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Hydrocephalus Clinical Pathway: James L. Patigayon

Hydrocephalus is a buildup of cerebrospinal fluid in the brain ventricles that increases pressure on the brain. It can occur at any age but is more common in infants and adults over 60. Surgical treatment can restore normal fluid levels and symptoms require various therapies. The document outlines clinical pathways for assessing and managing hydrocephalus in emergency departments and post-surgery, including for shunt placement, infection, and endoscopic procedures.

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Jayson Olile
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80 views6 pages

Hydrocephalus Clinical Pathway: James L. Patigayon

Hydrocephalus is a buildup of cerebrospinal fluid in the brain ventricles that increases pressure on the brain. It can occur at any age but is more common in infants and adults over 60. Surgical treatment can restore normal fluid levels and symptoms require various therapies. The document outlines clinical pathways for assessing and managing hydrocephalus in emergency departments and post-surgery, including for shunt placement, infection, and endoscopic procedures.

Uploaded by

Jayson Olile
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Hydrocephalus Clinical Pathway

James L. Patigayon
Hydrocephalus is the buildup of fluid in the cavities (ventricles) deep within the brain. The excess fluid
increases the size of the ventricles and puts pressure on the brain. Cerebrospinal fluid normally flows through the
ventricles and bathes the brain and spinal column. But the pressure of too much cerebrospinal fluid associated
with hydrocephalus can damage brain tissues and cause a range of impairments in brain function.
Hydrocephalus can happen at any age, but it occurs more frequently among infants and adults 60 and
over. Surgical treatment for hydrocephalus can restore and maintain normal cerebrospinal fluid levels in the brain.
Many different therapies are often required to manage symptoms or functional impairments resulting from
hydrocephalus.

Hydrocephalus: Emergency Department

Assessment
 NPO
 Conduct complete physical exam including
neuro exam
 Document Glascow Coma Score

Unstable?
YES NO

Assessment  NOTIFY ED ATTENDING IMMEDIATELY


 Evaluate and stabilize: ABCD
Imaging
 Elevate head of bed to 30
 DX shunt series degrees/head midline
 CT Head w/o contrast STEALTH  Place on full monitors with BP to cycle
 Abdominal signs or symptoms (acute abdomen) every 15 minutes
 Early (< 3 months of shunt placement): abdominal CT IV/PO contrast  If seizing initiate Seizure Acute
 Delayed (> 3 months of shunt placement): ultrasound abdomen - limited Management Pathway
Labs  Notify Neurosurgery on call
immediately
 Concern for new hydrocephalus: CBC w/diff, PT/PTT  Proceed with assessment
 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) SURGERY NEEDED? NO
 Concern for shunt malfunction: CBC w/diff

YES OFF PATHWAY


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 Surgery Preparation
 Shunt/Reservoir Tapping protocol
 Tap to be done by Neurosurgery only  Start admission process
 Tap if within 2 weeks of surgery with fever or  Initiate admission orders
 Tap if within 3 months of surgery with fever and no other source of infection  Admit patient directly to OR or to
 If > 3 months consider tap at neurosurgery discretion inpatient unit - see ED Job Aid: ED-OR
 If shunt/reservoir tapped send CSF for gram stain, culture, cell count, protein Transfer for Emergent or Urgent surgery
glucose, and bacterial PCR
Hydrocephalus: Postop Shunt Placement Phase Change
 Postop Shunt Placement
 Postop ETV-CPC
 Postop Infection

Discharge Criteria

 Afebrile x 24 hours
 No nausea or vomiting
 Tolerating up out of bed.
 Tolerating PO/PO pain med

Discharge Instruction

Follow-up with neurosurgery NP in 2 weeks for wound check, and with


neurosurgeon in 6 weeks for HASTE MR/CT
Management

 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:
 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)
Hydrocephalus: Endoscopic Third
Ventriculostomy (ETV)

Management

 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:
 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
 No nausea or vomiting
 Tolerating up out of bed.
 Tolerating PO/PO pain med

Discharge Instruction

Follow-up with neurosurgery NP in 2 weeks for wound check, and


with neurosurgeon in 6 weeks for HASTE MR/CT
Hydrocephalus: Suspected Shunt Infection

Management

 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: Bedrest. Out of bed with drain clamps 30 mins x 3 times/day
 Nursing:
 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

 Diet: Regular diet


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

Monitor Response to Therapy

 Check CSF gram stain, culture, cell count, glucose, and protein Patient returns to OR for
 Obtain CSF from ventriculostomy catheter (not the bag). new shunt
 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 Phase Change
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

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