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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 138-143

Hydrocephalus in pediatric patients: A clinical audit


1 Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
2 Department of Radiodiagnosis, SMS Medical College, Jaipur, Rajasthan, India

Date of Submission26-Oct-2020
Date of Decision09-Mar-2021
Date of Acceptance11-Mar-2021
Date of Web Publication17-Mar-2022

Correspondence Address:
Dr. Rahul Gupta
Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_177_20

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  Abstract 


Background: Ventriculoperitoneal (VP) shunt surgery is the most common procedure for treatment of hydrocephalus. The clinical outcomes of hydrocephalus patients following VP shunt surgery should be periodically appraised.
Aims: To analyze and perform a clinical audit of management of hydrocephalus patients according to the standards of quality care; suggest interventions to make further improvements.
Material and Methods: A retrospective study performed from January 2016 to December 2016. Pediatric patients with hydrocephalus who had undergone VP shunt surgery and those presenting with its complications were studied.
Results: There were 142 pediatric patients with 103 males and 39 females (M:F = 2.64: 1). Age ranged from 1 day (youngest) to 12 years (oldest); 47.89% (68) of the patients were between ≥1 to <6 months. Out of 142, 72.54% (103) were new admissions and 27.46% (39) were admitted for shunt related complications. Congenital malformations were the most common (59.86%) reasons for admission. Meningomyelocele and Encephalocele were the most common (2.11%) major associated malformations. In 72.54% (103) patient's new VP shunt placement was performed, while in 8.45% (12) cases, complete revision by shunt placement on left side was performed. Low pressure type of VP shunt was the most common (77.39%) procedure.
Conclusions: Approximately one fourth (27.46%) of the procedures performed for patients with hydrocephalus were for shunt related complications. Clinical audit helps to identify the complications and lacunae, develop effective methods for improvement in patient care. It gives an impetus to decrease the complications associated with it. We recommend a yearly clinical audit of pediatric patients managed with VP shunt surgery.

Keywords: Audit, clinical, hydrocephalus, pediatric, ventriculoperitoneal shunt


How to cite this article:
Gupta R, Sharma P, Bhandari A, Chaturvedi V, Gupta AK, Tanger RC, Shukla AK, Raipuria G, Mathur P. Hydrocephalus in pediatric patients: A clinical audit. J NTR Univ Health Sci 2021;10:138-43

How to cite this URL:
Gupta R, Sharma P, Bhandari A, Chaturvedi V, Gupta AK, Tanger RC, Shukla AK, Raipuria G, Mathur P. Hydrocephalus in pediatric patients: A clinical audit. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Nov 30];10:138-43. Available from: https://www.jdrntruhs.org/text.asp?2021/10/3/138/339802




  Introduction Top


Ventriculoperitoneal (VP) shunt introduced in 1908 is one of the most common neurosurgical procedures performed for patients with hydrocephalus.[1] In a few selected conditions endoscopic third ventriculostomy (ETV), an alternative to VP shunt surgery is performed. The clinical outcomes following VP shunt surgery depends on many factors.[2] There is a huge magnitude of pediatric patients with hydrocephalus managed in our department. A retrospective review of institutional records over 2 years from January 2014 to December 2015 revealed a total of 321 patients undergoing VP shunt operations.[1] This encouraged us to complete a clinical audit of patients with hydrocephalus. Clinical audit is the evaluation of patient care. It is a quality improvement cycle that involves measurement of the effectiveness of care against agreed and proven standards. [2,3] We aimed to analyze and perform a clinical audit of management of hydrocephalus patients according to the standards of quality care; suggest interventions to make further improvements.


  Material and Methods Top


A single center, retrospective study was performed from January 2016 to December 2016. The study included all pediatric patients with hydrocephalus for VP shunt surgery and its complications admitted in intensive care unit of our tertiary care institute. The clinical, operative records, and other details of these patients were analyzed. Charts were reviewed according to age at presentation, sex, clinical findings, investigations undertaken, and indications for surgery, operative procedure, intraoperative and postoperative complications, and final outcomes. All patients were assessed from the time of its admission, during the surgery to 3 months follow-up.

Standards were defined for the comparison for any deviation from the standard protocol for the surgical management of hydrocephalus patients after imbibing the work of recent study [Table 1].[2] Data collected by a team of pediatric surgeons on this particular topic from the case record files of the patients included in study sample. The study was done by the authors in addition to the resident and faculty of the department. Data were collected, analyzed and statistics were presented as frequencies and percentages. All statistical data analysis was obtained with statistical package for social sciences version 10.0 for Windows.
Table 1: Detail of Standards and Expected Targets[2]

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  Results Top


There were 142 pediatric patients with hydrocephalus admitted in our department. There were 103 males and 39 females (M:F = 2.64:1) as seen in [Table 2]. Age ranged from 1 day (youngest) to 12 years (oldest). Patients were sub-divided into 6 age groups [Table 3]. Among these groups, 47.89% (68) of the patients were between ≥1 to <6 months. Among these 72.54% (103) were new admissions and 27.46% (39) were admitted for shunt related complications [Table 4].
Table 2: Sex Distribution of Patients Admitted With Hydrocephalus For Ventriculoperitoneal Shunt Placement and its Complications

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Table 3: Age Distribution of Patients Admitted With Hydrocephalus For Ventriculoperitoneal Shunt Placement and its Complications

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Table 4: Admission Details of Patients With Hydrocephalus

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A comprehensive clinical assessment including major associated malformations pre-anesthetic examination, radiological investigations (ultrasound brain and/or CT scan of the brain) were done in all patients. Congenital malformations were the most common reasons for admission with 59.86% (85) patients; shunt obstruction/blockage was encountered in 16.90% (24) cases. An etiology of hydrocephalus and also VP shunt related complications as seen in our patients [Table 4]. Shunt extrusion (4.93%) through abdominal wound was encountered in 4 admissions, cranial wound in 1 patient, anal extrusion and oral extrusion was present in one each. Meningomyelocele and Encephalocele were the most common (2.11%) major associated malformations in our patients [Table 5].
Table 5: Associated Major Malformations in Patients With Hydrocephalus

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Per-operative ventricular tap was done in all cases to assess the depth of the cerebral ventricle from the cortical surface and the CSF pressure [Figure 1]. Intra-ventricular pressure measurement could be measured in 15.49% (22) cases [Figure 2] due to resource limitations. CSF was retrieved and its evaluation was performed in all the cases depending on the provisional diagnosis of the patient. In 72.54% (103) patient's new VP shunt placement (first time) was done, while in 8.45% (12) cases, complete revision by shunt placement on left side was performed. In 9.86% (14) patients, revision of either ventricular end or peritoneal end was performed [Table 6]. Low pressure type of VP shunt was placed in 77.39% (89) cases; being the most common type out of 115 patients [Table 7]. No patient died during or post-surgery during the 3 months follow-up. Out of 17 points that were considered as standard of care, 15 targets (points) were strictly completed. Point number 9 and 10 were not followed before performing the surgical procedure.
Figure 1: Per-operative ventricular tap being done to assess CSF pressure with help of CVP manometer instrument (a). The red ball (red arrow) moved to the present marking from “0” level (white arrow). Inset image (b) shows patient draped for the VP shunt procedure

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Figure 2: Intra-ventricular pressure measurement with adjustment of the CVP manometer indicator at “0” level (black arrow) as shown in image a; ventricular tap revealing ICP level of 11 cm of water (red arrow) as shown in image b

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Table 6: Procedures Performed in Patients With Hydrocephalus

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Table 7: Type of Pressure Valve in VP Shunt Patients With Hydrocephalus

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  Discussion Top


Audit can be defined as a systematic review of aspects of practice that results in a change in that practice. Audit is a means of quality control for medical practice by which the profession should regulate its activities with intention of improving overall patient care.[3] Aspects of the organization, method and outcome of care are selected and systematically appraised against explicit criteria. Where indicated changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery.[3] It gives an impetus for a related research project.

Surgical audit is an essential part of the practice to measure performance, reduce clinical risk, and improve quality of care.[4] In addition to surgical work, surgical audits must also warrant that outcomes include key performance indicators such as major complications, readmissions, reoperations, transfers, incident reports, complaints, and mortalities.[5] Audit is also an opportunity for self-education. An assessment of all complications aims to pinpoint errors in management and facilitate improvements in patients care. It needs to be documented, presented at a clinical meeting, deliberated on clinical outcomes, and should include recommendations for improvement with active involvement of surgical team.

The estimated incidence of congenital hydrocephalus range between 0.5 to 1 case per 1000 births.[6] The diagnosis of pediatric hydrocephalus is established on clinical signs and radiologic findings.[2] It is broadly classified into two types: (a) obstructive hydrocephalus: as a consequence to obstruction of CSF flow (b) communicating hydrocephalus: as result of impaired absorption of CSF.

Ultrasonography is the most important and screening investigation in small children before anterior fontanel closes.[2] Ultrasonography is usually done through anterior fontanel to classify its type. Ventricular hemispheric ratio, an index to measure lateral ventricular dilatation and brain parenchymal thickness are calculated to quantify severity of hydrocephalus. It is also able to identify aqueductal stenosis, ventriculitis, posterior fossa lesions, and postoperative functioning. It is useful investigation to identify pseudocyst formation, local collection, shunt migration into viscera and broken shunt.[1]

In our series, congenital hydrocephalus was the commonest cause of hydrocephalus (59.86%) followed by post-meningitic hydrocephalus (12.68%). Poor development of cognitive function in infants and children can complicate untreated hydrocephalus. Other complications include visual loss and tonsillar herniation secondary to raised ICP with compression of the brain stem and subsequent respiratory arrest.[2]

Medical management in pediatric patients awaiting surgery are treated with acetazolamide (carbonic anhydrase inhibitor) alone or in combination with furosemide. Surgical treatment with VP shunt is the mainstay of treatment; ETV and external ventricular drainage (EVD) are done in selected patients.[7] In patients with post-meningitic hydrocephalus, If CSF evaluation reveals pus or infection, EVD is inserted; otherwise VP shunt is done.[2]

The selection of shunt type, i.e., pressure valve depends on clinical features and underlying pathology and finally on the basis of CSF pressure on ventricular tap. In post-meningitic hydrocephalus, low pressure VP shunt is placed. In congenital hydrocephalus especially obstructive hydrocephalus due to aqueductal stenosis, a medium pressure right VP shunt is most appropriate.[2] In smaller children with severe congenital hydrocephalus and causes other than aqueductal stenosis, a low pressure VP shunt is preferred over medium pressure as: (a) brain parenchyma is smaller to generate significant pressure to open medium pressure valve, (b) skull bones are not fused and fontanelle are open which may not yield enough pressure to open medium pressure valve (personal experience, RG). Complications with low pressure VP shunt include over drainage and subdural hematoma. The right sided shunt surgery is commonly done as left side is dominant hemisphere. Only in some cases, e.g., obstructive hydrocephalus with left sided lateral ventricular enlargement, left VP shunt is done or in cases with VP shunt blockage/failure.[2]

The incidence of VP shunt complications is reported to be around 20% to 40%. [8,9] These include shunt infection, over drainage, shunt obstruction/malfunction, and disconnection. Peritoneal complications involve pseudocyst formation, intestinal obstruction or volvulus, perforations of hollow viscus, penetration into solid organs and abdominal wall, and protrusion outside body particularly through the abdominal incision, neck, chest, umbilicus, vagina, anus, and oral cavity.[10] Cranial and ventricular migrations are also rarely seen.[1] In a large series, all the malposition/migration cases were on the proximal side,[8] while in our study both proximal and distal (peritoneal end) migration were present. Incidence of both shunt failure and shunt infection is higher within 6 months after the original shunt surgery. [8,9]

Complications of the shunt especially infection can be reduced by thorough preoperative part preparation, prophylactic antibiotic, meticulous draping, operation theatre ergonomics, correct shunt type, surgical technique, minimal handling of the shunt assembly and changing of the gloves prior to its handling, sutures for securing shunt assembly and its fixation, CSF examination, post-operative antibiotic, and strict monitoring in an intensive care unit. [1,2] Once shunt is non-functioning or if there are complications, a comprehensive re-evaluation is essential. Shunt fracture is a rare complication being present in 0.70% cases, which is similar finding among other series also. [11,12] Doppler ultrasound with measurement of anterior cerebral artery resistance index, which is hemodynamic parameter of cerebral circulation, is done for assessment of successful drainage operation (postoperative shunt functioning). [13,14]

Follow-up of patients for long-term complication rate of VP shunt surgery for hydrocephalus during the designated time period was not possible due to resource constraints in a high-volume tertiary care institute. This was also similar state in one of the leading Pediatric Neurosurgery center of Korean peninsula.[8]

We suggest following additional recommendations/interventions to make further improvements in addition to meticulously following all the standards of care enumerated in [Table 1]:

  1. Broad spectrum perioperative antibiotics should be continued for at least 5 days postoperatively.[15] Scalp and skin hygiene is important; skin preparation using soap and water followed by diluted cetrimide solution.[16]
  2. The VP shunt should be posted as first operative procedure, preferably in the modular operation theatre complex. A regular implementation of operating protocols would result in minimizing the frequency of shunt infection and other related complications.[17]
  3. The shunt assembly must be dipped in antibiotic/antiseptic solution before its placement and is routinely flushed with clear colorless antibiotic solution of injection Amikacin (personal experience, RG).[16]
  4. Surgical techniques to prevent intracranial shunt migration include appropriate size burr hole, small dural incision, and suture the straight connector of shunt chamber to periosteum. [1,12]
  5. The distal length of the shunt assembly should be tapered proportional to the length of the child. The shunt tubing is cut 2–3 cm distal to the shunt chamber and the distal tubing is adjusted so that the peritoneal end reaches the right knee or inguinal region. We believe that excess length of the distal end is associated with bowel obstruction, volvulus, perforation, and shunt migration. This is in contrast to other study published in literature.[18]
  6. As far as possible, VP shunt procedure should be deferred beyond the neonatal age group especially babies with low birth weight and prematurity. The chances of shunt infection and failure are more during this period.


Audit helped the center to initiate measures to make further improvements to minimize the complications. Point number 9, i.e., pre-operative checklist signed by nursing staff and point number 10, i.e., signed pediatric neuro-anesthesia written informed consent form were not as per standard of care for the patients. This has initiated us to genuine efforts in incorporating and completion of both these prescribed forms before surgery.


  Conclusions Top


This paper illustrates the experience of authors in clinical audit of 142 hydrocephalus patients who underwent VP shunt surgery. Approximately one fourth (27.46%) of the procedures performed for patients with hydrocephalus were for shunt related complications. Clinical audit helps to identify the complications and lacunae, develop effective methods for improvement in patient care. It gives an impetus to decrease the complications associated with it. We recommend a yearly clinical audit of pediatric patients managed with VP shunt surgery.

Acknowledgements

We are sincerely thankful to faculty, residents and nursing staff of Department of Pediatric Surgery, Department of Anesthesia and Department of Radiodiagnosis, SMS Medical College, Jaipur, Rajasthan, India, for helping in our endeavor.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Gautam VKS, Singh R, Khurana S. Hydrocephalus treated with VP shunt surgery: A clinical audit. Int J Health 2014;2:26-9.  Back to cited text no. 2
    
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Watters DA, Green AJ, van Rij A. Guidelines for surgical audit in Australia and New Zealand. ANZ J Surg 2006;76:78-83.  Back to cited text no. 4
    
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Devlin HB. Professional audit; quality control; keeping up to date. Bailliere's Clin Anaesthesiol 1988;2:299-324.  Back to cited text no. 5
    
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Wang S, Muir R, Warf B. Global surgery for pediatric hydrocephalus in the developing world: A review of the history, challenges, and future directions. Neurosurg Focus 2016;41:E11. doi: 10.3171/2016.7.FOCUS16273.  Back to cited text no. 6
    
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Hamilton MG. Treatment of hydrocephalus in adults. Semin Pediatr Neurol 2009;16:34-41.  Back to cited text no. 7
    
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Park MK, Kim M, Park KS, Park SH, Hwang JH, Hwang SK. A retrospective analysis of ventriculoperitoneal shunt revision cases of a single institute. J Korean Neurosurg Soc 2015;57:359-63.  Back to cited text no. 8
    
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Reddy GK, Bollam P, Caldito G. Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus. World Neurosurg 2014;81:404-10.  Back to cited text no. 9
    
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Gupta R, Dagla R, Agrawal LD, Sharma P. Vesical calculi formation on the slit valves of a migrated distal end of ventriculoperitoneal shunt. J Pediatr Neurosci 2015;10:368-70.  Back to cited text no. 10
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Nishimaki S, Iwasaki Y, Akamatsu H. Cerebral blood flow velocity before and after cerebrospinal fluid drainage in infants with posthemorrhagic hydrocephalus. J Ultrasound Med 2004;23:1315-9.  Back to cited text no. 13
    
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Kolarovszki B, Zubor P, Kolarovszka H, Benco M, Richterova R, Matasova K. The assessment of intracranial dynamics by transcranial Doppler sonography in perioperative period in paediatric hydrocephalus. Arch Gynecol Obstet 2013;287:229-38.  Back to cited text no. 14
    
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Klimo P, Van Poppel M, Thompson CJ, Baird LC, Duhaime A, Flannery A. Pediatric hydrocephalus: Systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: A systematic review and meta-analysis. J Neurosurg Pediatr 2014;14:44-52.  Back to cited text no. 15
    
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Gupta M, Digra NC, Sharma N, Goyal S, Agrawal A. Length of peritoneal end of shunt catheters in hydrocephalus in children and rate of complications. J Cranio Max Dis 2012;1:12-6.  Back to cited text no. 18
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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