2010 cp on hydrocephalus

8/11/2019 2010 Cp on Hydrocephalus

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BIODATA OF THE PATIENT

Identification data

Name :Master Ashish

Age :7 months

Sex :male

C.R no :1040919

Bed no/ Wad :6/Emergency Ward

Re!igion :Sikh

Nationa!it" :Indian

Date of admi##ion :$%/$$/$&

Diagno#i# :Hydrocehal!s "ith #SMM$

S!rgery %&ot done yet

Con#'!tant :'r(Singhi

Fat(e)# ed'cation :$lass 10

Fat(e)# occ'*ation :)ri*ate o"n +!siness

+ot(e# ed'cation :$lass ,

+ot(e)# occ'*ation :Ho!se"i-e

Adde## %.harad Mohali

Infomant :Mother

CHIEF CO+P,AINTS D-RIN AD+ISSION

he mother gi*es a history o- the child "ith congenital meningomyeloceal "hich kees onenlarging so-t on the lo"er +ack( he child started crying ecessi*ely and +eing irrita+le -or

a+o!t 2 to 6 days the child head is so-t and has +een increasing since 4 month "ith +!lging

-ontanelle

HISTOR OF PRESENT I,,NESS

$hild "as kno"n case o- #SMM$( Mother noticed the increased in head si3e since 4 monthsold "hich "as rogressi*e in nat!re the child "as *ery irrita+le and cry ecessi*ely( hey "ent

to a ri*ate doctor hen re-erred to )I $handigarh -or -!rther management( he child "as


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admitted once at 4months -or the #SMM$ diagnosed as hydrocehal!s discharged and no"

admitted -or s!rgery(

HISTOR OF PAST I,,NESS

She has the no any e*idence o- ast disease +esides the #SMM$ and hydrocehal!s "hich

started at 4 months o- age

PERSONA, HISTOR:0

Antenata! Hi#to": here "as no comlaints d!ring the ante natal eriod(

Bit( Hi#to": 'eli*ered on ,/5/5010 at 16 M$H -!ll term &'( At ,month S "as done

detected as a case o- #SMM$(

De1e!o*menta! Hi#to":&o delay in any milestone( &ormal gro"th and de*eloment ecet

"eakness in lo"er lim+s

Imm'ni2ation Hi#to":imm!ni3ed aroriate to age according to mother +!t no e*idence

FA+I, HISTOR: N'c!ea fami!" 3it( 4 mem5e#

8ather0year Mother 57 year

4 years 6 months

In her -amily &o+ody has any e*idence o- disease s!ch as comm!nica+le :(;(


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;ody +!ilt % Weak

ital signs % emerat!re= , c

% )!lse 10 ;)M

% >esiration 6 ;)M

Weight %10 kg

Height % 6 cm

?8$ % 49 cm

$hest circ!m-erence % 40 cm

Head shae % large head ?8$@ 49 cm +!lging -ontanelle

Eyes % s!nken eyes

#is % &ormal

&ose % &ormal no discharge

Ears % &o discharge &ormal shae

eeth % nil

!ms % )ink color

ong!e % $oated "hitish color

&eck % #ymh nodes not ala+le no neck rigidity

hyroid % &o a+normal gro"th

$hest % &ormal shae

A+domen % So-t normal shae normal so!nd

;ack % )resence o- #SMM$

enitalia % $lean no discharge distended etremities

SSTE+IC ASSESS+ENT

eneral Aearance % #ooks "eak


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)ersonal hygiene % &ot "ell maintained

)ost!re % &ormal

&!tritional stat!s % )oor

$ongenital a+normality % &ot any

Anemia % &ot anemic

$yanosis % &o

8o!l +ody order % &o

8o!l +reath % &o

CARDIO7ASC-,AR SSTE+

&o history o- any cyanotic acynotic congenital heart disease(

&o allor &o cyanosis &o edema(

Heart >ate % 10 ;)M BAicalC

$8 5 sec(

&ormal heart so!nd resent S1 S5(

RESPIRATOR SSTE+

>esiratory rate 6 ;)M

&o h/o 'ysnea rachea in &ormal osition

&o enlargement o- hyroid

&o edema in *oice=+o

&ormal +reath so!nd

ASTRO0INTESTINA, SSTE+

&o h/o omiting Malena

h/o oor -eeding

A+dominal girth 6(2 cm(

;o"el so!nd resent in all -o!r D!adrants

&o organomegaly -o!nd &o tenderness

,+PHATIC SSTE+

&? #ymh node enlargement(

ENTO-RINATOR SSTE+


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&o any congenital disorder

&o h/o I

&o h/o incontinence 'ys!ria Haemat!ria

&o renal calc!li

&o h/o Hernia

Sel- *oiding /? is adeD!ate

Centa! Ne1o'# #"#tem:0

&o h/o o- sei3!res( &ormal >e-lees(

Endocina! #"#tem:0

&o endocrinal dys-!nction is yet noticed(

&o disease related to endocrine system is resent(

NE-RO,OICA, ASSESS+ENT

Interaction "ith eaminer % 8air

Interest in s!rro!nding % )oor

Acti*ity % )oor

Seech artic!lation % $hild +a++les

Hearing % ood

is!al % &ormal

is!al -iation %#'n8en e"e#

?c!lar mo*ement % A+normal

+OTOR F-NCTION

)ost!re % &ormal

ait % $o!ld not +e elicited

Ho % co!ld not +e elicite

M!scle mass % )oor/"eak

M!scle o"er % "eak secially lo"er lim+

M!scle coordination % &ot ood coordination

+-SC-,OS9ETA, SSTE+


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&o any h/o m!sc!losketal disease(

&o any e*idence o- kyhosis #ordosis scoliosis(

&o any congenital disorder s!ch as alies(

INTI-+ENTAR SSE+

&o h/o $yanosis

&o h/o allergy -rom any s!+stance o+ect or medicine

&o h/o rash !tricaria or any other skin disease

Scal clean no dandr!--

&ail F no cl!++ing o- nails

Skin= &ormal t!rgor skin integrity maintained no ress!re sore no edema resent

Skin temerat!re@ , $

DISEASE AS PER ,ITREAT-RE

HDROCEPHA,-S:

Hydrocehal!s is not a seci-ic diseaseG rather it reresents a di*erse gro! o- conditions

that res!lt -rom imaired circ!lation and a+sortion o- $S8 or in the rare circ!mstance -rom

increased rod!ction +y a choroid le!s ailloma( H"doce*(a!'# also kno"n as "ater on

the +rain is a medical condition in "hich there is an a+normal acc!m!lation o-cere+rosinal-l!id:$S8< in the *entricles or ca*ities o- the+rain( his may ca!se increased intracranial

ress!reinside the sk!ll and rogressi*e enlargement o- the head con*!lsion and mental

disa+ility( Hydrocehal!s can also ca!se death( he name deri*es -rom the reek "ords :h!dro=I can e*al!ate -or $hiari mal-ormation or cere+ellar or eriaD!ed!ctal t!mors( It

a--ords +etter imaging o- the osterior -ossa than $( M>I can di--erentiate normal

ress!re hydrocehal!s :&)H< -rom cere+ral atrohy altho!gh the distinctions may +e

challenging( 8lo" *oids in the third *entricle and transeendymal -l!id e!dates arehel-!l( Ho"e*er n!mero!s s!ita+le atients ha*e a +rain attern s!ggesti*e o- atrohy

and small *essel ischemic disease that may !ltimately +e &)H(,!idelines -or imaging

st!dies in s!sected &)H ha*e +een esta+lished(9

$/M>I criteria -or ac!te hydrocehal!s incl!de the -ollo"ing%


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o Si3e o- +oth temoral horns is greater than 5 mm clearly *isi+le( In the a+sence

o- hydrocehal!s the temoral horns sho!ld +e +arely *isi+le(

o >atio o- the largest "idth o- the -rontal horns to maimal +iarietal diameter :ie

E*ans ratio< is greater than 0J in hydrocehal!s(

o ranseendymal e!date is translated on images as eri*entric!lar

hyoatten!ation :$< or hyerintensity :M>I 5="eighted and -l!id=atten!ated

in*ersion reco*ery B8#AI>C seD!encesI s!ggests ac!te

hydrocehal!s(

$/M>I criteria -or chronic hydrocehal!s incl!de the -ollo"ing%

o emoral horns may +e less rominent than in ac!te hydrocehal!s(

o hird *entricle may herniate into the sella t!rcica(

o Sella t!rcica may +e eroded(

o Macrocrania :ie occiito-rontal circ!m-erence 9,thercentile< may +e resent(

o $or!s callos!m may +e atrohied :+est areciated on sagittal M>I


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'i--!sion tensor imaging :'I< is a no*el imaging techniD!e that detects di--erences in

-ractional anisotroy :8A< and mean di--!si*ity :M'< o- the +rain arenchyma

s!rro!nding the *entricles( Imairment o- 8A and M' thro!gh 'I allo"s the

recognition o- microstr!ct!ral changes in eri*entric!lar "hite matter region that may +e

too s!+tle on con*entional M>I(5

Ot(e Te#t#

A-ter sh!nt insertion con-irm correct ositioning o- installed hard"are "ith a lain

radiograh(

EE i- sei3!re occ!rs

BOO9S PATIENTS RES-,TS

History No fami!" (i#to"H/? enlarged head -or ast 1

month

Meas!rement o- ?8$ 4= cm

)erc!ssion o- the in-antNs sk!ll may rod!ce a

tyical cracked ot so!nd :Mace"enNs signI

;lood analysis


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+ANAE+ENT

oa!:

o achie*e eD!ili+ri!m +et"een rod!ction and a+sortion

Aceta3olamide decreases the rod!ction o- $S8

>eeated #)/*entric!lar ta to maintain normal ress!re

TREAT+ENT

+EDICA, TREAT+ENT:

Aceta2o!amide >Diamox?

&oncometiti*e re*ersi+le inhi+itor o- en3yme car+onic anhydrase "hich cataly3es the reaction+et"een "ater and car+on dioide res!lting in rotons and car+onate( his contri+!tes to

decreasing $S8 secretion +y choroid le!s(

'oses% 52 mg/kg/d )? tidG not to eceed 100 mg/kg/d

,oo* di'etic#

hese agents increase ecretion o- "ater +y inter-ering "ith the chloride=+inding cotransort

system "hich res!lts -rom inhi+ition o- rea+sortion o- sodi!m and chloride in the ascendingloo o- Henle and distal renal t!+!le(

F'o#emide >,a#ix?

Mechanisms roosed -or lo"ering I$) incl!de lo"ering cere+ral sodi!m !take a--ecting"ater transort into astroglial cells +y inhi+iting cell!lar mem+rane cation=chloride !m and

decreasing $S8 rod!ction +y inhi+iting car+onic anhydrase( sed as ad!ncti*e theray "ith

A$P in temorary treatment o- osthemorrhagic hydrocehal!s in neonates(

'oses% 1 mg/kg/d I

+EDiCINES: ecei1ed 5" *atient

S.R.No. +EDICINE DOSE RO-TE FRE@ENC RATIONA,E

1( Syr( )$M( 60 mg ?ral Q6H A&I)O>EI$

A&A#ESI$

5( In aim 200mg I/ ;' Anti+iotic 8or re*ent


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the secondary in-ection(

( In( Amikacin 152mg I/ ;' Anti+iotic 8or re*ent

the secondary in-ection(

S-RICA, TREAT+ENT:

Hydrocehal!s can +e treated thro!gh a *ariety o- s!rgical roced!res incl!ding direct oeration

on the lesion ca!sing the o+str!ction s!ch as a t!morG *entric!lostomy intracranial sh!nts -or

selected cases o- noncomm!nicating hydrocehal!s to di*ert -l!id -rom the o+str!cted segmento- the *entric!lar system to the s!+arachnoid saceG and etracranial sh!nts :most common< to

di*ert -l!id -rom the *entric!lar system to an etracranial comartment -reD!ently the

eritone!m or right atri!m(Etracranial Sh!nt )roced!res

7entic'!o*eitonea! >7P? #('nt

A *entric!loeritoneal sh!nt remo*es ecessi*e cere+rosinal -l!id -rom the *entricles

and sh!nts it to the eritone!m( A one="ay *al*e is resent in the t!+ing +ehind the ear(

o 'i*erts $S8 -rom a lateral *entricle or the sinal s!+arachnoid sace to the

eritoneal ca*ity(

o A t!+e is assed -rom the lateral *entricle thro!gh an occiital +!rr hole

s!+c!taneo!sly thro!gh the osterior asect o- neck and arasinal region to the

eritoneal ca*ity thro!gh a small incision in the right lo"er D!adrant(

o A *entric!lar access de*ice is an imlanted reser*oir and catheter !sed -orremat!re neonates less than 5000 g in lie! o- a sh!nt( he catheter drains -l!id

-rom the *entricles into the reser*oir "hich can then +e emtied !sing asetic

techniD!e( When "eight eceeds 5000 g a sh!nt !s!ally can +e laced(

7entic'!oatia! >7A? #('nt%

o A t!+e is assed -rom the dilated lateral *entricle thro!gh a +!rr hole in the

arietal region o- the sk!ll(

o It then is assed !nder the skin +ehind the ear and into a *ein do"n to a oint

"here it discharges into the right atri!m or s!erior *ena ca*a(

o A one="ay ress!re=sensiti*e *al*e "ill close to re*ent re-l! o- +lood into the

*entricle and oen as *entric!lar ress!re rises allo"ing -l!id to ass -rom the

*entricle into the +loodstream(

7entic'!o*!e'a! #('nt%

o 'i*erts $S8 to the le!ral ca*ity(


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o Indicated "hen the ) or A ro!te cannot +e !sed(

7entic!e0ga!! 5!adde #('nt%

o 'i*erts $S8 to the common +ile d!ct(

o sed "hen all other ro!tes are !na*aila+le(

+o#t #('nt# (a1e t(e fo!!o3ing com*onent#:

o entric!lar t!+ing(

o A one="ay or !nidirectional ress!re=sensiti*e -lo" *al*e(

o A !ming cham+er(

o 'istal t!+ing(

Pogamma5!e #('nt# ae a1ai!a5!e( hese can +e rogrammed to a certain -lo"

ress!re and ress!re settings can +e read!sted +ased !on atient resonse( A magnetic

de*ice is !sed to ad!st the ress!re setting o- the sh!nt *al*e( he !se o- a

rogramma+le sh!nt eliminates the need -or m!ltile s!rgeries or hosital *isits to ad!stsh!nt ress!re(

S('nt Com*!ication#

Altho!gh a sh!nt may -!nction "ell immediately a-ter insertion comlications mayarise in the -orm o- kinking searation or l!gging o- the sh!nt t!+ing( )ost oerati*e

artially sh!nt +lockage may occ!r +y +loced tiss!e dislodge d!ring s!rgical roced!re( he

most serio!s comlication is in-ection o- the sh!nt leading to *entric!litis seticemia(

When the sh!nt +ecomes in-ected it is !s!ally remo*ed massi*e anti+iotic theray isgi*en( ;eca!se o- gro"th d!ring early childhood sh!nts m!st +e re*ised eriodically(

&eed -or sh!nt re*ision -reD!ently occ!rs +eca!se o- occl!sion in-ection or mal-!nction

esecially in the -irst year o- li-e(

Sh!nt re*ision may +e necessary +eca!se o- gro"th o- the child( &e"er models ho"e*er

incl!de coiled t!+ing to allo" the sh!nt to gro" "ith the child(

Sh!nt deendency -reD!ently occ!rs( he child raidly mani-ests symtoms o- increased

I$) i- the sh!nt does not -!nction otimally( ?nset may +e s!dden or insidio!s(

$hildren "ith A sh!nts may eerience endocardial cont!sions and clotting leading to

+acterial endocarditis +acteremia and *entric!litis or throm+oem+olism and cor!lmonale(

$hildren "ith A sh!nts reD!ire +iann!al or ann!al chest L=ray to check length o- t!+ing(

$hest L=ray is also done d!ring gro"th s!rts esecially d!ring !+erty( When t!+ing is

short or close to +eing o!t o- the right atri!m sh!nt relacement needs to +e sched!led(

TESTIN SH-NT FOR PATENC:0


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$omressing o- the cham+er or reser*oir

)!m is comressed -irmly and D!ickly "ith -ore-ingers

Pogno#i#

)rognosis deends on early diagnosis and romt theray(

With imro*ed diagnostic and management techniD!es the rognosis is +ecomingconsidera+ly +etter(

o Many children eerience normal motor and intellect!al de*eloment(

o he se*erity o- ne!rologic de-icits is directly roortional to the inter*al +et"een

onset o- hydrocehal!s and the time o- diagnosis(

Hydrocehal!s d!e to meningitis might sontaneo!sly resol*e d!e to grad!al

disaearance o- adhesions(

Aroimately t"o=thirds o- atients "ill die at an early age i- they do not recei*e

s!rgical treatment(

Com*!ication#

Sei3!res(

Herniation o- the +rain(

Sontaneo!s arrest d!e to nat!ral comensatory mechanisms ersistent increased I$)

and +rain herniation(

'e*elomental delays(

'eression in adolescents is common(

PATIENT: #'ge" not done "et 5't accoding to docto t(e" 3i!! *!an fo 10* #('nt afte

#(ifting to t(e 3ad

N-RSIN +ANAE+ENT

&!rsing AssessmentIn-ants

Assess head circ!m-erence(

o Meas!re at the occiito-rontal circ!m-erence oint o- largest meas!rement(

o Meas!re the head at aroimately the same time each day(

o se a centimeter meas!re -or greatest acc!racy(

)alate -ontanelle -or tenseness +!lging(

Assess !illary resonse(


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Assess le*el o- conscio!sness :#?$eort changes in *ital signs Maintain n!trition% -eed +a+y -reD!ently

$hanges osition -reD!ently to lesser chances o- de*eloment o- ress!re on scal

s!ort +a+yRs head care-!lly "hile li-ting to re*ent tra!ma

)reare +a+y -or diagnostic roced!res

Ens!re In-ormed consent +y the arents

POST OPERATI7E

>ecord *ital signs e*ery 12 to 0 mins a-ter s!rgery

Monitor -or sign o- I$$) % "idened !lse ress!re slo" !lse change in +odytemerat!re

Assess !illary resonse(

Assess le*el o- conscio!sness :#?$


20/21

.ee the in-ant in the non oerati*e side to re*ent ress!re on sh!nt *al*e

.ee atient -lat a-ter 54 ho!rs o- s!rgery

I- -ontanelle is deressed in-ormed doctor

)ro*ide the medication as ordered

Ed!cate the arents on the -!nction o- the sh!nt and diagnostic roced!re care o- the

child a-ter dischargeN'#ing Diagno#e#

Ine--ecti*e $ere+ral iss!e )er-!sion related to increased I$) +e-ore s!rgery

Im+alanced &!trition% #ess han ;ody >eD!irements related to red!ced oral intake and

*omiting

>isk -or Imaired Skin Integrity related to alterations in #?$ and enlarged head

Aniety o- arents related to child !ndergoing s!rgery

>isk -or In!ry related to mal-!nctioning sh!nt

>isk -or 'e-icient 8l!id ol!me related to $S8 drainage decreased intakeostoerati*ely

>isk -or In-ection related to +acterial in-iltration o- the sh!nt

Ine--ecti*e 8amily $oing related to diagnosis and s!rgery

N-RSIN DIANOSES IN THE PATIENT

8e*er related to disease condition(

High risk -or in-ection related to s!rgical "o!nd in*asi*e line

&!trition alteration in less than +ody reD!irement(

.no"ledge de-icit regarding disease condition health ro+lem

SHORT TER+ OA,S

o maintain +ody temerat!re and monitoring o- *ital signs

o re*ent in-ection

o maintain n!tritional le*el

o ed!cate arents a+o!t the disease conditions

,ON TER+ OA,S

o reha+ilitate the client

o teach atient a+o!t the treatment regimen and -ollo" ! m o romote health

REFERENCES:

.liengman and et alG &elson et+ook o- )ediatricsG 1,thedition : E=;ook


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?) hai and et alG hai Essential )ediatricsG 7thEditionG ages 250=254

Issel+acher et alG HarrisonRs )rinciles o- Internal Medicine7th Edition :E=;ook

2010 cp on hydrocephalus

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