Recovery From Surgery for Shunt Infections in Children

Postoperative Orders 

• ICU vs. standard care unit: This choice depends on the clinical status of the patient and the institution’s protocol for dealing with a patient with an externalized shunt or EVD. With regard to EVD, thought should be given to the institution’s policies for care of such a system when setting it up. In some cases the inclusion of a valve in the system can dramatically simplify the child’s care.
• VS: Routine.
• HOB, positioning, activity, bathing: HOB can be ad lib; however, personnel and parents should be aware of the constant relationship between the height of the drainage chamber and the head of the patient. Parents and personnel should be aware of current EVD height parameters and should make adjustments as required. Activity is restricted in accordance with the severity of the infection, and in some cases isolation is required.
• EVD setup and ICP: As a rule, the author prefers to set the EVD up to obtain an ICP of 5 cm H2O in an infant, 10 cm H2O in a child, and 15 cm H2O in an adolescent.

Medications and dosages

• Antibiotics: Prior to identifying the infecting organism and its sensitivities to antibiotics, broad- spectrum coverage for gram-positive and gram-negative organisms using agents with good penetration into the CSF is employed. Once the infectious organism is identified, the antibiotic regimen is tailored to it.

Laboratory studies

• Routine analysis of EVD drainage: At the author’s institution CSF samples are collected from the EVD catheter on Mondays and Thursdays, thereby allowing cultures to grow between these days. A careful side-to-side rotation of the head is performed before cultures are obtained, as the author and associates have observed that WBC and bacteria can settle down in the sediment of the ventricular cavities. An initial 3-ml syringe is filled with CSF and discarded, as usually this draw contains the CSF within the EVD and drainage set tubing. A second syringe is then drawn with a more representative sampling of CSF, which is sent immediately for cultures and not allowed to coagulate when high protein content is suspected.
• Assessment of management of infection: CBCs are repeated every 48 hours or so to monitor progress in suppression of the infection. Peak and trough antibiotic levels can be obtained to adjust dosing. Renal and liver function are checked every 48 hours to monitor for any adverse effects of the antibiotics, and serum protein and albumin/globulin ratio should be obtained as a check on the patient’s metabolic state.

Radiologic studies

• Repeat CT scan: If fevers persist, new signs or symptoms of CNS dysfunction develop, or there is evidence of malfunction in the EVD, a repeat CT scan should be obtained.

Consultations

• Infectious diseases department: In most cases of infected shunt systems, it is helpful to obtain recommendations and ongoing assistance from infectious disease consultants.

Postoperative Management of the Infection

• Duration of treatment guided by response: There is no consensus on how to determine that a patient is ready for reimplantation of a shunt after treatment of the infection. Typically there is an “in-house” protocol guiding the duration of treatment of the infection with antibiotics. The author treats for a period of 10 days after the first negative culture is reported and awaits a second negative CSF culture before planning for the shunt’s reinsertion.
• Evaluation of persisting signs of infection: In cases where CSF pleocytosis and positive cultures persist, a follow-up contrasted CT scan must be obtained in order to rule out loculated ventricles, abscess or empyema formation.

Postoperative Morbidity

• Ileus and gastrointestinal distress:  Distal shunt infections can result in gastroenteritis.  Failure in rapid symptom resolution after initiation in treatment should trigger assessment for a bowel perforation.