Serum and Cerebrospinal Fluid Vancomycin and Gentamicin Concentrations during Ventriculoperitoneal Shunt Surgery: An Observational Study

2000 ◽  
Vol 16 (4) ◽  
pp. 155-160 ◽  
Author(s):  
Walter J Faillace ◽  
Paul Tan
Keyword(s):  
Cerebrospinal Fluid ◽  
Observational Study ◽  
Infection Rate ◽  
Ventriculoperitoneal Shunt ◽  
Control Measures ◽  
University Hospital ◽  
Csf Shunt ◽  
Shunt Surgery ◽  
Serum Concentrations ◽  
Period Range

Background: Ventriculoperitoneal shunts become infected predominantly during surgery. Optimal antibiotic prophylaxis during cerebrospinal fluid (CSF) shunt surgery has not been fully determined. Objective: To quantitate the concentrations of vancomycin and gentamicin in the serum and CSF during 100 ventriculoperitoneal shunt surgeries at the time of shunt manipulation. Design: Descriptive, prospective, observational study with a 27- to 76-month postoperative follow-up period range. Setting: University hospital. Patients: Eighty-three hydrocephalic patients ranging from premature to adult ages. Interventions: Intraoperatively, children received intravenous vancomycin 15 mg/kg/dose and gentamicin 2.5 mg/kg/dose; adults received vancomycin 1 g/dose and gentamicin 1.5 mg/kg/dose. Antibiotics were continued for 24 hours postoperatively, with dosage and schedule adjusted for age. Antibiotic serum and CSF concentrations were sampled one hour after infusion, and measured via fluorescence polarization immunoassay. Meticulous surgical infection control measures were followed. Main Outcome Measures: Correlation of intraoperative serum and CSF antibiotic concentrations with postoperative infection rate. Results: Intraoperative vancomycin serum concentrations ranged from 10.8 to 53.8 μg/mL (28.0 ± 9.5 μg/mL, mean ± SD). Intraoperative gentamicin serum concentrations ranged from 3.9 to 9.4 μg/mL (4.8 ± 2.0 μg/mL). In all surgeries, intraoperative CSF vancomycin and gentamicin concentrations were low (vancomycin <5 μg/mL, gentamicin <2 μg/mL). The infection rate among surgeries was 2.0%, and the infection rate among patients was 2.4%. Two shunt infections occurred, one with Candida albicans and one with Citrobacter freundii. Conclusions: Serum concentrations of vancomycin and gentamicin were above the minimum inhibitory concentrations for likely pathogens in 84% and 74% of surgeries, respectively. Intraoperative bacteriostatic and bactericidal CSF antibiotic concentrations may not be necessary to achieve a low postoperative shunt infection rate. Larger confirmatory studies are needed.

Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery

2012 ◽  
Vol 33 (5) ◽  
pp. E13 ◽  
Author(s):  
Judith M. Wong ◽  
John E. Ziewacz ◽  
Allen L. Ho ◽  
Jaykar R. Panchmatia ◽  
Angela M. Bader ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Adverse Events ◽  
Ventriculoperitoneal Shunt ◽  
Shunt Infection ◽  
Current Evidence ◽  
Csf Shunt ◽  
Complication Rates ◽  
Cerebrospinal Fluid Shunt ◽  
Shunt Surgery ◽  
Programmable Valves

Object As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality. Methods The authors performed a PubMed search using search terms “cerebral shunt,” “cerebrospinal fluid shunt,” “CSF shunt,” “ventriculoperitoneal shunt,” “cerebral shunt AND complications,” “cerebrospinal fluid shunt AND complications,” “CSF shunt AND complications,” and “ventriculoperitoneal shunt AND complications.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported. Results In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36–0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half. Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation. Conclusions Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes.

Operative Related Infection Rates for Ventriculoperitoneal Shunt Procedures in a Children's Hospital

1987 ◽  
Vol 8 (2) ◽  
pp. 67-70 ◽  
Author(s):  
Janara J. Younger ◽  
James C.H. Simmons ◽  
Fred F. Barrett
Keyword(s):  
Cerebrospinal Fluid ◽  
Ventriculoperitoneal Shunt ◽  
Shunt Infection ◽  
Infection Risk ◽  
Csf Shunt ◽  
Infection Rates ◽  
Surgical Infection ◽  
Shunt Procedure ◽  
Csf Shunt Infection

AbstractWe determined the operative related cerebrospinal fluid (CSF) shunt infection rates for our institution over a 3-year period (1982 to 1984) using strictly defined numerator and denominator data. The minimum post-operative follow-up period was 12 months. The average surgical infection risk for a CSF shunt procedure at our institution during the study period was 13.3%. Annual infection rates were relatively constant (13.8%, 13.2% and 12.9%), however both quarterly (5.7% to 23.3%) and surgeon-specific (5.7% to 22.8%) rates varied widely. Infection rates calculated by using “traditional” numerator and denominator data were considerably lower (6.5% to 9.2%).Operative related CSF shunt infection rates should be determined by utilizing strictly defined numerator and denominator values in order to allow valid comparisons of published rates.

scholarly journals Current epidemiology of cerebrospinal fluid shunt surgery in the UK and Ireland (2004–2013)

2019 ◽  
Vol 90 (7) ◽  
pp. 747-754 ◽  
Author(s):  
Rocío Fernández-Méndez ◽  
Hugh K Richards ◽  
Helen M Seeley ◽  
John D Pickard ◽  
Alexis J Joannides
Keyword(s):  
Cerebrospinal Fluid ◽  
Intraventricular Haemorrhage ◽  
Normal Pressure ◽  
Incidence Rates ◽  
Shunt Revision ◽  
Csf Shunt ◽  
First Year ◽  
Shunt Surgery ◽  
Potential Risks ◽  
The Uk

ObjectivesTo determine current epidemiology and clinical characteristics of cerebrospinal fluid (CSF) shunt surgery, including revisions.MethodsA retrospective, multicentre, registry-based study was conducted based on 10 years’ data from the UK Shunt Registry, including primary and revision shunting procedures reported between 2004 and 2013. Incidence rates of primary shunts, descriptive statistics and shunt revision rates were calculated stratified by age group, geographical region and year of operation.Results41 036 procedures in 26 545 patients were submitted during the study period, including 3002 infants, 4389 children and 18 668 adults. Procedures included 20 947 (51.0%) primary shunt insertions in 20 947 patients, and 20 089 (49.0%) revision procedures. Incidence rates of primary shunt insertions for infants, children and adults were 39.5, 2.4 and 3.5 shunts per 100 000 person-years, respectively. These varied by geographical subregion and year of operation. The most common underlying diagnoses were perinatal intraventricular haemorrhage (35.3%) and malformations (33.9%) in infants, tumours (40.5%) and malformations (16.3%) in children, and tumours (24.6%), post-haemorrhagic hydrocephalus (16.2%) and idiopathic normal pressure hydrocephalus (14.2%) in adults. Ninety-day revision rates were 21.9%, 18.6% and 12.8% among infants, children and adults, respectively, while first-year revision rates were 31.0%, 25.2% and 17.4%. The main reasons for revision were underdrainage and infection, but overdrainage and mechanical failure continue to pose problems.ConclusionsOur report informs patients, carers, clinicians, providers and commissioners of healthcare, researchers and industry of the current epidemiology of shunting for CSF disorders, including the potential risks of complications and frequency of revision.

Morbidity of Ventricular Cerebrospinal Fluid Shunt Surgery in Adults: An 8-Year Study

Neurosurgery ◽  
2011 ◽  
Vol 68 (4) ◽  
pp. 985-995 ◽  
Author(s):  
Anne-Marie Korinek ◽  
Laurence Fulla-Oller ◽  
Anne-Laure Boch ◽  
Jean-Louis Golmard ◽  
Bassem Hadiji ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cerebrospinal Fluid ◽  
Operating Time ◽  
Shunt Infection ◽  
Csf Leak ◽  
Csf Shunt ◽  
High Morbidity ◽  
Neurosurgical Procedures ◽  
Shunt Surgery ◽  
Shunt Placement

Abstract BACKGROUND: Cerebrospinal fluid (CSF) shunt procedures have dramatically reduced the morbidity and mortality rates associated with hydrocephalus. However, despite improvements in materials, devices, and surgical techniques, shunt failure and complications remain common and may require multiple surgical procedures. OBJECTIVE: To evaluate CSF shunt complication incidence and factors that may be associated with increased shunt dysfunction and infection rates in adults. METHODS: From January 1999 to December 2006, we conducted a prospective surveillance program for all neurosurgical procedures including reoperations and infections. Patients undergoing CSF shunt placement were retrospectively identified among patients labeled in the database as having a shunt as a primary or secondary intervention. Revisions of shunts implanted in another hospital or before the study period were excluded, as well as lumbo- or cyst-peritoneal shunts. Shunt complications were classified as mechanical dysfunction or infection. Follow-up was at least 2 years. Potential risk factors were evaluated using log-rank tests and stepwise Cox regression models. RESULTS: During the 8-year surveillance period, a total of 14 275 patients underwent neurosurgical procedures, including 839 who underwent shunt placement. One hundred nineteen patients were excluded, leaving 720 study patients. Mechanical dysfunction occurred in 124 patients (17.2%) and shunt infection in 44 patients (6.1%). These 168 patients required 375 reoperations. Risk factors for mechanical dysfunction were atrial shunt, greater number of previous external ventriculostomies, and male sex; risk factors for shunt infection were previous CSF leak, previous revisions for dysfunction, surgical incision after 10 am, and longer operating time. CONCLUSION: Shunt surgery still carries a high morbidity rate, with a mean of 2.2 reoperations per patient in 23.3% of patients. Our risk-factor data suggest methods for decreasing shunt-related morbidity, including peritoneal routing whenever possible and special attention to preventing CSF leaks after craniotomy or external ventriculostomy.

scholarly journals Reconsidering Ventriculoperitoneal Shunt Surgery and Postoperative Shunt Valve Pressure Adjustment: Our Approaches Learned From Past Challenges and Failures

2022 ◽  
Vol 12 ◽  
Author(s):  
Shigeki Yamada ◽  
Masatsune Ishikawa ◽  
Madoka Nakajima ◽  
Kazuhiko Nozaki
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Early Period ◽  
Csf Shunt ◽  
Symptom Improvement ◽  
Shunt Surgery ◽  
Shunt Valve ◽  
Improvement Rate ◽  
Shunt Implantation ◽  
Csf Drainage ◽  
Valve Pressure

Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2–4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.

scholarly journals Longitudinal morphological changes during recovery from brain deformation due to idiopathic normal pressure hydrocephalus after ventriculoperitoneal shunt surgery

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Shigeki Yamada ◽  
Masatsune Ishikawa ◽  
Makoto Yamaguchi ◽  
Kazuo Yamamoto
Keyword(s):  
Cerebrospinal Fluid ◽  
Ventriculoperitoneal Shunt ◽  
Subarachnoid Space ◽  
Normal Pressure ◽  
Fluid Distribution ◽  
Shunt Surgery ◽  
Evans Index ◽  
Subarachnoid Spaces ◽  
The Brain

AbstractThe present study aimed to examine time-dependent change in cerebrospinal fluid distribution and various radiological indices for evaluating shunt effectiveness in patients with idiopathic normal pressure hydrocephalus (iNPH). This study included 54 patients with iNPH who underwent MRI before and after ventriculoperitoneal shunt surgery. The volume of the total ventricles and subarachnoid spaces decreased within 1 month after shunting. However, more than 1 year after shunting, the volume of the total ventricles decreased, whereas that of the total subarachnoid spaces increased. Although cerebrospinal fluid distribution changed considerably throughout the follow-up period, the brain parenchyma expanded only 2% from the baseline brain volume within 1 month after shunting and remained unchanged thereafter. The volume of the convexity subarachnoid space markedly increased. The changing rate of convexity subarachnoid space per ventricle ratio (CVR) was greater than that of any two-dimensional index. The brain per ventricle ratio (BVR), callosal angle and z-Evans index continued gradually changing, whereas Evans index did not change throughout the follow-up period. Both decreased ventricular volume and increased convexity subarachnoid space volume were important for evaluating shunt effectiveness. Therefore, we recommend CVR and BVR as useful indices for the diagnosis and evaluation of treatment response in patients with iNPH.

Recanalization of Obstructed Cerebrospinal Fluid Ventricular Catheters Using Ultrasonic Cavitation

2006 ◽  
Vol 59 (suppl_4) ◽  
pp. ONS-403-ONS-412 ◽  
Author(s):  
Howard J. Ginsberg ◽  
James M. Drake ◽  
Thomas M. Peterson ◽  
Richard S.C. Cobbold
Keyword(s):  
Adverse Effect ◽  
Cerebrospinal Fluid ◽  
Choroid Plexus ◽  
Ultrasonic Waves ◽  
Ultrasonic Cavitation ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Shunt Surgery ◽  
Csf Shunts ◽  
Ventricular Catheters

Abstract OBJECTIVE: Fifty percent of implanted cerebrospinal fluid (CSF) shunts fail within 2 years, primarily because of obstruction of the proximal catheter. Percutaneous techniques to reduce the morbidity of shunt revision are being developed. The authors describe the development of a device that uses ultrasonic cavitation to unblock ventricular catheters. METHODS: In collaboration with Cybersonics, Inc. (Erie, PA), we designed, built, and tested a system that produces low-frequency ultrasound (20–28 kHz). Extensional ultrasonic waves are transmitted along a tapered wire (final diameter, approximately 0.8 mm) to the tip, where cavitation is produced in a highly localized region. An in vitro model of sheep choroid plexus occluding typical ventricular catheters was developed. The device was safety tested in vivo in rat and pig brains by introducing the device into shunt catheters inserted during simulated shunt surgery. A clinical safety trial using the device to attempt to remove blocked and adherent ventricular catheters has commenced. RESULTS: In the sheep choroid plexus model, at least 90% of the occluded holes were unblocked in a few minutes, restoring normal flow. There was no adverse effect of the device within shunt catheters inserted into live animal brains. Four patients have undergone treatment with the device at open CSF shunt surgery without adverse effect, and the device seems effective at unblocking and freeing the occluded catheters. CONCLUSION: Ultrasonic cavitation produced at the end of a fine wire that is introduced percutaneously into a CSF shunt promises to be a useful technique for minimally invasive proximal ventricular CSF shunt catheter revision.

scholarly journals Nasopharyngeal Testing among Healthcare Workers (HCWs) of a Large University Hospital in Milan, Italy during Two Epidemic Waves of COVID-19

2021 ◽  
Vol 18 (16) ◽  
pp. 8748
Author(s):  
Agnese Comelli ◽  
Dario Consonni ◽  
Andrea Lombardi ◽  
Giulia Viero ◽  
Massimo Oggioni ◽  
...  
Keyword(s):  
Observational Study ◽  
Infection Rate ◽  
Healthcare Workers ◽  
Northern Italy ◽  
Demographic Characteristics ◽  
University Hospital ◽  
Retrospective Observational Study ◽  
Health Related ◽  
Epidemic Wave

Background: since October 2020, a second SARS-CoV-2 epidemic wave has hit Italy. We investigate the frequency of positive nasopharyngeal swabs among HCWs during the two waves and the association with occupation and demographic characteristics. Methods: this is a retrospective, observational study conducted in a large university hospital in Milan, Northern Italy. We defined two epidemic waves: 1st (February 2020–July 2020) and 2nd (August 2020–January 2021). Occupational and demographic characteristics of HCWs who underwent nasopharyngeal swabs for SARS-CoV-2 were collected. Results: in the 1st wave, 242 positive subjects (7.2%) were found among 3378 HCWs, whereas in the 2nd wave, the positive subjects were 545 out of 4465 (12.2%). In both epidemic waves positive NPSs were more frequent among HCWs with health-related tasks and lower among students (p < 0.001). However, in the 2nd wave, workers engaged in non-health-related tasks had a peak of 20.7% positivity. Among 160 positive HCWs in the 1st wave who were tested again in the 2nd wave, the rate of reinfection based on SARS-CoV2 RNA cycle quantification value was 0.6%. Conclusions: during the 2nd epidemic wave, we confirmed a significant impact of COVID-19 among HCWs. The rise of infection rate among HCWs seems to reflect the increasing spread of SARS-CoV-2 among the overall population.

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