Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The management of hydrocephalus by means of a ventriculoperitoneal shunt (VPS) has, as a major threat, surgical infections. Factors, such as cause of hydrocephalus, age below six months, shunt primary insertion, trainaing curve of surgeons, conditions of antisepsis and length of the procedure contribute to the occurrence of infectious complications. The study aimed at determining the incidence, cause, site of ocurrence and clinical and laboratory manifestations of infections in the children and teenagens who underwent VPS in Hospital Gov. João Alves (HGJAF), Aracaju, SE. Fifteen patients were studied prospectively from January 2003 to October 2004. Hospital records were analised and data were obtained during hospital stay and after discharge. The results were analised through Yates Chi-square, Fisher s exact test, relative risk and odds ratio. A confidence interval of 95% was used. All patients underwent VPS because of hipertensive hydrocephalus and subsequent infection rate per procedure was 27.6%. Infection rates according to surgical risk index were 25.7% for risk 0 and 30.4% for risk 1/2 (NNISSCDC). Surgical site infection (deep and superficial) was the major complication (87.5%) with early appearance (mean 27.6 days). Fever was the most frequent sign in 13 of 16 cases. Infection related mortaliy rate was 10% (5/50). However, there was no statistical significance for cause of hydrocephalus (p = 0.858), type of procedure (p = 0.330), age at diagnosis (p = 0.926), pre-operative length of stay (p = 0.172), duration of procedure (p = 0.534, RR = 1.09, IC95% [0.6-2.0]), antibiotic prophylaxis (p = 0.567), previous use of CNS catheter (P = 0.361) and risk index (0, 1, 2) (p = 0.926, RR = 1.07, IC95% [0.76-1.49]. The present study was meant to caracterize the management of hydrocephalus at HGJAF and identify problems that could be mimimized through prevention of infectious complications. / O tratamento cirúrgico da hidrocefalia através da derivação ventrículo peritoneal (DVP), tem nas complicações infecciosas o seu maior desafio. A etiologia da hidrocefalia, crianças menores de seis meses, inserção primária do sistema de derivação, inadequada habilidade técnica da equipe cirúrgica, condições de assepsia e anti-sepsia e duração da cirurgia são alguns dos fatores de risco que contribuem para a persistência das taxas de infecção. A proposta do presente estudo foi determinar a freqüência, as causas, o sítio específico e as manifestações clínicas e laboratoriais das infecções em crianças e adolescentes após a implantação de dispositivos neurológicos no HGJAF (Aracaju-SE). Prospectivamente, foram estudados 50 pacientes entre 0 e 17 anos, submetidos a DVP (58 procedimentos), no período de janeiro de 2003 a outubro de 2004, através de levantamento de dados dos prontuários durante a internação e após a alta hospitalar. Os resultados foram analisados pelo teste do qui-quadrado, teste exato de Fischer, odds ratio e risco relativo. Foi considerado significante valor de p < 0,005. Observou-se que todas as indicações de sistema de DVP foram por hipertensão intracraniana em hidrocefalia e que a taxa de infecção por procedimento (27,6%) e as taxas de infecção de acordo com o índice de risco cirúrgico zero (25,7%) e índice de risco cirúrgico 1 e 2 (30,4%) (metodologia NNISS-CDC) foram elevadas. A infecção de sítio cirúrgico (superficial e cavidade) foi a principal complicação infecciosa (87,5%), com precocidade na sua manifestação (média de 27,6 dias). A manifestação clínica mais freqüente foi a febre com 81,3% (13/16). A taxa de mortalidade por infecção em DVP foi de 10% (5/50). No entanto, não houve significância estatística com relação à etiologia da hidrocefalia (p = 0,858), ao tipo de procedimento (derivação primária e reinserção) (p = 0,330), idade do paciente (p = 0,926), tempo de internação pré-operatória (p = 0,172), duração da cirurgia (p = 0,534, RR = 1,09, IC95% [0,6-2,0]), uso de antibioticoprofilaxia (p = 0,567), uso de cateter SNC prévio (p = 0,361) e índice de risco cirúrgico (0, 1, 2) (p = 0,926, RR = 1,07, IC95% [0,76-1,49]). Este estudo serviu para caracterizar a infecção após implantação de sistema de DVP no HGJAF, apontar problemas a serem discutidos através de uma política de prevenção e intervenção precoces.

<p>Ventriculo-peritoneal shunting is the most commonly used method for the treatment of paediatric hydrocephalus. Despite improved shunts and surgical techniques there are still complications. This retrospective study focuses on diagnoses and treatment of shunt malfunction and infections. Cost/benefit of using an adjustable shunt was assessed. Two adjustable cerebrospinal fluid shunts and their compatible antisiphon devices were compared in-vitro.</p><p>In 21 of 46 children the standard shunt was changed to an adjustable one due to over-drainage. Adjustment of the shunt was performed in 73% of the children thereby avoiding surgery in several cases. This was a financial advantage.</p><p>Ascites or an abdominal pseudocyst without infection was detected in eight children due to resorption difficulties. A ventriculo-atrial shunt was inserted for a period of time. In three children it could successfully be reverted to a ventriculo-peritoneal.</p><p>In six children papilloedema was the only sign of shunt dysfunction. At revision the intracranial pressure ranged from 25 to 52 cm H₂O. Fundoscopic examination in children older than 8 years may detect symptomless shunt malfunction.</p><p>During a 13-year period 39 shunt infections were diagnosed. Skin bacteria were found in 80%. Prolonged and anaerobic cultures increased the detection rate by more than one third. The intraventricular infections were treated with intraventricular and systemic antibiotics resulting in quick sterilisation. No relapses were encountered. In five older children with distal catheter infection <i>Propionibacterium acne</i> was found. These were treated with intravenous antibiotics and exchanging of the shunt system.</p><p>Strata NSC^TM and Codman Hakim^TM worked according to the manufacturers except at the lowest setting. The resistance was below and in the lower range of the physiological one respectively. The antisiphon device of Strata shunt had to be placed in line with shunt to function properly. </p>

Ventriculo-peritoneal shunting is the most commonly used method for the treatment of paediatric hydrocephalus. Despite improved shunts and surgical techniques there are still complications. This retrospective study focuses on diagnoses and treatment of shunt malfunction and infections. Cost/benefit of using an adjustable shunt was assessed. Two adjustable cerebrospinal fluid shunts and their compatible antisiphon devices were compared in-vitro. In 21 of 46 children the standard shunt was changed to an adjustable one due to over-drainage. Adjustment of the shunt was performed in 73% of the children thereby avoiding surgery in several cases. This was a financial advantage. Ascites or an abdominal pseudocyst without infection was detected in eight children due to resorption difficulties. A ventriculo-atrial shunt was inserted for a period of time. In three children it could successfully be reverted to a ventriculo-peritoneal. In six children papilloedema was the only sign of shunt dysfunction. At revision the intracranial pressure ranged from 25 to 52 cm H2O. Fundoscopic examination in children older than 8 years may detect symptomless shunt malfunction. During a 13-year period 39 shunt infections were diagnosed. Skin bacteria were found in 80%. Prolonged and anaerobic cultures increased the detection rate by more than one third. The intraventricular infections were treated with intraventricular and systemic antibiotics resulting in quick sterilisation. No relapses were encountered. In five older children with distal catheter infection Propionibacterium acne was found. These were treated with intravenous antibiotics and exchanging of the shunt system. Strata NSCTM and Codman HakimTM worked according to the manufacturers except at the lowest setting. The resistance was below and in the lower range of the physiological one respectively. The antisiphon device of Strata shunt had to be placed in line with shunt to function properly.

Hintergrund: Die Anlage einer externen Ventrikeldrainage (EVD) ist ein gängiger Notfalleingriff in der Neurochirurgie, und Infektionen während der Liegezeit treten regelmäßig auf. Für die Antibiotikaprophylaxe bei Patienten mit EVD gibt es jedoch keine allgemeingültige Empfehlung oder Leitlinie. Daher hat jede Klinik ihre eigenen Standards. Fragestellung: Ziel der Arbeit war es herauszufinden, welchen Einfluss die Art der Antibiotikaprophylaxe auf die EVD-Infektionen sowie auf eine mögliche spätere Shuntimplantation und Infektion hat. Zudem sollten weitere Einflussfaktoren für Infektionen und Komplikationen mit einbezogen werden. Material und Methoden: Im Rahmen einer retroperspektiven Analyse von 564 Patienten (267 mit Subarachnoidalblutung, 297 mit intrazerebraler Blutung) aus den Jahren 2009-2015 mit externer Ventrikeldrainage am Universitätsklinikum Dresden wurde der Einfluss der Antibiotikaprophylaxe auf die Infektionen der externen Ventrikeldrainagen sowie auf eine spätere Shuntimplantation und deren Infektion untersucht. Ergebnisse: Insgesamt hatten 37% der Patienten mindestens eine Komplikation der EVD, wobei der größte Anteil der Patienten eine Verstopfung der EVD (13,5%) hatte, gefolgt von Fehllagen (9,2%) und Liquorinfektionen (6,2%). Insbesondere Verstopfungen und Infektionen traten in Kombination mit anderen Komplikationen auf. Durch eine Antibiotikaprophylaxe während der Liegezeit zeigte sich keine erniedrigte Infektionsrate, sondern eher eine leichte, nicht signifikante Steigerung der Infektionsrate. Mit zunehmender Anzahl der EVD-Wechsel, sowie Seitenwechsel, stieg die Infektionsrate signifikant. Auch eine initial okzipitale Lage der EVD war mit einer signifikant erhöhten Infektionsrate verbunden. Patienten, die nicht nur auf Intensivstationen behandelt wurden, zeigten ebenfalls eine erhöhte Infektionsrate. 272 Patienten erhielten einen ventrikuloperitonealen Shunt (61,4% mit SAB, 36,4% mit ICB), wovon bei 23,2% mindestens eine Komplikation auftrat. Hierunter waren 10,4% 51 Infektionen des Shunts. Patienten mit einer ICB hatten, im Gegensatz zu Patienten mit einer SAB, durch eine Infektion keine signifikant höhere Shuntpflichtigkeit. Sowohl bei den EVD- als auch bei den Shuntinfektionen bilden Hautkeime einen entscheidenden Anteil. Schlussfolgerung: In Zusammenschau der Ergebnisse und der Literaturrecherche ist eine Antibiotikaprophylaxe lediglich im Rahmen der operativen Eingriffe gegenüber einer Prophylaxe über die gesamte Liegezeit vorzuziehen. Da insbesondere die Komplikationen Verstopfung und Infektion in Kombination auftreten, ist hierbei besondere Aufmerksamkeit wichtig. Steriles Arbeiten und Vorsicht sind nicht nur im Rahmen der Operation, sondern auch in der täglichen Pflege notwendig, da Hautkeime das Hauterregerspektrum bilden. Die EVD-Anlage sollte, sofern möglich, frontal erfolgen.