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

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.

Hydraulic synchronizing lifting steel template based on AMEsim modeling simulation technology research

Steel formwork is used for concrete casting and forming, and plays a key role in the construction of high-rise buildings with asymmetrical large loads. In order to make the inner and outer formwork can be lifted synchronously, the difficult problem of unbalanced inner and outer formwork must also be overcome. According to the synchronization principle of the hydraulic lifting system and the performance parameters of its main components, AMESim model was created and the simulation was done for two hydraulic cylinders bearing the same heavy load and different weight load respectively. Therefore, the synchronization scheme of shunt valve is proposed.

Ventriculopleural shunts in a pediatric population: a review of 170 consecutive patients

OBJECTIVE The authors sought to determine the outcome of using the pleural space as the terminus for ventricular CSF-diverting shunts in a pediatric population. METHODS All ventriculopleural (VPl) shunt insertions or revisions done between 1978 and 2018 in patients at Children’s Hospital Los Angeles were identified. Data recorded for analysis were age, sex, weight, etiology of hydrocephalus, previous shunt history, reason for VPl shunt insertion or conversion from a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt, valve type, nature of malfunction, presence of shunt infection or pleural effusion, and conversion to a different distal site. RESULTS A total of 170 patients (mean age 14 ± 4 years) with a VPl shunt who were followed up for a mean of 57 ± 53 months were identified. The reasons for conversion to a VPl shunt for 167 patients were previous shunt infection in 57 (34%), multiple abdominal procedures in 44 (26%), inadequate absorption of CSF in 34 (20%), abdominal pseudocyst in 25 (15%), and obesity in 7 (4%). No VPl revisions were required in 97 (57%) patients. Of the 73 (43%) patients who did require revision, the most common reason was proximal obstruction in 32 (44%). The next most frequent complication was pleural effusion in 22 (30%) and included 3 patients with shunt infection. All 22 patients with a clinically significant pleural effusion required changing the distal end of the shunt from the pleural space. Pleural effusion was more likely to occur in VPl shunts without an antisiphon valve. Of the 29 children < 10 years old, 7 (24%) developed a pleural effusion requiring a revision of the distal catheter to outside the pleural space compared with 15 (11%) who were older (p = 0.049). There were 14 shunt infections with a rate of 4.2% per procedure and 8.2% per patient. CONCLUSIONS VPl shunts in children younger than 10 years of age have a significantly higher rate of symptomatic pleural effusion, requiring revision of the shunt’s terminus to a different location. VPl shunt complication rates are similar to those of VP shunts. The technical difficulty of inserting a VPl shunt is comparable to that of a VP shunt. In a patient older than 10 years, all else being equal, the authors recommend that the distal end of a shunt be placed into the pleural space rather than the right atrium if the peritoneal cavity is not suitable.

607 A Close Loop Audit on Proper Documentation of Ventriculo-Peritoneal (VP) Shunt Valve Settings in Operation Note

Aim Re-audit the practice of proper documentation of shunt type and settings in VP shunt surgery in Queen's Medical Centre, Nottingham for the period of 1st November 2019 – 31st October 2020. It is very important as programmable shunt setting could get changed during MRI, causing shunt failure. Method It was a retrospective collection of data of patients admitted to Queens medical Centre, Nottingham who had undergone VP shunt procedure. Exceptions: 4 files were excluded from study as they did not undergo VP shunt procedure. Results Total number of patients: 98. 4 patients were excluded. Actual sample size 94. Total VP shunt procedure done: 107. In 96 out of 107 procedures the shunt valve type and settings were properly documented. In 11 out of 107 procedures the shunt valve type and settings were not documented. In 33 out of 107 procedures programmable shunt valves were used. All 33 procedures had proper documentations. Previous audit result Duration of data collection: 2 years (from March 2016 to February 2018). Sample size 200. Total VP shunts done 247. Proper documentation of shunt valve type and settings were done in 209 out of 247 procedures. In 38 out of 247 procedures shunt valve type and settings were not documented. In 55 out of 247 procedures programmable shunt valves were used. 3 out of these 55 procedures (programmable shunt valves) lacked proper documentation. Conclusions There is an overall improvement in the practice of documentation of VP shunt valve type and settings in operative notes after implementing the plan of actions decided on first audit.