Factors associated with early shunt revision within 30 days: analyses from the National Surgical Quality Improvement Program

View More View Less
  • 1 Department of Neurologic Surgery, Mayo Clinic; and
  • | 2 Mayo Clinic Alix School of Medicine, Rochester, Minnesota
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

OBJECTIVE

CSF shunt insertion is the most commonly performed neurosurgical procedure for pediatric patients with hydrocephalus, and complications including infections and catheter obstruction are common. The rate of readmission in the first 30 days after surgery has been used across surgical disciplines to determine healthcare quality. In the current study, the authors sought to assess factors associated with early shunt revision within 30 days using real-world data.

METHODS

Targeted shunt data set participant user files of the National Surgical Quality Improvement Program (NSQIP) from 2016 to 2019 were queried for patients undergoing a shunt procedure. A multivariable logistic regression model was performed to assess the impact of demographics, etiologies, comorbidities, congenital malformations, and shunt adjuncts on shunt revision within 30 days, as well as shunt revision due to infection within 30 days.

RESULTS

A total of 3919 primary pediatric shunt insertions were identified in the NSQIP database, with a mean (± SD) patient age of 26.3 ± 51.6 months. There were a total of 285 (7.3%) unplanned shunt revisions within 30 days, with a mean duration of 14.9 ± 8.5 days to first intervention. The most common reason for intervention was mechanical shunt failure (32.6% of revision, 2.4% overall, n = 93), followed by infection (31.2% of all interventions, 2.3% overall, n = 89) and wound disruption or CSF leak (22.1% of all interventions, 1.6% overall, n = 63). Patients younger than 6 months of age had the highest overall unplanned 30-day revision rate (8.5%, 203/2402) as well as the highest 30-day shunt infection rate (3%, 72/2402). Patients who required a revision were also more likely to have a cardiac risk factor (34.7%, n = 99, vs 29.2%, n = 1061; p = 0.048). Multivariable logistic regression revealed that compared to patients 9–18 years old, those aged 2–9 years had significantly lower odds of repeat shunt intervention (p = 0.047), while certain etiologies including congenital hydrocephalus (p = 0.0127), intraventricular hemorrhage (IVH) of prematurity (p = 0.0173), neoplasm (p = 0.0005), infection (p = 0.0004), and syndromic etiology (p = 0.0136), as well as presence of ostomy (p = 0.0095), were associated with higher odds of repeat intervention. For shunt infection, IVH of prematurity was found to be associated with significantly higher odds (p = 0.0427) of shunt infection within 30 days, while use of intraventricular antibiotics was associated with significantly lower odds (p = 0.0085).

CONCLUSIONS

In this study of outcomes after pediatric shunt placement using a nationally derived cohort, early shunt failure and infection within 30 days were found to remain as considerable risks. The analysis of this national surgical quality registry confirms that, in accordance with other multicenter studies, hydrocephalus etiology, age, and presence of ostomy are important predictors of the need for early shunt revision. IVH of prematurity is associated with early infections while intraventricular antibiotics may be protective. These findings could be used for benchmarking in hospital efforts to improve quality of care for pediatric patients with hydrocephalus.

ABBREVIATIONS

ACS = American College of Surgeons; CI = confidence interval; CPT = Current Procedural Terminology; ETV = endoscopic third ventriculostomy; EVD = external ventricular drain; GI = gastrointestinal; HCRN = Hydrocephalus Clinical Research Network; IVH = intraventricular hemorrhage; NSQIP = National Surgical Quality Improvement Program; OR = odds ratio; SCR = surgical clinical reviewer.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Venable GT, Rossi NB, Morgan Jones G, Khan NR, Smalley ZS, Roberts ML, Klimo P Jr. The Preventable Shunt Revision Rate: a potential quality metric for pediatric shunt surgery. J Neurosurg Pediatr. 2016;18(1):715.

    • Search Google Scholar
    • Export Citation
  • 2

    Rekate HL. The definition and classification of hydrocephalus: a personal recommendation to stimulate debate. Cerebrospinal Fluid Res. 2008;5:2.

    • Search Google Scholar
    • Export Citation
  • 3

    Simon TD, Riva-Cambrin J, Srivastava R, Bratton SL, Dean JM, Kestle JR. Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr. 2008;1(2):131137.

    • Search Google Scholar
    • Export Citation
  • 4

    Bondurant CP, Jimenez DF. Epidemiology of cerebrospinal fluid shunting. Pediatr Neurosurg.1995;23(5):254259.

  • 5

    Patwardhan RV, Nanda A. Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery. 2005;56(1):139145.

    • Search Google Scholar
    • Export Citation
  • 6

    Lam SK, Srinivasan VM, Luerssen TG, Pan IW. Cerebrospinal fluid shunt placement in the pediatric population: a model of hospitalization cost. Neurosurg Focus. 2014;37(5):E5.

    • Search Google Scholar
    • Export Citation
  • 7

    Fernández-Méndez R, Richards HK, Seeley HM, Pickard JD, Joannides AJ. Current epidemiology of cerebrospinal fluid shunt surgery in the UK and Ireland (2004-2013). J Neurol Neurosurg Psychiatry. 2019;90(7):747754.

    • Search Google Scholar
    • Export Citation
  • 8

    Hauptman JS, Kestle J, Riva-Cambrin J, Kulkarni AV, Browd SR, Rozzelle CJ, et al. Predictors of fast and ultrafast shunt failure in pediatric hydrocephalus: a Hydrocephalus Clinical Research Network study. J Neurosurg Pediatr. 2021;27(3):277286.

    • Search Google Scholar
    • Export Citation
  • 9

    Al-Tamimi YZ, Sinha P, Chumas PD, Crimmins D, Drake J, Kestle J, et al. Ventriculoperitoneal shunt 30-day failure rate: a retrospective international cohort study. Neurosurgery. 2014;74(1):2934.

    • Search Google Scholar
    • Export Citation
  • 10

    Teisberg E, Wallace S, O’Hara S. Defining and implementing value-based health care: a strategic framework. Acad Med. 2020;95(5):682685.

    • Search Google Scholar
    • Export Citation
  • 11

    Piatt JH Jr. Thirty-day outcomes of cerebrospinal fluid shunt surgery: data from the National Surgical Quality Improvement Program-Pediatrics. J Neurosurg Pediatr. 2014;14(2):179183.

    • Search Google Scholar
    • Export Citation
  • 12

    Quality Positioning System. National Quality Forum. Accessed January 1, 2021. http://www.qualityforum.org/QPS/QPSTool.aspx?m=146&e=1

  • 13

    ACS NSQIP Pediatric Participant Use Data File. FACS.org. Accessed August 19, 2021.https://www.facs.org/Quality-Programs/Childrens-Surgery/pediatric/Program-Specifics/Quality-Support-Tools/puf

    • Search Google Scholar
    • Export Citation
  • 14

    Harrell FE. Regression Modeling Strategies: With Applications to Linear Models, Logistic Regression, and Survival Analysis. Springer;2013.

    • Search Google Scholar
    • Export Citation
  • 15

    Riva-Cambrin J, Kestle JRW, Holubkov R, Butler J, Kulkarni AV, Drake J, et al. Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study. J Neurosurg Pediatr. 2016;17(4):382390.

    • Search Google Scholar
    • Export Citation
  • 16

    Lee RP, Ajmera S, Thomas F, Dave P, Lillard JC, Wallace D, et al. Shunt failure-the first 30 days. Neurosurgery. 2020;87(1):123129.

  • 17

    Lakomkin N, Hadjipanayis CG. The role of prophylactic intraventricular antibiotics in reducing the incidence of infection and revision surgery in pediatric patients undergoing shunt placement. Neurosurgery.2021;88(2):301-305.

    • Search Google Scholar
    • Export Citation
  • 18

    Simon TD, Butler J, Whitlock KB, Browd SR, Holubkov R, Kestle JR, et al. Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study. J Pediatr. 2014;164(6):14628.e2.

    • Search Google Scholar
    • Export Citation
  • 19

    Raygor KP, Oh T, Hwang JY, Phelps RRL, Ghoussaini K, Wong P, et al. Ventriculoperitoneal shunt infection rates using a standard surgical technique, including topical and intraventricular vancomycin: the Children’s Hospital Oakland experience. J Neurosurg Pediatr. 2020;26(5):504512.

    • Search Google Scholar
    • Export Citation
  • 20

    Klimo P, Thompson CJ, Ragel BT, Boop FA. Antibiotic-impregnated shunt systems versus standard shunt systems: a meta-and cost-savings analysis. J Neurosurg. 2014;14(Suppl 1):5359.

    • Search Google Scholar
    • Export Citation
  • 21

    Mallucci CL, Jenkinson MD, Conroy EJ, Hartley JC, Brown M, Dalton J, et al. Antibiotic or silver versus standard ventriculoperitoneal shunts (BASICS): a multicentre, single-blinded, randomised trial and economic evaluation. Lancet. 2019;394(10208):15301539.

    • Search Google Scholar
    • Export Citation
  • 22

    Kestle JRW, Riva-Cambrin J, Wellons JC III, Kulkarni AV, Whitehead WE, Walker ML, et al. A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr. 2011;8(1):2229.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 121 121 121
Full Text Views 14 14 14
PDF Downloads 19 19 19
EPUB Downloads 0 0 0