CSW Hydrocephalus Pathway

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To Surgery Hydrocephalus: Emergency Department v.1.1 Approval & Citation Explanation of Evidence Ratings Summary of Version Changes Last Updated: 03/2016 Next Expected Revision:03/2021 © 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer For questions concerning this pathway, contact: [email protected] Assessment Imaging · DX shunt series · CT Head w/o contrast STEALTH · Abdominal signs or symptoms (acute abdomen) · Early (< 3 months of shunt placement): abdominal CT IV/PO contrast · Delayed (> 3 months of shunt placement): ultrasound abdomen - limited Labs · Concern for new hydrocephalus: CBC w/diff, PT/PTT · Concern for shunt infection: CBC w/diff, ESR, CRP, serum glucose, BUN and serum creatinine, blood cultures. · Consider workup for other source of infection (could include respiratory panel, urinalysis, throat culture, urine culture, stool culture, chest XR if indicated) · Concern for shunt malfunction: CBC w/diff Notify Neurosurgery after labs are resulted · Neurosurgery to determine if and when to begin antibiotics · Determine if surgery needed · Shunt/Reservoir tap per shunt tap protocol below · Shunt/Reservoir Tapping protocol · Tap to be done by Neurosurgery only · Tap if within 2 weeks of surgery with fever or · Tap if within 3 months of surgery with fever and no other source of infection · If > 3 months consider tap at neurosurgery discretion · If shunt/reservoir tapped send CSF for gram stain, culture, cell count, protein glucose, and bacterial PCR (use CSF Studies Orderset) Definitions Clinical signs of shunt malfunction · Children < 1 year old bulging fontanelle, rapidly increasing OFC, downward deviation of the eyes, less interest in feeding · Children > 1 year old Headaches, cranial nerve signs, changes in vision · All ages vomiting, lethargy, swelling along shunt tract, irritability without another recognized cause, lethargy · Please note that an isolated seizure is not a prognostic indication of a shunt malfunction Clinical signs of shunt infection · Fever (38.5°C) and shunt placement within last 3 months and no other source of infection · Fever (38.5°C) and shunt placement within the last 2 weeks · Wound overlying the implanted shunt material · Erythema, swelling or drainage from incisions · Redness along the shunt tract New Hydrocephalus · Radiographic imaging with findings of new hydrocephalus Unstable Patient · Abnormal vital signs (bradycardia/ hypertension/altered respiratory rate, obtunded/unresponsive) Emergent Surgery: patient to OR in <1 hour Urgent Surgery: patient to OR in 1-4 hours (can be transferred to inpatient unit) No Surgery Off Pathway Surgery Preparation · Start admission process · Initiate admission orders · Admit patient directly to OR or to inpatient unit - see ED Job Aid: ED-OR Transfer for Emergent or Urgent surgery (for SCH only) Surgery Needed · NOTIFY ED ATTENDING IMMEDIATELY · Evaluate and stabilize: ABCD · Elevate head of bed to 30 degrees/head midline · Place on full monitors with BP to cycle every 15 minutes · If seizing initiate Seizure Acute Management Pathway · Notify Neurosurgery on call immediately · Proceed with assessment ! Unstable? Stable Notify ED attending For screening Unstable Inclusion Criteria · New hydrocephalus including scheduled referral, suspected shunt malfunction, or suspected shunt infection Exclusion Criteria · <1 month of age, <44 wks PMA · New brain tumor · Non-accidental trauma/trauma · Patients who undergo ETV who have had prior shunt Emergent Urgent Assessment · NPO · Conduct complete physical exam including neuro exam · Document Glascow Coma Score Phase Change · Postop Shunt Placement · Postop ETV · Postop Infection CT Head w/o contrast STEALTH Postop ETV-CPC Postop Shunt Placement Postop Infection

Transcript of CSW Hydrocephalus Pathway

Page 1: CSW Hydrocephalus Pathway

To

Surgery

Hydrocephalus: Emergency Department v.1.1

Approval & Citation Explanation of Evidence RatingsSummary of Version Changes

Last Updated: 03/2016

Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: [email protected]

AssessmentImaging

· DX shunt series

· CT Head w/o contrast STEALTH

· Abdominal signs or symptoms (acute abdomen)

· Early (< 3 months of shunt placement): abdominal CT IV/PO contrast

· Delayed (> 3 months of shunt placement): ultrasound abdomen - limited

Labs

· Concern for new hydrocephalus: CBC w/diff, PT/PTT

· Concern for shunt infection: CBC w/diff, ESR, CRP, serum glucose, BUN and serum

creatinine, blood cultures.

· Consider workup for other source of infection (could include respiratory panel,

urinalysis, throat culture, urine culture, stool culture, chest XR if indicated)

· Concern for shunt malfunction: CBC w/diff

Notify Neurosurgery after labs are resulted

· Neurosurgery to determine if and when to begin antibiotics

· Determine if surgery needed

· Shunt/Reservoir tap per shunt tap protocol below

· Shunt/Reservoir Tapping protocol

· Tap to be done by Neurosurgery only

· Tap if within 2 weeks of surgery with fever or

· Tap if within 3 months of surgery with fever and no other source of infection

· If > 3 months consider tap at neurosurgery discretion

· If shunt/reservoir tapped send CSF for gram stain, culture, cell count, protein

glucose, and bacterial PCR (use CSF Studies Orderset)

Definitions

Clinical signs of shunt

malfunction· Children < 1 year old – bulging

fontanelle, rapidly increasing OFC,

downward deviation of the eyes, less

interest in feeding

· Children > 1 year old – Headaches,

cranial nerve signs, changes in vision

· All ages – vomiting, lethargy,

swelling along shunt tract, irritability

without another recognized cause,

lethargy

· Please note that an isolated seizure

is not a prognostic indication of a

shunt malfunction

Clinical signs of shunt infection· Fever (38.5°C) and shunt placement

within last 3 months and no other

source of infection

· Fever (38.5°C) and shunt placement

within the last 2 weeks

· Wound overlying the implanted shunt

material

· Erythema, swelling or drainage from

incisions

· Redness along the shunt tract

New Hydrocephalus· Radiographic imaging with findings of

new hydrocephalus

Unstable Patient· Abnormal vital signs (bradycardia/

hypertension/altered respiratory rate,

obtunded/unresponsive)

Emergent Surgery: patient to OR in

<1 hour

Urgent Surgery: patient to OR in 1-4

hours (can be transferred to inpatient

unit)

No

Surgery

Off

Pathway

Surgery Preparation· Start admission process

· Initiate admission orders

· Admit patient directly to OR or to inpatient unit - see ED Job Aid: ED-OR Transfer for

Emergent or Urgent surgery (for SCH only)

Surgery Needed

· NOTIFY ED ATTENDING IMMEDIATELY

· Evaluate and stabilize: ABCD

· Elevate head of bed to 30 degrees/head midline

· Place on full monitors with BP to cycle every 15 minutes

· If seizing initiate Seizure Acute Management Pathway

· Notify Neurosurgery on call immediately

· Proceed with assessment

!Unstable?

Stable

Notify ED attending

For screening

Unstable

Inclusion Criteria

· New hydrocephalus including scheduled

referral, suspected shunt malfunction, or

suspected shunt infection

Exclusion Criteria

· <1 month of age, <44 wks PMA

· New brain tumor

· Non-accidental trauma/trauma

· Patients who undergo ETV who have

had prior shunt

Emergent Urgent

Assessment· NPO

· Conduct complete physical exam

including neuro exam

· Document Glascow Coma Score

Phase Change· Postop Shunt Placement

· Postop ETV

· Postop Infection

CT Head w/o contrast STEALTH

Postop ETV-CPC

Postop Shunt Placement

Postop Infection

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Hydrocephalus: Clinic/Inpatient Admit v.1.1

Surgery

needed?No

Off

Pathway

Surgery Preparation· Start admission process

· Initiate admission orders

· Admit patient directly to OR or to inpatient unit (Emergent vs. Urgent)

Yes

To Surgery

AssessmentSend unstable patient to ER

Imaging

· New presentation hydrocephalus

· CT brain without contrast STEALTH

· MRI brain Hydrocephalus Protocol to evaluate if candidate for ETV, if indicated

· Shunt malfunction or shunt infection

· CT brain without contrast STEALTH

· If previous CT at Seattle Children’s: order low-dose CT

· If clinically stable and has Strata valve, non-programmable valve, or no valve:

order MRI brain HASTE

· XR Shunt Series

· Abdominal signs or symptoms (acute abdomen)

· Early (<3 months of shunt replacement): abdominal CT IV/PO contrast

· Delayed (>3 months of shunt placement): Ultrasound Abdomen – Limited

Labs

· Concern for new hydrocephalus: CBC w/ diff, PT/PTT

· Concern for shunt infection:

· CBC w/ diff, ESR, CRP, serum glucose, BUN and serum creatinine, blood

cultures

· Consider workup for other source of infection (could include respiratory panel,

urinalysis, throat culture, urine culture, stool culture, chest XR if indicated)

· Concern for shunt malfunction: CBC w/ diff

· Shunt/Reservoir tap per shunt tap protocol below

· Shunt/Reservoir Tapping protocol

· Tap to be done by Neurosurgery only

· Tap if within 2 weeks of surgery with fever or

· Tap if within 3 months of surgery with fever and no other source of

infection

· If > 3 months consider tap at neurosurgery discretion

· If shunt/reservoir tapped send CSF for gram stain, culture, cell count, protein

glucose, and bacterial PCR (use CSF Studies Orderset)

· Determine if surgery needed

Definitions

Clinical signs of shunt

malfunction· Children < 1 year old – bulging

fontanelle, rapidly increasing OFC,

downward deviation of the eyes, less

interest in feeding

· Children > 1 year old – Headaches,

cranial nerve signs, changes in vision

· All ages – vomiting, lethargy,

swelling along shunt tract, irritability

without another recognized cause,

lethargy

· Please note that an isolated seizure

is not a prognostic indication of a

shunt malfunction

Clinical signs of shunt infection· Fever (38.5°C) and shunt placement

within last 3 months and no other

source of infection

· Fever (38.5°C) and shunt placement

within the last 2 weeks

· Wound overlying the implanted shunt

material

· Erythema, swelling or drainage from

incisions

· Redness along the shunt tract

New Hydrocephalus· Radiographic imaging with findings of

new hydrocephalus

Unstable Patient· Abnormal vital signs (bradycardia/

hypertension/altered respiratory rate,

obtunded/unresponsive)

!

Inclusion Criteria

· New hydrocephalus including scheduled

referral, suspected shunt malfunction, or

suspected shunt infection

Exclusion Criteria

· <1 Month of age, <44 weeks PMA

· New brain tumor

· Non-accidental trauma/trauma

· Patients who undergo ETV who have

had prior shunt

Phase Change· Postop Shunt Placement

· Postop ETV

· Postop Infection

Last Updated: 03/2016

Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: [email protected]

Approval & Citation Explanation of Evidence RatingsSummary of Version Changes

Imaging

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Hydrocephalus: Postop Shunt Placement/Revision v.1.1

Management

Discharge

Instructions· Follow-up with

neurosurgery NP in 2

weeks for wound

check, and with

neurosurgeon in 6

weeks for HASTE MR/

CT

· Patient transferred from OR to inpatient unit

· Vitals:

· Neurological checks: q2 hours x 6hours; q 4 hours till

discharge

· Monitors: Continuous cardiorespiratory monitors x 12

hours then only when asleep

· Activity: Ad Lib

· Nursing: see Hydrocephalus GOC

· Elevate head of bed to 30 degrees

· Bathing: patient may bathe at 48 hours postoperative; no

soaking.

· Diet: Standard diet

· Fluids:

· ≥ 1 month of age: D5NS + KCl 20 mEq/L

· Post-op Imaging:

· CT scan

· DX shunt series

· Medications

· Miralax/Docusate scheduled, suppository or senna PRN

· Pain:

· Acetaminophen scheduled x 1 day then PRN

starting in OR/PACU.

· Alternate ibuprofen with acetaminophen, but delay

starting ibuprofen until 4 hours postop to minimize

bleeding risk

· Labs: none

· Place discharge orders (anticipated 24-48 hours)

Discharge Criteria· Afebrile x 24 hours

· Tolerating PO/PO pain med

· No nausea or vomiting

· Tolerating up out of bed.

Inclusion Criteria

· Postop shunt placement

Exclusion Criteria

· < 1 Month of age, <44 weeks PMA

· New brain tumor

· Non-accidental trauma/trauma

· Patients who undergo ETV who

have had prior shunt

Last Updated: 03/2016

Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: [email protected]

Approval & Citation Explanation of Evidence RatingsSummary of Version Changes

Hydrocephalus GOC (for SCH only)

≥ 5 years

< 5 years

Patient Age

Outpatient Follow-up

Shunt

Haste MRI yearly

· Follow up every other year with a

HASTE MRI and shunt series

· If patient has codman: CT every

other year per provider discretion

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Management

Discharge

Instructions· Follow-up with

neurosurgery NP in 2

weeks for wound

check, and with

neurosurgeon in 6

weeks for HASTE

MRI/CT

· Patient transferred from OR to inpatient unit

· Vitals:

· Neurological checks: q2 hours x 6hours; q 4 hours till

discharge

· Monitors: Continuous cardiorespiratory monitors x 12

hours then only when asleep

· Activity: Ad Lib

· Nursing: see Hydrocephalus GOC

· Elevate head of bed to 30 degrees

· Bathing: patient may bathe at 48 hours postoperative; no

soaking.

· Diet: Standard diet

· Fluids:

· ≥ 1 month of age: D5NS + KCl 20 mEq/L

· Post-op Imaging:

· CT scan

· DX shunt series

· Medications

· Miralax/Docusate scheduled, suppository or senna PRN

· Pain:

· Acetaminophen scheduled x 1 day then PRN

starting in OR/PACU.

· Alternate ibuprofen with acetaminophen, but delay

starting ibuprofen until 24 hours postop to minimize

bleeding risk

· Labs: Check sodium night of surgery and next AM

· Place discharge orders (anticipated 24-48 hours)

Discharge Criteria· Afebrile x 24 hours

· Tolerating PO/PO pain med

· No nausea or vomiting

· Tolerating up out of bed.

Hydrocephalus: Endoscopic Third Ventriculostomy (ETV)/

Choroid Plexus Cauterization v.1.1

Inclusion Criteria· Postop ETV/CPC

Exclusion Criteria· <1 Month of age, <44 weeks

PMA

· New brain tumor

· Non-accidental trauma/trauma

· Patients who undergo ETV who

have had prior shunt

Last Updated: 03/2016

Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: [email protected]

Approval & Citation Explanation of Evidence RatingsSummary of Version Changes

≥ 5 years

< 5 years

Patient Age

Outpatient Follow-up

ETV

Haste MRI yearly

Order full CINE MRI first year,

followed by yearly HASTE MRI

Management

Hydrocephalus GOC (for SCH only)

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Hydrocephalus: Suspected Shunt Infection v.1.1

Management

Phase

Change

Patient returns to OR for new shunt

· Diet: Regular Diet

· Fluids:

· ≥ 1 month of age: D5NS +20KCl

· Fluid replacement NS 1:1 for drain output

· Medications

· Miralax/Docusate scheduled, suppository or senna PRN

· Pain:

· Acetaminophen scheduled x 1 day then PRN starting

in OR/PACU

· Oxycodone PRN for breakthrough pain

· Consult Infectious Disease

· Initiate antibiotics in consultation with ID

· Patient transferred from OR to inpatient unit

· Vitals:

· Neurological checks: q 2 hours x 6 hours then q 4 hours

· Monitors: Continuous CR monitors

· Activity: Bedrest. Out of bed with drain clamps 30 mins x 3

times/day

· Nursing: see Hydrocephalus GOC and

P&P: Ventriculostomy and Lumbar Drain Care

· PICC line

· Elevate head of bed to 30 degrees

· Bacitracin to insertion site BID

· No bathing with EVD in place

· Record strict I&O

· Refer to orders for EVD output parameters Click here for guidance on empiric antibiotic therapy

Monitor Response to Therapy

· Check CSF gram stain, culture, cell count, glucose, and

protein

· Obtain CSF from ventriculostomy catheter (not the bag).

· Order daily until there are 3 negative cultures, then every

Monday/Thursday

· Check CBC/differential daily for 7 days then Monday/Thursday

· Check ESR/CRP, electrolytes every other day for 7 days then

Monday/Thursday

· For ventriculitis caused by gram-negative organisms, order

MRI with and without contrast prior to discontinuing therapy

· For Complicated CSF Shunt Infection

· Consider CT scan of head with contrast, bone scan,

antibiotic levels in CSF to investigate reasons for

persistent sites of infection

· Additional or prolonged therapy may be necessary,

consult outpatient ID

· Insert new shunt after definitive completion of antibiotic

therapy

Inclusion Criteria· Postop suspected shunt or CSF

infection

Exclusion Criteria· <1 Month of age, <44 weeks PMA

· New brain tumor

· Non-accidental trauma/trauma

· Patients who undergo ETV who

have had prior shunt

Last Updated: 03/2016

Next Expected Revision:03/2021© 2016 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: [email protected]

Approval & Citation Explanation of Evidence RatingsSummary of Version Changes

P&P: Ventriculostomy and Lumbar Drain Care (for SCH Only)Hydrocephalus GOC

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Return to ED Return to Clinic

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Return to Postop ETV-CPC

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Return to Postop Infection

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Return to Postop Infection

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Return to Postop Infection

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Hydrocephalus Approval & Citation

Approved by the CSW Hydrocephalus for 3/1/2016

CSW Hydrocephalus Team:

CSW Owner: Sam Browd, MD

Neurosurgery, Nurse Practitioner: Angela Forbes, RN, MN, ARNP

Neurosurgery, Nurse Practitioner: Mandy Breedt, RN, MN, ARNP

Clinical Pharmacist: Anna Zhen

Eric Harvey, PharmD, MBA

Pharmacy Informatics: Rebecca Ford, PharmD

Emergency Department, CNS: Sara Fenstermacher, RN, MSN, CPN

Surgery, CNS Erin Moriarty, RN, MSN, CPN

Surgery, CNS Kristine Lorenzo, RN

Emergency Department, Physician: Ryan Kearney, MD

Emergency Department, Physician: Russ Migita, MD

Laboratory: Xuan Qin, PhD

Radiology, Physician: Dennis Shaw, MD

Clinical Effectiveness Team:

Consultant: Jennifer Hrachovec, PharmD, MPH

Project Manager: Kate Drummond, MS, MPA

Project Manager: Gioia Gonzalez, MSW, LICSW

CE Analyst: Nate Deam, MHA

CIS Informatician: Michael Leu, MD

CIS Analyst: Heather Marshall

Librarian: Sue Groshong, MLS

Project Manager Associate: Asa Herrman

Executive Approval:

Sr. VP, Chief Medical Officer Mark Del Beccaro, MD

Sr. VP, Chief Nursing Officer Madlyn Murrey, RN, MN

Surgeon-in-Chief Bob Sawin, MD

Retrieval Website: http://www.seattlechildrens.org/pdf/hydrocephalus-pathway.pdf

Please cite as:

Seattle Children’s Hospital, Browd S, Breedt Mandy, Drummond K, Fenstermacher S, Forbes A,

Ford R, Gonzalez G, Hrachovec J, Kearney R, Leu M, Lorenzo K, Migita R, Moriarty E , Shaw D,

2016 March. Hydrocephalus Pathway. Available from: http://www.seattlechildrens.org/pdf/

hydrocephalus-pathway.pdf

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Evidence Ratings

We used the GRADE method of rating evidence quality. Evidence is first assessed as to

whether it is from randomized trial, or observational studies. The rating is then adjusted in the following manner:

Quality ratings are downgraded if studies:• Have serious limitations

• Have inconsistent results• If evidence does not directly address clinical questions• If estimates are imprecise OR

• If it is felt that there is substantial publication bias

Quality ratings can be upgraded if it is felt that:• The effect size is large• If studies are designed in a way that confounding would likely underreport the magnitude

of the effect OR• If a dose-response gradient is evident

Quality of Evidence: High quality

Moderate quality

Low quality

Very low quality

Expert Opinion (E)

Reference: Guyatt G et al. J Clin Epi 2011: 383-394

To Bibliography Return to ED Return to Clinic

Page 13: CSW Hydrocephalus Pathway

Summary of Version Changes

· Version 1 (3/1/2016): Go live

· Version 1.1 (3/9/2016): Removed amphotericin dosing

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Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience

broaden our knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to

provide information that is complete and generally in accord with the standards

accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences,

neither the authors nor Seattle Children’s Healthcare System nor any other party

who has been involved in the preparation or publication of this work warrants that

the information contained herein is in every respect accurate or complete, and

they are not responsible for any errors or omissions or for the results obtained

from the use of such information.

Readers should confirm the information contained herein with other sources and

are encouraged to consult with their health care provider before making any

health care decision.

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Bibliography

Identification

Screening

Eligibility

Included

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

To Bibliography, Pg 2

782 records identified

through database searching

2 additional records identified

through other sources

764 records after duplicates removed

764 records screened 613 records excluded

110 full-text articles excluded,

101 did not answer clinical question

8 did not meet quality threshold

1 outdated relative to other included study

151 records assessed for eligibility

41 studies included in pathway

Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian, Susan Groshong. Searches were performed in August and September, 2013. The following databases were searched – on the Ovid platform: Medline, Cochrane Database of Systematic Reviews (2005 to date), Cochrane Central Register of Controlled Trials; elsewhere: Embase, CINAHL, Clinical Evidence, National Guideline Clearinghouse, TRIP, Cincinnati Children’s Evidence-Based Care Guidelines, Registered Nurses' Association of Ontario and Nursing+. Retrieval was limited to ages 0 – 18 (0 – 24 in Medline), English language and 2002 to current. In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, along with text words, and the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words. Concepts searched were hydrocephalus, ventricular or cerebrospinal shunts, ventriculostomy and any of the following: diagnostic imaging, laboratory tests, infections, postoperative care. All retrieval was further limited to certain evidence categories, such as relevant publication types, Clinical Queries, index terms for study types and other similar limits. Additional articles were identified by team members and added to results.

Susan Groshong, MLIS

December 2, 2013

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Page 16: CSW Hydrocephalus Pathway

Bibliography

To Bibliography, Pg 2

Arnell K, Cesarini K, Lagerqvist-Widh A, Wester T, Sjolin J. Cerebrospinal fluid shunt infections in

children over a 13-year period: Anaerobic cultures and comparison of clinical signs of

infection with propionibacterium acnes and with other bacteria. J Neurosurg Pediatrics

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Banks JT, Bharara S, Tubbs RS, et al. Polymerase chain reaction for the rapid detection of

cerebrospinal fluid shunt or ventriculostomy infections. Neurosurgery [Hydrocephalus

(Added)]. 2005;57(6):1237-43; discussion 1237-43.

Baradkar VP, Mathur M, Sonavane A, Kumar S. Candidal infections of ventriculoperitoneal shunts.

J Pediatr Neurosci [Hydrocephalus]. 2009;4(2):73-75.

Baykan N, Isbir O, Gercek A, Dagcnar A, Ozek MM. Ten years of experience with pediatric

neuroendoscopic third ventriculostomy: Features and perioperative complications of 210

cases. J Neurosurg Anesthesiol [Hydrocephalus]. 2005;17(1):33-37.

Benca J, Ondrusova A, Huttova M, Rudinsky B, Kisac P, Bauer F. Neuroinfections due to

enterococcus faecalis in children. Neuroendocrinol Lett [Hydrocephalus]. 2007;28(Suppl

2):32-33.

Bhatia R, Tahir M, Chandler CL. The management of hydrocephalus in children with posterior

fossa tumours: The role of pre-resectional endoscopic third ventriculostomy. Pediatr

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10.1159/000222668.

Bouras T, Sgouros S. Complications of endoscopic third ventriculostomy. World Neurosurg

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Bouras T, Sgouros S. Complications of endoscopic third ventriculostomy. J Neurosurg Pediatrics

[Hydrocephalus]. 2011;7(6):643-649. Accessed 20110602; 8/13/2013 5:50:53 PM. http://

dx.doi.org/10.3171/2011.4.PEDS10503.

Buxton N, Turner B, Ramli N, Vloeberghs M. Changes in third ventricular size with

neuroendoscopic third ventriculostomy: A blinded study. J Neurol Neurosurg Psychiatry

[Hydrocephalus]. 2002;72(3):385-387.

Chern JJ, Muhleman M, Tubbs RS, et al. Clinical evaluation and surveillance imaging in children

with spina bifida aperta and shunt-treated hydrocephalus. J Neurosurg Pediatrics

[Hydrocephalus]. 2012;9(6):621-626. Accessed 09/23/2013. http://dx.doi.org/10.3171/

2012.2.PEDS11353.

Chugh A, Husain M, Gupta RK, Ojha BK, Chandra A, Rastogi M. Surgical outcome of tuberculous

meningitis hydrocephalus treated by endoscopic third ventriculostomy: Prognostic factors and

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Cinalli G, Spennato P, Ruggiero C, et al. Complications following endoscopic intracranial

procedures in children. Childs Nerv Syst [Hydrocephalus]. 2007;23(6):633-644.

Conen A, Walti LN, Merlo A, Fluckiger U, Battegay M, Trampuz A. Characteristics and treatment

outcome of cerebrospinal fluid shunt-associated infections in adults: A retrospective analysis

over an 11-year period. Clin Infect Dis [Hydrocephalus]. 2008;47(1):73-82. Accessed 09/23/

2013. http://dx.doi.org/10.1086/588298.

Desai KR, Babb JS, Amodio JB. The utility of the plain radiograph "shunt series" in the evaluation

of suspected ventriculoperitoneal shunt failure in pediatric patients. Pediatr Radiol

[Hydrocephalus]. 2007;37(5):452-456.

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Page 17: CSW Hydrocephalus Pathway

Bibliography

Di Rocco F, Grevent D, Drake JM, et al. Changes in intracranial CSF distribution after ETV. Childs

Nerv Syst [Hydrocephalus]. 2012;28(7):997-1002. Accessed 09/23/2013. http://dx.doi.org/

10.1007/s00381-012-1752-6.

Dincer A, Yildiz E, Kohan S, Memet Ozek M. Analysis of endoscopic third ventriculostomy patency

by MRI: Value of different pulse sequences, the sequence parameters, and the imaging planes

for investigation of flow void. Childs Nerv Syst [Hydrocephalus]. 2011;27(1):127-135. Accessed

09/23/2013. http://dx.doi.org/10.1007/s00381-010-1219-6.

Faggin R, Calderone M, Denaro L, Meneghini L, d'Avella D. Long-term operative failure of

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Fukuhara T, Luciano MG, Kowalski RJ. Clinical features of third ventriculostomy failures classified

by fenestration patency. Surg Neurol [Hydrocephalus]. 2002;58(2):102-110.

Hader WJ, Walker RL, Myles ST, Hamilton M. Complications of endoscopic third ventriculostomy in

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