia is associated with seizures and in-hospital mortality, and greater sodium fluctuations are associated with in-hospital mortality.

DESIGN

Retrospective observational study.

SETTING

Tertiary care PICU.

PATIENTS

All pediatric patients treated in the PICU with an externalized ventricular drain from January 2005 to December 2009. Patients were identified by searching the physician order entry database for externalized ventricular drain orders. Hyponatremia was defined as the minimum sodium during patients' externalized ventricular drain time and was categorized as mild (131-134 mEq/L) or moderate to severe (≤ 130 mEq/L). Magnitude of sodium fluctuation was defined as the difference between a patient's highest and lowest sodium during the time in which an externalized ventricular drain was in use (up to 14 d). Seizure was defined as a clinically evident convulsion during externalized ventricular drain presence. A priori confounders were age, history of epilepsy, and externalized ventricular drain indication. Multivariable regression was performed to test the association between sodium derangements and outcomes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Three hundred eighty patients were eligible. One hundred nine (29%) had mild hyponatremia, and 30 (8%) had moderate to severe hyponatremia. Twenty-eight patients (7%) had a seizure while hospitalized. Eighteen patients died (5%) prior to discharge. Survivors had a median daily sodium fluctuation of 1 mEq/L [0-5] vs non-survivors 9 mEq/L [6-11] (p < 0.001) and a median sodium fluctuation of 5 mEq/L [2-8] vs non-survivors 15 mEq/L [9-24] (p < 0.001) during externalized ventricular drain management. After controlling for a priori covariates and potential confounders, hyponatremia was not associated with an increased odds of seizures or in-hospital mortality. However, greater fluctuations in daily sodium (odds ratio, 1.38; 95% CI, 1.06-1.8) and greater fluctuations in sodium during externalized ventricular drain management were associated with increased odds of in-hospital mortality (odds ratio, 1.59; 95% CI, 1.2-2.11).

CONCLUSIONS

Hyponatremia was common in PICU patients treated with externalized ventricular drains but not associated with seizures or in-hospital mortality. Greater sodium fluctuations during externalized ventricular drain management were independently associated with increased odds of in-hospital mortality.

External ventricular drains in pediatric patients

OBJECTIVE

To determine the indications and complications of external ventricular drain (EVD) placement in pediatric patients.

DESIGN

Retrospective chart review.

SETTING

University associated, tertiary-level Children's Hospital.

PATIENTS

Sixty-six [median age, 10.1 years (interquartile range, 5.9)] patients between 1994 and 2006 with 96 EVDs.

MEASUREMENTS AND RESULTS

Clinical indications for EVD insertion include traumatic brain injury (TBI; 36%), acute hydrocephalus (35%), and ventriculoperitoneal shunt failure (29%). Of the 96 EVDs, 65% were inserted at the bedside in the pediatric critical care unit (PCCU) and 33% in the operating room (OR). Median duration of EVD insertion was 7.0 days (interquartile range, 8.8). Complications occurred with 26% of EVD insertions and included infection (9.4%), misplacement (6.3%), hemorrhage (4.2%), obstruction (3.1%), and malfunction (3.1%). The primary infectious etiology was coagulase-negative Staphylococcus (67% of infections). Despite patients with TBI having significantly smaller lateral ventricles than hydrocephalus patients (p < 0.05), EVD complications were similar (risk ratios 1.41; 95% confidence interval 0.68-2.72). Furthermore, the complication rate was the same for EVDs inserted in either the PCCU or OR (risk ratios 1.10; 95% confidence interval 0.55-2.29).

CONCLUSION

EVDs were placed for TBI, ventriculoperitoneal shunt failure and new-onset hydrocephalus. The overall complication rate was 26%. Complication rates were similar in TBI and hydrocephalus patients, and with EVDs inserted in either the PCCU or OR. Prophylactic antibiotics or antimicrobial-impregnated catheters directed against coagulase-negative Staphylococcus may reduce EVD infections.