Postoperative cerebrospinal fluid wound leakage as a predictor of shunt infection: a prospective analysis of 205 cases. Clinical article

The collagen matrix dural substitute graft prevents postoperative cerebrospinal fluid leakage after ventriculoperitoneal shunt surgery in patients aged <1 year

Background:

Cerebrospinal fluid (CSF) leakage is a common complication of ventriculoperitoneal shunt (VPS) and has the potential to induce shunt infection. Especially in infants and children, these are serious complications. DuraGen is a collagen matrix dural substitute used to reduce the risk of CSF leakage in various neurosurgeries. We report our VPS procedure with DuraGen for preventing postoperative CSF leakage in patients aged <1 year.

Methods:

We used DuraGen to prevent postoperative CSF leakage in six VPS surgeries. Antibiotic-impregnated shunt catheters and programmable valves with anti-siphon devices were also used in all cases. DuraGen was placed inside and atop the burr hole. All cases had an initial shunt pressure of 5 cmH2O. Fibrin glue was not used.

Results:

The patients underwent follow-up for a year after VPS surgery. There was no postoperative subcutaneous CSF collection or leakage after all six VPS surgeries. Furthermore, no postoperative shunt infections or DuraGen-induced adverse events were noted.

Conclusion:

We speculate that DuraGen has a preventive effect on postoperative CSF leakage in VPS cases aged <1 year.

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.

Opening and closure of intraventricular neuroendoscopic procedures in infants under 1 year of age: institutional technique, case series and review of the literature

PURPOSE

Intraventricular neuroendoscopic techniques, particularly third ventriculostomy, are employed increasingly in the management of infantile hydrocephalus. However, surgical access to the ventricular cavities is associated with a risk of post-operative cerebrospinal fluid (CSF) leak. Here, we describe a structured, multi-layered approach to wound opening and closure which aims to maximise the natural tissue barriers against CSF leakage. We present a series of patients undergoing this technique and subsequently review the literature regarding opening and closure techniques in paediatric intraventricular neuroendoscopic procedures.

METHODS

We performed a retrospective case series analysis of patients under 1 year of age who underwent intraventricular neuroendoscopic procedures in a single institution over a 5-year period. Patients were identified from an institutional operative database, and operation notes and clinical records were subsequently reviewed.

RESULTS

28 patients fulfilled the inclusion criteria for this study. The mean age at operation was 9 weeks. 27 patients underwent endoscopic third ventriculostomy whilst 1 underwent endoscopic septostomy, and all patients underwent our structured, multi-layered opening and closure technique. Follow-up ranged from 4 months to 5 years. There were no cases of post-operative CSF leak, infection or wound breakdown. 12 patients remained shunt-free at the last follow-up, with the remaining 16 requiring shunt insertion for progressive hydrocephalus at a mean of 24 days post-operatively.

CONCLUSION

Various methods aiming to prevent post-operative CSF leak have been reported in the literature. We propose that our institutional technique may be of benefit in minimising this risk in infants undergoing endoscopic third ventriculostomy and similar intraventricular neuroendoscopic procedures.

Stopping CSF leaks at external ventricular drain exit sites: a technical note

PURPOSE

Cerebrospinal fluid (CSF) leak is a major risk factor for external ventricular drain infection. Here, we present a surgical technique to reduce the possibility of CSF leak at the external ventricular drain (EVD) exit site in high-risk patients.

METHODS

Vertical mattress sutures are placed circumferentially around the EVD catheter tract as it passes under the skin, so to close off the tract along which CSF may travel toward the exit site.

RESULTS

Specific case examples are discussed where the introduction of this technique was found to be helpful in stopping exit-site CSF leak.

CONCLUSION

In our experience, these surgical steps are useful adjuncts that should be considered in all high-risk patients undergoing EVD placement.

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.

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.

Recurrent cerebrospinal fluid shunt infection and the efficacy of reusing infected ventricular entry sites

OBJECT

The objective of this investigation was to review the clinical characteristics of recurrent CSF shunt infections in a large pediatric neurosurgical practice and to assess the safety and efficacy of reusing original ventricular entry sites for external ventricular drainage during treatment of infections and for subsequent reinsertion of shunts.

METHODS

Prospectively accrued clinical data on all patients treated at Children's Hospital Colorado for CSF shunt infections within a 10.5-year span were retrospectively investigated.

RESULTS

One hundred twenty-one consecutive cases of CSF shunt infection met inclusion criteria. Recurrent shunt infection attributable to the management of these infections occurred in 14 cases (11.6%). Three recurrent infections were with their original organisms, 7 were organisms different from the original organisms, and 4 were indeterminate.

CONCLUSIONS

Half or more of recurrent shunt infections were with organisms different from the original organism, and hence were new-type infections introduced during the management of the original infections. Incomplete eradication of original pathogens accounted for 3 (21.4%) of the 14 recurrent infections. Reusing recently infected or contaminated ventricular entry sites, both for CSF drainage during treatment and for implantation of new shunts, was as safe, with regard to risk of recurrent infection, as switching to new entry sites. Prior evidence of shunt infection is not, alone, a sufficient reason to change to a previously well-functioning site, and reuse of contaminated ventricular entry sites avoids all risks associated with making new ventricular entries.

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

BACKGROUND

Shunt infection markedly impairs the clinical result of shunt surgery. The infection rate can be reduced by dedicated protocols. This study was undertaken to determine the efficacy of introducing a perioperative protocol for control of shunt infections.

METHOD

The shunt infection rate and risk factors for shunt infection were determined for two periods, namely the period 2001-2002 (Patient Material A), and the period 2005-2008 (Patient Material B). The perioperative protocol was introduced in 2005 before the second period.

RESULTS

The total patient material includes 901 patients, in whom 1,404 shunt procedures were performed during the study periods. While the overall infection rate dropped nonsignificantly from 6.5 % to 4.3 %, infection rate dropped markedly and significantly from 18.4 % to 5.7 % among the children younger than 1 year (p = 0.016). The significant risk factors for shunt infection were in Patient Material A age below 1 year (p < .001), and in Patient Material B premature birth (p = 0.045), postoperative cerebrospinal fluid (CSF) leakage (p < .001) and high American Society of Anaesthesiologists (ASA) score (p = 0.039). Of the protocol steps, only the lack of preoperative wash with 4 % clorhexidine gluconate (Hibiscrub®) showed a tendency of influencing the shunt infection rate (p = 0.051).

CONCLUSIONS

This study showed that implementation of a perioperative protocol markedly and significantly reduced shunt infection rate in children younger than 1 year, even though no significant overall reduction in shunt infection rate was found.

Predictors of ventricular shunt infection among children presenting to a pediatric emergency department

OBJECTIVES

Among a population of children with a ventricular shunt presenting to a pediatric emergency department (ED), and in whom cerebrospinal fluid (CSF) was obtained, we sought to (1) determine the rate of positive CSF bacterial culture and (2) identify clinical predictors of ventricular shunt infection.

METHODS

We performed a retrospective cohort study of children 3 months to 21 years of age evaluated in a single pediatric tertiary ED from 1995 to 2008. All included children had CSF obtained within 24 hours of presentation to the ED. A shunt infection was defined by growth of bacteria in the CSF of a child who underwent shunt removal within 7 days of presentation.

RESULTS

Nine hundred seventy-nine children met the inclusion criteria; 130 patients (13%) had growth of bacteria in CSF, of which 58 (5.9% of total) had a shunt infection. The median time since last shunt revision or replacement was shorter for patients with a shunt infection compared with children without shunt infection (44 vs 209 days, P = 0.001). After adjustment for patient age, the following factors were associated with shunt infection: shunt revision within the prior 90 days (adjusted odds ratio [aOR], 2.4; 95% CI, 1.3-4.4), presence of fever (aOR, 8.4; 95% CI, 4.3-16.3), and white blood cell count greater than 15,000/μL (aOR, 3.2; 95% CI, 1.5-6.6).

CONCLUSIONS

Among children with a ventricular shunt who had CSF obtained in the ED, the presence of recent shunt revision, fever, and leukocytosis was associated with ventricular shunt infection.

Huge hydrocephalus: definition, management, and complications

OBJECTIVE

Lack of comprehensive knowledge and numerous socioeconomic problems may make the parents leave hydrocephalic children untreated, leading to progressive hydrocephalus and eventual unordinary big head. Management of huge hydrocephalus (HH) differs from common hydrocephalus. We present our experience in the management of these children.

METHODS

HH is defined as head circumference larger than the height of the infant. Nine infants with HH have been shunted in Children's Hospital Medical Center and followed up for 0.5 to 7 years.

RESULTS

The most common cause of hydrocephalus was aqueductal stenosis. The mean age of patients during shunting was 3 months. The head circumference ranged from 56 to 94 cm with the average of 67 cm. Cognitive statuses were appropriate based on their age in five patients. Motor development was normal only in one patient. Complications were found in most cases which included subdural effusion (six patients), shunt infection (four patients), skin injury (three patients), proximal catheter coming out of ventricle to the subdural space (two patients), and shunt exposure (one patient). Three patients died due to shunt infection and sepsis.

CONCLUSION

Numerous complications may occur in patients with HH after shunt operation such as subdural effusion, ventricular collapse, electrolyte disturbance, skull deformity, scalp injury, and shunt infection. Mental and motor disabilities are very common in patients with HH. Many of these complications can be related to overdrainage; therefore, drainage control using programmable shunts is advisable.

Perioperative factors associated with prolonged intensive care unit and hospital length of stay after pediatric neurosurgery

OBJECTIVES

This study aims to describe the association between different postoperative complications and the length of hospital stay among children undergoing neurosurgical procedures.

METHODS

A retrospective cohort study was carried out between May 2004 and May 2009 in a tertiary community hospital. All postoperative complications following neurosurgical procedures and their association with the main outcomes [length of intensive care unit (ICU) and hospital stay] were investigated in a univariate and multivariate analysis.

RESULTS

The medical records of 198 patients treated during the study period were reviewed. The most frequently performed surgeries were ventriculoperitoneal shunting (16.7%), correction of craniosynostosis (30%) and brain tumor resections (28.3%). Of the 198 patients eligible for this analysis, 79 (39.9%) suffered from at least one complication. The most frequent complications were fever (30.3%), hypothermia (16%), postextubation laryngitis (15.1%) and postoperative bleeding (7%). Factors independently associated with a longer pediatric ICU stay were fever (odds ratio 1.39, 95% confidence interval 1.1-3.2; p = 0.001), laryngitis (odds ratio 2.24, 95% confidence interval 1.8-5.2; p = 0.001), postoperative bleeding requiring reoperation (odds ratio 1.8, 95% confidence interval 1.4-3.9; p < 0.001) and infection (odds ratio 3.71, 95% confidence interval 1.8-12.4; p = 0.033). Fever (odds ratio 2.54, 95% confidence interval 2-7.4; p = 0.001) and infection (odds ratio 11.23, 95% confidence interval 4-22.4; p = 0.003) were related to the total length of the patient's hospital stay.

CONCLUSIONS

In this study population, most elective neurosurgical procedures were not associated with significant complications, and morbidity and mortality were low. Some complications significantly influenced patients' outcomes and should be monitored for early diagnosis. This study may improve our understanding and identification of postoperative outcomes in pediatric neurosurgery.

Reuse of ventricular drain sites for cerebrospinal fluid shunting in patients with no prior infection

OBJECT

The safety of reusing ventricular drain sites for shunting CSF in patients with no history of infection involving either the ventricular drain or the CSF was the focus of this investigation.

METHODS

Prospectively accrued clinical data on all patients who, in an 8-year span ending in June 2008, underwent external ventricular drain placement and subsequently required CSF shunts were retrospectively evaluated for evidence of shunt infection and other complications.

RESULTS

The infection rate for 50 consecutive operations in 50 patients who met the inclusion criteria was 2.0%.

CONCLUSIONS

Data from this study support the position that the reuse of ventriculostomy tracts when implanting first-time CSF shunts is, with regard to the risk of infection, a safe practice and avoids all risks associated with making a new ventricular entry.