Risks of Hydrocephalus Surgery: A Guide for Families

Inquiry about the risks of hydrocephalus surgery?

Hello, doctor! Recently, I have read many articles that only describe symptoms, sequelae, and surgical methods.
I am inquiring about the risks during the surgical process.
The patient has experienced elevated intracranial pressure and has undergone one surgery to remove part of the skull.
Currently, during the recovery process, the patient is in a comatose state and has involuntary seizures.
A CT scan has confirmed the presence of hydrocephalus, which has worsened.
The physician at Chang Gung Memorial Hospital has suggested a shunt procedure.
This surgery cannot guarantee improvement for the patient, but the family is eager to understand the risks involved in the surgical process before deciding whether to proceed with the drainage, as concerns about potential medical disputes have led the physician to remain silent.
I understand this situation, and I have been unable to find relevant articles, so I am seeking help here.
Since the patient has already undergone one surgery, there is concern that the patient's condition may not withstand another operation.
Therefore, I would like to ask the following questions:
1.
What are the potential sequelae of general anesthesia for a patient who is still in a comatose state? Is the risk high?
2.
What improvements can be expected after the surgery? (e.g., faster recovery, prevention of brain herniation, etc.)
3.
After the drainage procedure, what infections and precautions should be considered?
4.
Since the hydrocephalus has not yet been resolved, is it normal for the patient to have involuntary seizures during nursing care or when coughing? (The family is concerned that improper nursing care may worsen the condition.)
5.
Following up on the previous question, could the movement cause the hydrocephalus to shift and exert pressure on the brain, leading to this condition?
Your responses will be for reference only, and all decisions will be made by the family.
Thank you for taking the time to respond to the confused family amidst your busy schedule.

Měngqín, 30~39 year old female. Ask Date: 2018/06/15

Dr. Hong Weibin reply Neurology

1.
General anesthesia typically involves the use of intravenous and inhalational anesthetics to block pain.
In a normal human body, the brainstem's respiratory center sends signals to the respiratory muscles to facilitate breathing.
However, during the administration of anesthetics, respiratory function may be suppressed, necessitating the insertion of an endotracheal tube along with a ventilator to maintain the patient's oxygen exchange.
These medications often lead to a decrease in blood pressure, so if the patient's blood pressure is unstable, the risks associated with anesthesia are higher, potentially leading to shock due to the anesthetic agents.
It is advisable to consult an anesthesiologist for an evaluation.
2.
The cause of the initial increased intracranial pressure is unknown.
If the patient has already undergone surgery but the recovery is poor, subsequent follow-up with a CT scan of the head revealing hydrocephalus may indicate that the purpose of the second surgery is to relieve the hydrocephalus.
Relieving hydrocephalus does not necessarily mean that the patient's consciousness will return; it is essential to investigate the underlying cause of the increased intracranial pressure.
Alleviating hydrocephalus can certainly reduce the chances of brain herniation and increase the patient's survival chances, but survival does not guarantee that the patient will regain consciousness.
It is recommended to have a thorough discussion about the patient's condition with the attending physician, and family members can request a case discussion meeting (this is your right) to collectively discuss the current situation and future treatment plans with the medical team.
3.
Typically, a shunt procedure for hydrocephalus involves placing a ventricular-peritoneal shunt, which involves inserting a tube from the brain's ventricles to the abdominal cavity, or a lumbar-peritoneal shunt, which involves placing a tube from the lumbar region to the abdominal cavity.
This allows excess cerebrospinal fluid to be drained into the abdominal cavity for absorption.
Since the shunt is a foreign object (not part of the human body), the primary concern is the risk of infection, particularly meningitis.
After placement, it is crucial to closely monitor the patient's level of consciousness, as potential complications may include shunt obstruction, preventing cerebrospinal fluid drainage and worsening hydrocephalus, or misplacement of the shunt leading to improper drainage.
4.
If the patient is unclear in consciousness and occasionally experiences seizures, particularly if they are triggered by nursing interventions such as repositioning or suctioning, it is advisable to consult a neurologist.
An electroencephalogram (EEG) may be needed to rule out seizures.
Seizures occur when brain cells are in an unstable state and discharge abnormally, causing muscle contractions or spasms.
If seizures are confirmed, antiepileptic medications will be necessary to manage the abnormal discharges.
Every nurse works with a spirit of professionalism and assistance; nursing is a demanding profession, and repositioning and suctioning are essential nursing interventions for patients with altered consciousness to prevent complications such as aspiration pneumonia and pressure ulcers, which can complicate subsequent treatment.
If there are any concerns regarding nursing techniques, it may be beneficial to discuss them with the primary nurse or the head nurse for mutual improvement.
5.
Repositioning and chest percussion may indeed cause discomfort due to the movement of cerebrospinal fluid in hydrocephalus, but as mentioned above, these nursing interventions are necessary to prevent other hospital-acquired infections and complications.
You can discuss with the primary nurse to ensure that they perform these interventions gently.
Wishing your loved one a speedy recovery.

Reply Date: 2018/06/15

More Info

Understanding the risks associated with hydrocephalus surgery is crucial for families facing such a challenging situation. Hydrocephalus, characterized by an accumulation of cerebrospinal fluid (CSF) in the brain, can lead to increased intracranial pressure and various neurological symptoms. When surgical intervention is recommended, particularly in a patient who has already undergone a previous procedure, it is essential to weigh the potential benefits against the risks involved. Here, I will address the specific concerns raised regarding the surgical process, potential outcomes, and postoperative care.

1. Risks of General Anesthesia: General anesthesia is typically required for hydrocephalus surgery. In patients who are already in a comatose state, the risks associated with anesthesia can be heightened. Potential complications include respiratory depression, cardiovascular instability, and adverse reactions to anesthetic agents. The patient's current condition, including any existing comorbidities, will significantly influence the risk profile. It is vital to have a thorough preoperative assessment by an anesthesiologist to evaluate the patient's overall health and to discuss any concerns about anesthesia-related complications.

2. Postoperative Improvements: The primary goal of the surgery, such as a ventriculoperitoneal shunt placement, is to alleviate the pressure caused by excess CSF. Successful drainage can lead to several positive outcomes, including reduced intracranial pressure, decreased risk of brain herniation, and potentially improved neurological function over time. However, it is important to note that while the surgery may prevent further deterioration, it does not guarantee a return to baseline cognitive function, especially in patients who have been in a prolonged state of altered consciousness.

3. Infection Risks and Postoperative Care: After a drainage procedure, there is a risk of infection, particularly meningitis, due to the introduction of foreign materials (the shunt) into the body. Close monitoring for signs of infection, such as fever, increased intracranial pressure, and changes in neurological status, is essential. Families should be educated on the signs of infection and the importance of maintaining a sterile environment during care. Regular follow-ups with the healthcare team are crucial to ensure the shunt is functioning correctly and to address any complications promptly.

4. Involuntary Movements and Nursing Care: It is not uncommon for patients with hydrocephalus to exhibit involuntary movements or seizures, especially if there is ongoing pressure on the brain. These movements can be exacerbated by nursing interventions, such as repositioning or suctioning. While it is essential to provide adequate care to prevent complications like aspiration pneumonia, it is equally important to approach these procedures gently to minimize discomfort. If seizures are frequent or concerning, a consultation with a neurologist may be warranted to evaluate the need for antiepileptic medications.

5. Impact of Movement on Hydrocephalus: The concern that movement may exacerbate the condition is valid. Sudden movements can potentially cause shifts in CSF dynamics, leading to increased pressure or discomfort. However, appropriate nursing care, including gentle handling and careful monitoring, can help mitigate these risks. It is crucial for the nursing staff to be aware of the patient's condition and to adjust their care accordingly.

In conclusion, while the decision to proceed with hydrocephalus surgery involves significant considerations, understanding the risks and potential benefits can help families make informed choices. Open communication with the healthcare team, including discussions about anesthesia risks, expected outcomes, and postoperative care, is essential. Families should feel empowered to ask questions and seek clarification on any aspect of the treatment process. Ultimately, the goal is to enhance the patient's quality of life while minimizing risks and complications.

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