Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures |
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Authors: | Benoit J M Pirotte Alphonse Lubansu Michael Bruneau Chakir Loqa Nathalie Van Cutsem Jacques Brotchi |
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Institution: | (1) Department of Neurosurgery, ERASME Hospital, Université Libre de Bruxelles, 808 route de Lennik, 1070 Brussels, Belgium;(2) Department of Anesthesiology, ERASME Hospital, Université Libre de Bruxelles, Brussels, Belgium |
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Abstract: | Objective The objective of this study was to evaluate whether the rigid application of a sterile protocol for shunt placement was applicable
on a routine basis and allowed the reduction of shunt infections (SI) in children.
Materials and methods Since 2001, a rigid sterile protocol for shunt placement in children using neither antibiotic-impregnated catheters nor laminar
airflow was prospectively applied at Erasme Hospital, Brussels, Belgium. For assessing the protocol efficacy before continuation,
we preliminarily analyzed the results of the first 100 operated children (43 females, 57 males, 49 aged <12 months; 115 consecutive
shunt placement/revision procedures). All procedures were performed by the same senior surgeon, one assistant, one circulating
nurse, one anesthesiologist. The sterile protocol was rigidly imposed to these four staff members: uniformed surgical technique;
limited implant and skin edge manipulation; minimized human circulation in the room; scheduling surgery as first morning operation;
avoiding postoperative cerebrospinal fluid (CSF) leak; double gloving; procedures of less than 30-min duration; systemic antibiotics
prophylaxis. We analyzed separately: (1) children carrying an increased risk of SI (n = 38) due to preoperative external ventricular drainage, CSF leak, meningitis, glucocorticoids, chemotherapy; (2) children
aged <12 months; (3) procedures for shunt revision.
Results Errors in protocol application were recorded in 71/115 procedures. They were mainly done by non-surgical staff, decreased
with time and were medically justified in some young children. Surprisingly, no SI occurred (follow-up, 4 to 70 months). One
child developed an appendicitis with peritonitis (Streptococcus faecalis) after 6 months. No SI was found. After peritonitis was cured, shunt reinsertion was uneventful.
Conclusion These preliminary results suggest that a uniform and drastic sterile surgical technique for shunt placement: (1) can be rigidly
applied on a routine basis; (2) can lower the early SI rate below 1%; (3) might have a stronger impact to reduce SI than using
antibiotic-impregnated catheters and optimizing the operative environment such as using laminar airflow and reducing the non-surgical
staff. This last issue will be evaluated further in the present ongoing protocol. |
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Keywords: | Shunt infection rate Ventriculoperitoneal shunt Shunt placement Shunt revision Children Sterile technique Double gloving Antibiotics prophylaxis |
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