MANAGEMENT OF HYDROCEPHALUS

PRESENTER;

PEDRO MALONZA

KRPON-KNH THEATRES

Introduction

• The term hydrocephalus is derived from the Greek words `hydro` meaning water and `cephalus` meaning head.
• Hydrocephalus is a condition in which the primary characteristic excessive accumulation of cerebrospinal fluid in the brain. Caused by an imbalance in the ventricular system.

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Classification

• Based on its underlying mechanisms, can be classified into
• Communicating
• Non communicating(obstructive).both can be acquired or congenital.
• communicating
• Caused by impaired CSF resorption in the absence of any CSF-flow obstruction between the ventricles and subarachnoid space

Non communicating

Caused by a CSF-flow obstruction ultimately preventing CSF from flowing into the subarachnoid space(either due to external compression or due to intraventricular mass lesions.

Congenital the cranial bones fuse by the end of 3^rd year of life. For head enlargement to occur, hydrocephalus must occur before then.

The causes are usually genetic but can also be acquired and usually occur within the first few months of life.

• Acquired ;results due to consequence of CNS infections,meningitis,brain tumours,head trauma,intra cranial haemorrhage and is usually extremely painful.

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Preoperative considerations

� .NPO orders: 

• IVF rate: Fluid replacement should be started according to patient’s weight and fasting time prior to surgery.

.Antibiotics: Prophylactic antibiotics should be administered before anaesthesia.

• Clamp time for CSF drain: A period of 6–12 hours prior to surgery is recommended for clamping of external CSF drainage systems, under strict monitoring of vital signs and neurological status to detect clinical deterioration or raised ICP.
• Surgical site scrub: Chlorhexidine body wash night before and morning of surgery.

• Prematurity: Premature infants are more prone to shunt complications. Consider a temporary CSF diversion until patient has reached a minimum weight of 2000–2500 g,
• Malnutrition: correction of malnutrition (if present) is advisable for patients who will have a shunt insertion, in order to decrease the risk of infection, wound dehiscence, and shunt exposure.
• Coagulopathy and platelet disorders: Coagulation and platelet disorders must be corrected before surgery to avoid haemorrhagic complications such as intraparenchymal or intraventricular haemorrhage.
• Remote sepsis: Systemic infections must be completely treated before placing a shunt.
• Seizures: Anti-epileptic medications must be continued on regular dosage during the perioperative period

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Management

• Management is directed towards;
• Relief of hydrocephalus
• Treatment of complications
• Management of problems related to the effect of the disorder on psychomotor development.

1) Medical management

2) Surgical management

3) Nursing management

Surgical management consist of….

• Removal of the obstruction(tumour haemorrhage or cyst) to the flow of CSF.
• Reduction in the amount of CSF produced through destruction of a portion of the choroid plexus or a third or fourth vestriculostomy.
• Shunting of CSF from the ventricle to another site in the normal circulatory passageway of the fluid.
• Shunting of CSF from the ventricle to an area outside the CNS,an extracranial body compartment/

• Ventriculoperitonial(VP) shunt-is the most preferred procedure especially in neonates and young infants.
• There's is a greater allowance for excess tubing which minimizes the number of revisions needed as the child grows.
• An incision is made in abdomen & through rectus muscle into the peritoneum.
• The proximal catheter end of the catheter is slipped beneath the skin of anterior abdominal &chest wall to the neck.
• The ventricular catheter with attached valve is then sutured to the peritoneal catheter. The CSF is absorbed by tissues in the abdominal cavity.

Ventriculoatrial(VA) shunt

• Reserved for older children who have attained most of their somatic growth & children with abdominal pathology.
• It requires repeated lengthening as child grows.
• A silicone catheter is inserted in lateral ventricle &down through the internal jugular vein into the left atrium of heart.
• The CSF drains into circulating blood.
• NB-this type of shunt may become easily obstructed or infected.
• If infection occurs bacterial endocarditis,ventriculitis & bacteraemia may result.

Ventriculopleural shunts

• These shunts are sometimes used in children over 5yrs.
• Drains fluid from lateral ventricle to the pleural cavity.
• Drainage of CSF may cause hydrothorax, necessitating either removal of the shunt or a thoracentesis.
• The nurse must observe these children carefully for respiratory difficulties.

Endoscopic third ventriculostomy

• It is a procedure that has a potential for greater independence from VP or VA shunting in children with non communicating hydrocephalus.
• A small opening is made in the floor of the 3^rd ventricle allowing CSF to flow freely through previously blocked ventricle, thus bypassing the aqueduct of sylvius.
• Reports of success in children,however as surgical techniques &advances continue,it is expected that neonates & small children will sucessfully treated with this procedure rather than conventional shunting.

Complications of shunts

• Major are infection and malfunction.
• All shunts are subjected to mechanical difficulties eg kinking,plugging or separation &migration of tubing.
• 1) Malfunction; caused by mechanical obstruction either within the ventricles from articulate matter or at distal end from thrombosis or displacement as a result of growth.
• The child with shunt obstruction oten presents as an emergency with clinical manifestations of ICP, frequently accompanied by worsening neurologic status.

2) Infection; period of greatest risk is 1-2 months following placement. This include sepsis, bacterial endocarditis, wound infection, shunt nephritis, meningitis.

3)Subdural hematoma;caused by rapid reduction of ICP & size.

4)others-peritonitis,abdominal abscess, perforation of abdominal organs by catheter or trochar,fistula,hernia.

Nursing management

A)Teach the family about the management for the disorder-1)treatment is by surgical by direct removal of obstruction and insertion of a shunt to provide drainage

-Major complications are infection and malfunction

B)provide perioperative nursing care;assess head circumference,fontanelles,cranial sutures,altered feeding habits and high pitched cry.

• Firmly support the head and neck when holding the child
• Provide skin care for the head to prevent breakdown
• Encourage parental-newborn bonding

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C) Provide post operative nursing care

-Assess for signs of increased ICP and check head circumference(daily) anterior fontanelles for size and fullness and behaviour.

-Administer prescribed medications to prevent infection and pain

-If increased ICP elevate the head of the bed or allow the child to sit up to enhance gravity flow through shunt.

-observe the child for abdominal distension

-maintain input-output chart.

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Provide shunt care-

• monitor for shunt infection-rapid onset of vomitting,severe headache,irritbility,lethargy,fever,redness along the shunt tract.

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-prevent infection

-monitor for shunt overdrainage-headache,dizziness and nausea,overdrainage may lead to slit ventricle syndrome limiting the buffering ability to increased ICP variations.

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Encourage the child to participate in age-appropriate activities as tolerated.

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recommendations

Treatment with ventriculo-peritoneal shunts remains the best method of preventing life-long disability from increased ICP in Africa.

• Prevention of hydrocephalus can be accomplished through efforts directed at the correct management of neonatal infections
• Both mechanical and infectious shunt complications can be significantly reduced through meticulous technique and experience.

• Children for hydrocephalus must be followed up for life and have rapid access to health care facilities in the case of complications.

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• Shunt placement must be a thoroughly sterile procedure perfomed by skilled, experienced surgeons.
• Endoscopic 3^rd ventriculostomy shows significant promise for avoiding shunt morbidity with hydrocephalus,but remains limited by technology and skills.

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references

• Marlow R. Dorothy,Redding A. Barbara;Textbooks od Pediatric Nursing;sixth edition;Saunders Elsevier;522-527
• Hockenberry,Wilson;Wongs Nursing care of infants and children;7 edition Mosby;436-443
• Ghai OP, Paul K Vinod,Bagga Arvind;Ghai essentia l padiatrics;7^th edition CBS Publications,548-549
• Datta Parul;pediatric Nursing;2^nd edition;Jaypee 406-409
• Singh Meharban;Care of the Newborn;5^th edition;Sagar Publications;338