Tag Archives: procedure

Neuroendoscopic Ventricular Irrigation for Ventriculitis

Ventriculitis carries a high  mortality and morbidity, even with prompt diagnosis and treatment with antibiotics.  A retrospective study from Kyoto Univeristy Graduate School of Medicine concluded that neuroendoscopic irrigation effectively treats ventriculitis, with lower mortality and duration of drainage catheter compared to historical control.  The study population was small and the design was retrospective.  Larger, prospective studies are needed to confirm these promising initial results.

Since 2011, this institution has adopted neuroendoscopic irrigation as standard treatment for ventriculitis.  After diagnosis on MRI (high intensity on DWI and gad enhancement of ventricular lining), antibiotics was started and neuroendoscopic irrigation was performed, followed by drainage catheter insertion.  Intraparenchymal abscess </=3cm in diameter was treated by placement of drainage catheter (without irrigation).  Abscesses >3cm was surgically evacuated.

Method of Neuroendoscopic Irrigation:

An oval-shaped Burr hole was created in the left frontal bone for insertion of 2 drainage tubes.  One tube was advanced into the abscess and the other was placed in the lateral ventricle under neuronavigator guidance.  Pus was aspirated from the intraparenchymal abscess.  A sheath was introduced to the lateral ventricle along with the ventricular drainage.  Artificial CSF was flushed through the drainage tube.  Ventricle was inspected with a rigid neuroendoscope, and white material suspended in the CSF was irrigated out.  After sufficient irrigation, structures around foramen of Monro (initially covered by white material) were visualized.  Under endoscopic guidance, the tip of drainage tube was placed at the posterior part of the lateral ventricle.

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(a) Lateral ventricle filled with white, sticky material;  (b) ventricular wall and choroid plexus (arrow) covered with grayish infectious material; (c) normal structures, choroid plexus (arrow), visualized after irrigation

 

Reference

Terada, Yukie et al. “Effectiveness Of Neuroendoscopic Ventricular Irrigation For Ventriculitis”.Clinical Neurology and Neurosurgery 146 (2016): 147-151.

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SEPS

SEPS

SEPS = Subdural Evacuating Port System  (Medtronic)

“The SEPS™ Cranial Access Kit is indicated when access to the subdural space and evacuation of a cranial subacute or chronic hematoma or hygroma is necessary. The SEPS Cranial Access Kit consists of surgical instruments and accessories used for draining subdural fluid accumulations such as hygromas and liquid-state subdural hematomas to an external suction reservoir without touching the brain. Utilizing a minimally invasive technique, the SEPS Cranial Access Kit’s components are designed to promote gradual brain re-expansion by creating a low homogeneous negative pressure throughout the subdural space as fluid is drained to an external suction reservoir.”

Instructions for Putting a SEPS drain:

  1. perform SEPS under local or general anesthesia
  2. identify area of greatest subdural fluid thickness using CT scan or MRI
  3. prep and drape selcected site with Chloraprep
  4. Mark incision site with sterile marking pen
  5. make a 5 mm incision through skin, subcutaneous tissue, galea and periosteum.
  6. apply holzheimer retractor to expose skull
  7. attach safety stop collar to drill bit
  8. secure drill bit with safety stop collar to hand drill
  9. place drill into chuck, hold chuck motionless while rotating handle clockwise.
  10. create twist drill hole through outer and inner tables of the skull
  11. incise dura, remove all exposed dura and subdural membranes form twist drill hole before inserting evacuating port (use #11 scalpel blade and forceps or unipolar cautery)
  12. Do not insert evacuating port until fluid is flowing freely from twist drill hole
  13. remove self-retaining scalp retractor and insert evacuating port by twisting clockwise. (4 turns will seat port securely into skull above inner table.
  14. evacuating port should never protrude beyond inner table
  15. attach silicone tubing to evacuating port and to suction reservoir bulb
  16. apply low homogenous negative pressure with suction reservoir bulb
  17. close wound around evacuating port
  18. fluid evacuation generally completed within 24-48h.  Monitor suction reservoir blood and empty as needed with repeated reapplication of negative pressure.

 

 

REFERENCE:

http://www.medtronicbrasil.com.br/wcm/groups/mdtcom_sg/@mdt/@nt/documents/documents/mns-seps-ifu.pdf

Lung Point

Intensivists are required to put in multiple central lines in critically ill patients.  One of the dreaded complications of line placement is a pneumothorax.  This complication is typically ruled out with a post-procedural chest xray.  Since most central lines are now being inserted with ultrasound guidance, it is an easy adjunct to the procedure to check with the ultrasound for a “lung point” that is seen with a pneumothorax.

LUNG POINT is an ultrasound sign showing a fleeting appearance of a lung pattern (lung sliding or pathologic comet-tail artifacts) replacing a pneumothorax pattern (absent lung sliding plus exclusive horizontal lines) in a particular location of the chest wall.

Sensitivity: 66 %
Specificity:  100%.

This link to a video of a lung point seen with an ultrasound opens in a new window/tab.

Lung point must not be just found, but actively sought for.
A lung point found by chance (esp anteriorly near the sternum) has little chance to be a PTx.

Regular M-mode outlook of a lung point.

Mmode

Seashore sign seen on the left, arising from the pleural line.  Stratosphere sign (total absence of any dynamic arising from the pleural line) seen on the right.

References

Lichtenstein, Daniel et al. ‘The “Lung Point”: An Ultrasound Sign Specific To Pneumothorax’. Intensive Care Med 26.10 (2000): 1434-1440. Web.

Moreno-Aguilar, German, and Daniel Lichtenstein. ‘Lung Ultrasound In The Critically Ill (LUCI) And The Lung Point: A Sign Specific To Pneumothorax Which Cannot Be Mimicked’. Critical Care 19.1 (2015): n. pag. Web.

Intraventricular Antibiotics for Ventriculitis

Prepare the following:

1.  Three 3-way stopcocks

2.  One sterile saline flush (preservative-free)

3.  2-4 10cc syringes

4.  sterile gloves, sterile towels

5.  gauze with betadine

6.  cap, gown, mask

7.  antibiotic in 2cc syringe

Put drape underneath shunt access port.  Clean shunt access port with betadine thoroughly, paint line and port with betadine.  Prepare sterile field (won’t be completely sterile), put on gown, mask and sterile gloves.  Prepare stopcock, flush, empty syringe and antibiotic – connect in series as shown in photograph.  Maintain one hand as sterile and another hand as “dirty.”  Lock CSF drain to patient.  Connect free end of stopcock to shunt access port.  and open empty syringe (distal port) to patient.  Withdraw CSF into empty syringes – draw fluid slowly, to max of 20 cc. (volume equal to or slightly more than amount of antibiotic and sterile flush to be infused).  Close empty syringe (now filled with CSF) to patient.  Open antibiotic port (proximal port) to patient and push antibiotic slowly.  Close antibiotic port and open sterile flush port (middle port) to patient.  Flush enough saline to push antibiotic in tubing into patient, and then push an extra 1-2 ml more.  Close sterile flush port and disconnect intraventricular infusion set up from shunt access port.  Maintain EVD clamped x 1 hour.

TREATMENT OF VENTRICULITIS:

Empiric treatment:

Vancomycin 15mgkg q8-12h (max 2g) plus one of the following

  1. ceftazidime 2g IV q8h
  2. cefepime 2g IV q8h
  3. meropenem 2g IV q8h

Gram positive:

  • Vancomycin for MRSA
  • Nafcillin or Oxacillin for MSSA
  • Add rifampin if refractory
  • Linezolid 600mg IV q12h if VRE or vancomycin allergy

Duration of treatment:

  1. normal CSF and CONS (+) – possible contaminatin, replace shunt on day 3 if cultures negative
  2. if CONS(+) and abnormal CSF – ABx while device in plus 1 week; document sterile CSF prior to shunt placement
  3. if virulent organism then >10d for staph or 14-21d for GNB; document sterile CSF x 10d prior to shunt
  4. if device cannot be removed, cont ABx until 7-10d after sterile CSF

INRAVENTRICULAR ANTIBIOTICS

  • best experience with gentamicin and vancomycin
  • may use colistin for MDROs (i.e. acinetobacter)
  • no PCN or cephalosporins (neurotoxic!)
  • goal is INHIB QUOTIENT of <10-20  … INHIB QUOTIENT is trough of CSF ABx / MIC

CHOICES: vanc 5-20mg/d; gent 4-8mg/d; ampho 0.1-1mg/d

INTRAVENOUS ABx PROPHYLAXIS PERIOP FOR CNS DEVICE PLACEMENT

  • IDSA recommends cefazolin but UPTODATE prefer vancomycin over cefazolin (pred CONS)
  • vancomycin 15mgkg (<2g) IV 2h prior (since vanc requires 60 minute infusion)
  • if al, then cefazolin 1-2g IV 1h prior

Capture

 

Intraventricular application of antibiotics to reach effective concentrations within the CNScapture

 

Very comprehensive review of intra-CSF antibiotics was published May, 2018 – author went over 200 articles on this topic – by Mrowczynski, et al published in Clinical Neurology and Neurosurgery.  See reference #3 below.  A short summary is provided here.

  1. Vancomycin
    • studies on intrathecal vancomycin for prophylaxis – potential use, 10mg/day x <10d
    • dosage ranges from 0.075 to 50mg/day, most common doses used 5-20mg/day
    • adverse effect: nerve root irritation in 1 case
  2. Teicoplanin
    • most commonly used for gram positive infections
    • most common doses used 5-20 mg/day, treatment duration 7-30 days
    • no significant side effects
  3. Daptomycin
    • useful for methicillin and vancomycin resistant strains
    • most common doses 2.5-10mg/day, treatment duration 1-4 weeks
    • adverse effect: transient pyrexia in 1 case, generally well tolerated
  4. Gentamicin
    • most common doses used 1-10mg/day, treatment duration 3-35 days
    • adverse effect: meningeal inflammation in 2 cases, mostly no significant side effects
  5. Amikacin
    • used at 4-50mg/day over 3 days to 6 months, ave duration 2 weeks
    • side effects:  hearing loss in 4 cases, tonic-clonic seizures in 1 case, vomiting in  1 case, back pain in 1 case
  6. Tobramycin
    • most often administered at 5-20mg/day x 2 infusions to every day for 40 days
    • no significant side effects
  7. Netilmicin
    • only 1 recent case report – 1mg to 150mg/day, no significant side effects
  8. Streptomycin
    • dosage varied from 2-100mg
    • associated with significant side effects – convulsions, apnea, coma, shock, pallor, vomiting, death
  9. Kanamycin
    • discontinued
    • used previously at dose of 5mg/day
  10. Penicillins
    • intrathecal therapy abandoned – multiple cases of severe seizures
  11. Lincomycin
    • older antibiotic used for gram positive infections
    • dose used 2mg/day x 5-9 days
  12. Cephalosporins
    • most common dosages used were between 25-100mg/d
    • note:  significant risk of seizures
  13. Erythromycin
    • varied from 3mg/day to 25mg/day, no significant side effects
  14. Polymyxin B
    • useful for multidrug resistant bacteria
    • most common dosages ranged from 2000 to 100,000 units x 5dto 4 weeks
    • one case described severeside effects: meningealirritation, decreased reflexes, but most reports noted no toxicity
  15. Colistin (Polymyxin E)
    • useful for resistant gram negative infections
    • predominantly used to treat acinetobacter baumanii infections at doses from 12,500 IU to 500,000 IU per day
    • Most common dose 125,000 IU
    • does not commonly cause toxicity, limited cases of chemical meningitis, nephrotoxicity, seizures and cauda equina syndrome noted
  16. Chloramphenicol
    • doses varied from 0.1mg to 50mg/day
    • no side effects noted
    • use can lead to aplastic anemia (intravenous) thus has been all but abandoned
  17. Rifampin
    • used at 2-5mg/day x 7-50 days
    • some patients have developed jaundice
  18. Isoniazid
    • dose range from 5-100mg/day, usually 3x per week
    • increased risk of significant side effects: hemiplegia, quadriplegia, convulsions, partial optic atrophy, hydrocephalus

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References:

Uptodate.com

Nau, R., F. Sorgel, and H. Eiffert. “Penetration Of Drugs Through The Blood-Cerebrospinal Fluid/Blood-Brain Barrier For Treatment Of Central Nervous System Infections”. Clinical Microbiology Reviews 23.4 (2010): 858-883.

Mrowczynski, O., Langan, S. and Rizk, E. (2018). Intra-cerebrospinal fluid antibiotics to treat central nervous system infections: A review and update. Clinical Neurology and Neurosurgery, 170, pp.140-158.