HAPPY SUMMER! It’s time again for our semi-annual newsletter. I will take every opportunity available to thank my referring physicians for the trust they have put in me to care for their wards. I was reminded again this week, as the 14-year old boy with C4-6 fractures from a diving accident walked into the office, asymptomatic, that many of our best surgical outcomes, are the outcomes on whom we never operated. I do believe that, as physicians, we have great power to do good, and we must remember to use that power, only when necessary. I mean no political statement with this belief, only to re-iterate that, as a surgeon, while I like to do surgery, I want to be sure that I am aiding the patient with the surgery. By avoiding unnecessary surgery, we are able to accomplish many things. In 2006, I was the only pediatric neurosurgeon in the US who performed >50 shunts, with >50% of them new implants, rather than revisions. We have been blessed with a high success rate and a low failure rate. Our infection rate has dropped so low, we are publishing our outcomes, documenting one of the most dramatic drops in infection rates ever described. The abstract is to the right.
Introduction: Ventriculo-peritoneal shunt infections are the most common infectious complication in pediatric neurosurgery. In 2003, the Orlando pediatric ventriculo-peritoneal shunt infection rate of 8.6% was slightly above the national average. In an effort to reduce the infection rate, a protocol was introduced to be used in all shunt surgeries.
Methods: We prospectively gathered data on all shunt implants. Our protocol consisted of: 1. Minimizing surgical personnel in the OR(<4 is preferred) 2. Eliminating use of surgical assistance 3. Minimizing surgical time(<15 minutes is preferred) 4. Using anti-biotic impregnated shunts(if possible) 5. Minimizing use of programmable valves 6. Performing shunts with neuro team, as a first case. We followed all shunts for a minimum of 6 months, and defined a shunt infection as a positive CSF culture within 6 months of surgery. Variables such as patient age, number of shunt operations, length of stay, concomitant medical diagnoses, etc were analyzed to minimize confounding factors.
Results: The ventriculo-peritoneal shunt infection rate dropped from 8.6% in 2003 to 1.8% in 2006, while other variables usually associated with increased infection risk, e.g. younger patient age, more complex medical issues/diagnoses, trended toward higher risk. The only infection in 2006 was in a patient with >100 previous shunt operations, whose skin broke down and she developed a candidal shunt infection.
Conclusions: With stringent adherence to a strict protocol, <2% is an attainable goal for ventriculo-peritoneal shunt infection rates. |
