Cerebral hemmorhages in premies

[krobertson]

Hi~

I'm a student nurse and I'm doing a paper on a patient I had in clinicals. He had a cerebral hemmorhage from being a premie and had to have an internal shunt put in. While I was taking care of him, they had put an external shunt in. I was wondering if you could give me some information about such a patient, such as patient care or more information about the shunts, like degrees or long lasting effects. Thanks!

Kelly

[nurs4kids]

Hi Kelly!

The external shunt is called an External Ventricular Drain(EVD). The internal shunts are NORMALLY ventriculo peritoneal shunts (VP shunts). There are other internal, such as a VA (ventriculo atrial) shunt. All internal shunts are comprised of a small tube that's placed in the ventricle, a valve (this is the bulb you will see under the scalp) and then the other end of the tube is placed in the respected place (peritoneum, atrium, etc). The preferred shunt is the VP, because there are less chances for a malfunction in the peritoneal area. If a child has had numerous abdominal surgeries, the scar tissue will often render the peritoneal area insufficient for a VP shunt. The valve is the pressure regulator of the shunt. It opens and closes to regulate the flow of CSF, thereby controlling ICP. The internal shunts often malfunction in childhood d/t growth spurts. The child will essentially "outgrow" the shunt, causing the end to be pulled apart. Abdominal or head trauma while playing can occassionally cause this too. However, surgeons have become much better at placing these shunts and often leave enough spare tubing to allow for growth, so many kids will go 12 yrs or longer before a revision is required. Then some will require a revision every couple of years.

The external shunt is used for a couple reasons. Most often, when the internal shunt has become infected, the shunt will be externalized while the patient receives abx. When the infection clears, the shunt is then reconnected, or replaced internally. Another reason for externalization is to monitor ICP and for patients not tolerating internal shunts. External shunts are also used to drain cysts, in a few cases. With external shunts, the flow of csf is controlled by gravity, so the physician can elect to monitor and control flow based on the patient's response(I LOVE an EVD for this reason, lessens the likelyhood of a code ).

There is also a relatively new type "shunt" called a third-ventriculostomy. This does not have the same negative features of a VP shunt (infection& malfunction), but most patients do not meet requirements for a 3rd vent. I'm not exactly sure of the specifics of this one, so I'll let you research it if you want more info. If I remember correctly, it consist of a tube or whole placed from one ventricle to another to allow the flow of csf, but I'm not positive.

Kids with shunts range from little or no neurological deficits to complete neuro devastation. They are placed for a variety of reasons, basically for hydrocephalus. HCP can be caused from a variety of things from birth defects/ birth trauma to tumors to head injury. The earlier the HCP is diagnosed (for congenital HCP), the better the outcome (less deficit). Many kids are completely normal and live full productive lives with few limitations. On the other side of the coin is that many also have severe brain injury from HCP or anoxia and suffer from CP and the multiple other medical problems associated with cerebral palsy.

There are numerous websites dedicated to hydrocephalus. They have wonderful information on shunts and prognosis. Just do a search on hydrocephalus.

Hope this wasn't too much info . If you need anything else, just let me know...I LOVE pediatric neuro.

Tracy

[prmenrs, RN]

Did the baby have a cerebral hemorrhage or an Intraventricular hemorrhage?

[nurs4kids]

Kelly,

My bad, I DID assume the child either had a cerebral AVM (ateriovenous malformation) or a subarachnoid hemmorage. To my knowledge, these are the most common bleeds in newborns. In both cases, the blood has the potential to flow into the surrounding spaces and obstruct the normal flow of CSF through the ventricles, thereby causing hydrocephalus.

In the previous post, I forgot to address the nursing duties for caring for these infants.

Assessment would include the following:

Fontanels-assess for tight and/or bulging fontanel (indicates increased icp) or for sunken (dehydration and/or excessive drainage of csf). Preferable, fonatanel will be soft and flat.

Assess respiratory rate, note any increased work of breathing.

Pupilary reaction-should be equal, round and reactive to light. This is one of the key indicators of increased ICP as they may become sluggish in reaction or completely non-reactive and unequal.

Activity level- Is the infant alert, arousable, irritable, lethargic?

Vital signs- The two I use most often are heart rate and temperature. Another good indicator is oxygen saturation.

In the case of increased icp, the infant will become bradycardic in early on as the body attempts to compensate. In the later stages of increased icp, as the body begins to decompensate, the heart rate will drastically increase (above baseline). This fact is true with children, I believe it is different with adults.

If the child has the EVD because of infection, the temperature is a good indicator of sepsis. Low temp will also cause bradycardia, so before determining increased icp d/t bradycardia the temp should be assessed.

Oxygen saturation will also begin to decrease as icp increases, but in my experience this comes after bradycardia.

Monitor strict input and output. Don't forget to account for the csf output. We often replace the amount of csf output with IV fluids if the csf output is high, or if the infant is becoming dehydrated.

Also, monitor and record the color and clarity of the csf (clear, cloudy, yellow, bloodtinged, etc).

Assess the dressing at the exit site. A wet dressing is a source of infection, and the md should be notified.

You can also monitor the mean arterial pressure, but this isn't something we do on the floor and I know very little about it--prmenrs??

You didn't say what setting this infant was in (ICU or floor) nor what type monitoring was available. With some of the newer external systems, you can monitor icp fairly accurately without a manometer. Until recently we had no way to do this on the floor. You also didn't say if this child was on a vent or had any other medical problems, so I'm going on the assumption that this is all the child had.

It's very important with an EVD to keep it level with the patient (normally at ear level) this would mean the zero point on the evd should be level with the patients mid-ear. The physician will also order where he wants the pop-off. Verify that the popoff is at the ordered level. Also, verify the EVD is clamped or unclamped, depending on the physician's order. They are usually unclamped to allow drainage, except just prior to surgery. They will often clamp the EVD several hours before surgery to allow the ventricles to fill, which gives the surgeon a better view. All the systems I've seen also must be clamped while the burrette(the fluid collection chamber) is being emptied, or a vaccum will be created. We also clamp 15-30 mins at a time to allow parents to hold for feedings and bonding. The EVD must be clamped anytime the patient is being transferred or held. Should the evd be left unclamped and the patient is raised above the evd or the evd is dropped below the patient, there is risk of bleeding and/or herniation. So, be very careful not to knock the evd over.

Ummm, I think that's the basics. If this was a NICU baby, prmenrs can give you alot more info than me. I also found you a pretty good website, just click the link below.

Tracy

http://webmd.lycos.com/content/asset/adam_disease_avm

or

http://webmd.lycos.com/

on the above, just search for hydrocephalus, bleeds, etc. Wonderful information source!

[NicuGal, MSN, RN]

Most likely the kid had a Grade 3-4 intraventricular hemmorage...AVM is uncommon in preemies as is a subrac. After the bleed into the ventricles then it starts to reabsorb and then sometimes a clot forms and blocks off the CSF flow...then you get hydro. These kids also have a high incidence of perventricular leukomalacia...or softening of the white matter that leads to swiss cheese like holes in the white matter. If the baby is too small for a shunt and LP's aren't successful, as most of them aren't as it is usually a noncommunicating block, then they will get a Rickham reservior so that the docs can tap it and withdraw CSF everyday until they are big enough for the shunt. The will place an external shunt if the protein count is high...otherwise the internal shunt would block off and it would have to be replaced. The other gal covered the care of the shunt wonderfully!

As for development...they are all different....most have some high degree of delay...most have some CP...some are deaf and blind. Every kid is different. But once the white matter is damaged, it is damaged, and sometimes they can learn to compensate for the damaged areas.