[Drainage-associated meningitis in neurocritical care patients. The results of a five-year prospective study]

Bacterial meningitis in children with an abnormal craniocerebral structure

Background

We studied the causative pathogens, clinical characteristics, and outcome of bacterial meningitis in children with an abnormal craniocerebral structure.

Methods

A retrospective single-center study was conducted on children aged in the range of 29 days to 14 years by using data obtained from the pediatric intensive care unit in Shengjing Hospital between January 2014 and August 2021. All children were diagnosed with bacterial meningitis. They were divided into complex and simple groups by taking into account the presence of an abnormal craniocerebral structure before they contracted bacterial meningitis. We collected data on demographics, clinical presentations, laboratory results, imaging studies, treatments, and outcomes.

Results

A total of 207 patients were included in the study (46 in the complex group and 161 in the simple group). Patients in the complex group had a lower mortality rate (6.5% vs. 11.2%, p < 0.05), positive blood culture (13.0% vs. 34.8%; p < 0.05), multiple organ dysfunction syndrome (0% vs. 9.3%; p < 0.05), and shock (2.2% vs. 9.3%; p = 0.11). These patients were more often detected with neurological sequelae (80.4% vs. 53.4%; p < 0.05), cerebrospinal fluid drainage (50% vs. 15.5%; p < 0.05), nosocomial infection (54.3% vs. 3.1%; p < 0.05), and multidrug-resistant bacteria (62.5% vs. 55.6%, p = 0.501). In patients in the simple group, infection was mostly confined to the nervous system.

Conclusion

Bacterial meningitis patients with an abnormal craniocerebral structure had fewer bloodstream infections, lower mortality rates, and higher incidence rates of neurological sequelae. Pathogens were more likely to be nosocomial and multidrug-resistant bacteria.

External Ventricular Drainage Complication Risks and Accuracy Analysis

OBJECTIVE

The setting of external ventricular drainage (EVD) is one of the most frequent procedures in the neurosurgical practice. However, complication risks of this procedure may grow from 5% to 39%. The number of publications concerning the advancement of ventricular drainage setting technique and complication risks identification is increasing year after year. We posed a question on the dependence of complication risks and catheter setting accuracy on the different factors of routine practice of the N. N. Burdenko National Medical Research Center for neurosurgery within the scope of this work.

METHODS

The data on patients whose EVD was set in the premotor area in 2019 were collected retrospectively. The surgeons were divided into 3 groups according to their experience valued in years.

RESULTS

The result of drainage setting was considered satisfactory if its end was in the frontal horn or body of the ipsilateral ventricle. Generally, 122 patients passed EVD placement during 2019. According to computed tomography scans of the brain, the drainage position was satisfactory in 85 patients (75.9%) and unsatisfactory in 27 patients (24.1%).

CONCLUSIONS

The procedures were performed by surgeons with <2 years of experience in 16.1% of cases, 2-5 years of experience in 25% of cases, and >5 years of experience in 58.9% of cases. The complication risk and accuracy of drainage setting do not depend on surgeon experience, type of bone access, and position in the premotor area.

External Ventricular Drainage in Patients With Acute Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping: Our 2006-2018 Experience and a Literature Review

Introduction

The placement of an external ventricular drain (EVD) is widely practiced in neurosurgery for various diseases and conditions accompanied by impaired cerebrospinal fluid (CSF) circulation, intracranial hypertension (ICHyp), intraventricular hemorrhage (IVH), and hydrocephalus. Specialists have been using this method in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) for more than 50 years. Extensive experience gained at the Burdenko Neurosurgical Center (BNC) in Moscow, the Russian Federation, in the surgical treatment of patients with acute aSAH enabled us to describe the results of using an EVD in patients after microsurgery. The objective of the research was to assess the effectiveness and safety of the EVD and clarify the indications for the microsurgical treatment of aneurysms in patients with acute SAH.

Materials and methods

From 2006 until the end of 2018, 645 patients registered in the BNC database underwent microsurgery for acute (0-21 days) aSAH. During the case study, we assessed the severity of hemorrhage according to the Fisher scale, the condition of patients on the Hunt-Hess (H-H) scale during surgery, the time of placement of EVD (before, during, and after surgery), and the duration of EVD. The number of patients with parenchymal intracranial pressure (ICP) transducers was assessed by the degree of correlation of ICP data through the EVD and parenchymal ICP transducer. One of the aims of the research was to compare the frequency of using EVD and decompressive craniectomy (DCH). The incidence of EVD-associated meningitis was analyzed. The need for a ventriculoperitoneal shunt (VPS) in patients after using EVD was also assessed. Overall outcomes were assessed using a modified Rankin scale (mRS) at the time of patient discharge. Exclusion criteria were as follows: patients aged less than 18 years and the lack of assessed data. Patients undergoing endovascular and conservative treatments also were excluded.

Results

Among the patients enrolled in the study, 22% (n=142) had EVD. Among these, 99 cases (69.7%) had EVD installed in the operating room just before the start of the surgical intervention. In some cases, ventriculostomy was performed on a delayed basis (16.3%). A satisfactory outcome (mRS scores of 1 and 2) was observed in 24.7% (n=35). Moderate and profound disability at the time of discharge was noted in 55.7% (n=79). Vegetative outcome at discharge was noted in 8.4% (n=12), and mortality occurred in 12.3% (n=15).

Conclusion

EVD ensures effective monitoring and reduction of ICP. EVD is associated with a relatively low risk of infectious, liquorodynamic, and hemorrhagic complications and does not worsen outcomes when used in patients with aSAH. We propose that all patients in the acute stage of SAH with H-H severity of III-V should receive EVD immediately before surgery.

[Risk factors of nosocomial meningitis in neurological intensive care unit. Results of a five-year prospective study]

Nosocomial meningitis (NM) is a serious complication in neurosurgery. Understanding the risk factors of nosocomial meningitis is important for their prevention.

OBJECTIVE

To determine the main risk factors of NM in neurological intensive care unit.

MATERIAL AND METHODS

A prospective study included all patients (n=2140) treated at the neurological intensive care unit for more than 48 hours between October 1, 2010 and October 31, 2015. Cases of nosocomial meningitis were registered. We analyzed risk factors in 2 groups of patients (with and without NM).

RESULTS AND DISCUSSION

The incidence of NM in neurological intensive care unit was 8.4% (95% CI 6.8-10.0) (n=180). Relative risk of NM under external ventricular drainage was 3.98 (99 cases of NM, p<0.05). Relative risk of NM in patients with CSF leakage (including nasal CSF leakage after transsphenoidal surgery) was 5.2 (49 cases of NM, p<0.05). The incidence of nosocomial meningitis was significantly higher among patients with surgery time ≥8 hours (17.68%, p<0.01). Nosocomial meningitis was also significantly more common after redo surgery (13.07%, p<0.05). Insertion of intracranial pressure sensor was not a significant risk factor of NM. The risk of meningitis was 2.67% if the above-mentioned factors were absent. Extracranial factors are not specific for NM. No significant relationship between certain neurosurgical disease and NM was found.

CONCLUSION

We found higher risk of NM in ICU patients with the following factors: external ventricular drainage, CSF leakage, redo surgery and surgery time.