Bedside placement of ventricular access devices under local anaesthesia in neonates with posthaemorrhagic hydrocephalus: preliminary experience

Erik J Van Lindert,Hans Delye,K Djien Liem,Martin Geerlings

doi:10.1007/s00381-019-04361-3

Abstract

PurposePosthaemorrhagic ventricular dilatation in preterm infants is primarily treated using temporising measures, of which the placement of a ventricular access device (VAD) is one option. Permanent shunt dependency rates are high, though vary widely. In order to improve the treatment burden and lower shunt dependency rates, we implemented several changes over the years. One of these changes involves the setting of the surgery from general anaesthesia in the OR to local anaesthesia in bed at the neonatal intensive care unit (NICU), which may seem counterintuitive to many. In this article, we describe our surgical technique and present the results of this regimen and compare it to our previous techniques.MethodsRetrospective study of a consecutive series of 37 neonates with posthaemorrhagic ventricular dilatation (PHVD) treated using a VAD, with a cohort I (n = 13) treated from 2004 to 2008 under general anaesthesia in the OR, cohort II (n = 11) treated from 2009 to 2013 under general anaesthesia in the NICU and cohort III (n = 13) treated from December 2013 to December 2017 under local anaesthesia on the NICU.ResultsThe overall infection rate was 14%; the VAD revision rate was 22% and did not differ significantly between the cohorts. Procedures under local anaesthesia never required conversion to general anaesthesia and were well tolerated. After an average of 33 tapping days, 38% of the neonates received a permanent ventriculoperitoneal (VP) shunt. The permanent VP shunt rate was 9% with VAD placement under local anaesthesia and 52% when performed under general anaesthesia (p = 0.02).ConclusionBedside placement of VADs for PHVD under local anaesthesia in neonates is a low-risk, well-tolerated procedure that results in at least equal results to surgery performed under general anaesthesia and/or performed in an OR.

Highlights

Germinal matrix/intraventricular haemorrhage (IVH) is the most common intracranial haemorrhage among preterm infants and tends “to occur in the sickest preterm infants” [15]
All surgical procedures are performed under general anaesthesia and in an OR under optimised conditions to prevent complications, while the procedures themselves are relatively simple and straightforward
We describe our alternative surgical ventricular access device (VAD) placement procedure under local anaesthesia in neonates in an incubator at the neonatal intensive care unit (NICU) and report our initial results in comparison to our previous protocols

Summary

Introduction

Germinal matrix/intraventricular haemorrhage (IVH) is the most common intracranial haemorrhage among preterm infants and tends “to occur in the sickest preterm infants” [15]. A complication of intraventricular haemorrhage is the Childs Nerv Syst (2019) 35:2307–2312. All surgical procedures are performed under general anaesthesia and in an OR under optimised conditions to prevent complications (e.g., infections and malpositioning of catheters in ventricles increasing the risk of new intraparenchymatous haemorrhage), while the procedures themselves are relatively simple and straightforward. We describe our alternative surgical VAD placement procedure under local anaesthesia in neonates in an incubator at the neonatal intensive care unit (NICU) and report our initial results in comparison to our previous protocols

Methods

Results

Conclusion