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Ventriculo-Atriostomy
VENTRICULO - ATRIOSTOMY Ruth W . Davis, R.N. Although hydrocephalus has been treated in various ways for many years, real hope for its victims came only with the development of the shunt. Medicine has few more dramatic precedents than when self-styled engineer John Holter, Philadelphia suburbanite, pitting his ingenuity against his son’s death, followed the guide lines of Dr. Eugene B. Spitz, and created the first pressure-relieving ventricular valve. The Holter valve ushered in a new era in neurosurgery for this enigmatic cranial disorder found only in mammals. According to Dr. David Reynolds, Chairman of the De-
w.
Ruth Davis is a graduate of Conemaugh Memorial Hospital School of Nursing in Johnstown, Pennsylvania and has taken additional courses in nursing at both the Universities of Pittsburgh and Pennsylvania. Currently employed as a part time general duty nurse in the operating room at Jackson Memorial Hospital in Miami, Florida, Miss Davis has held a variety of positions in her nursing career including those of emergency room nurse, head nurse, assistant supervisor and night supervisor. In the last few years she has been engaged in free-lance writing for such publications as Health. the New York Times, London Express, and the Washington Post. Miss Davis wishes to thank Dr. David Reynolds, Chairman of the Department of Neurology at Jackson Memorial Hospital, and Mrs. Virginia Gary, head nurse of the department, for their help in writing this article.
Murch 1967
partment of Neurosurgery at Jackson Memorial Hospital, Miami, Florida, hydrlocephalus is far from a simple disease. It has many origins -congenital, postinfectious, posttraumatic, neoplastic, postoperative. Its etiology can lie in the brain tissues themselves, or in the vascular structures that nourish them. Secreted by the choroid plexus o f the lateral and other ventricles, the cerebrospinal fluid normally passes along the aqueduct of Sylvius to the fourth ventricle, then to the basal cisterns of the sub-arachnoid space. From there it follows narrow channels between the brain stem and tentorium, finally laking in the cerebral portion of the sub-arachnoid space. It also passes frlom the basal cisterns into the spinal canal where samples can be withdrawn by lumbar puncture. This transparent, slightly yellowish, watery fluid surrounds the brain on all sides, helping to support the organ’s weight and acting as a buffer. Obstruction of normal channels causes the ventricles to dilate, bringing an accompanying pressure atrophy of the cerebral tissue. Common points of obstruction are in the aqueduct of Sylvius and in the roof of the fourth ventricle, causing internal hydrocephalus, and around the mesencephalon where it passes through the narrow opening into the tentorium, causing communicating hydrocephalus. Formation of cerebro-spinal fluid is related to cranial metabolism, and its composition is not uniform throughout the brain chan-
59
Fig. 1 shows the cards and photos which describe the techniques and equipment used in the basic neuro setup at Jackson Memorial Hospital. These two devices aid those technicians who may be unfamiliar with the hospital’s routines.
nels, varying in chemical and protein content. Neither is its pressure constant, changing slightly with pulsations from each heart beat. Suspected hydrocephalic cases are diagnosed by air study via lumbar puncture. If this proves to be inconclusive and visualization of the aqueduct and fourth ventricle is not satisfactory, a ventriculography is performed to identify pathology. Many surgical techniques for controlling this condition have been employed before the valves were available to the neurosurgeon : ventricular drainage, ventriculocisternostomy, third ventriculostomy, choroid plexectomy. arachnoid ureterostomy, ventriculo-
60
ureterostomy and ventriculoperitoneostomy. Many adults living today can testify to their success, but the cases which did not survive, or lived on in mental retardation, pointed the need for a more efficient shunting device. Basically, the procedure involves inserting a catheter into the ventricle, permitting the fluid to flow outward to a valve which permits only one-way traffic, then proceeds downward through the jugular vein to the right atrium. Some physicians assume an attitude of permanency about this procedure, that “once a shunt, always a shunt.” Others are inclined to disagree, in the hopeful belief that sometimes the basic etiology will correct itself so
AORN Journal
F i g . 2 shows O R Technician Juanita McCune working with the basic neuro setup used at Jackson Memorial Hospital.
the by-pass device can be removed. Hydrocephalus is really a symptom, not a disease, and as previously stated, has many origins. Since preservation of intellect is a prime object in this procedure, once diagnosed, long delay before surgery is not tolerable. The basic setup for this procedure, outlined by Mrs. Virginia Gary, Head Nurse in Neurosurgery at Jackson Memorial Hospital is: instruments for trephining the skull, plus routine dissecting instruments for separating the neck vein from the surrounding tissue. Besides the valve and its components, Mrs. Gary includes a small pair of curved iris scissors for slitting the vein, a fine mousetoothed tissue forceps, blunted 16 gauge
March 1967
needle for injecting the tubes, 2 ml imd 10 ml. syringes, small bulldog clamp!j, two uterine dressing forceps for inserting the catheters, umbilical tape, right angle clamps, mastoid retractors, small rongeurs, currettes and bone wax. The setup includes Hypaque and syringes and, Mrs. Gary adds: “skin towels must be sewed in place, as clips interfere with X-ray visualization.” All shunting devices must be checked before implanting to insure efficiency of the valves and patency of the tubes. The problems of tube stickiness and narrowing of the lumen disappeared at Jackson Memorial when heat sterilization was replaced by gas. The patient is placed in supine position with the head rotated 45-60 degrees to the
61
HOLTER VENTRICULO-CAVAL SHUNT VALVE SI LlCO N E CATHETER
I N VENTRICLE
SUBCUTANEOUS PUMP
SILICONE TUBING
DIVIDED JUGULAR
SUPERIOR VENA CAVA Joan Eldon
left side. A pad is placed under the shoulders to extend the neck. A cassett must be placed under the patient’s chest for X-Ray verification that the tube is in the atrium. Mrs. Gary reminds the reader to keep the Mayo stand clear of the chest. She remembers a few roentograms that had to be “done over” because of the blunder of misplaced furniture. The operative site is outlined with methylene blue or gentian violet. It is important that cerebro-spinal fluid loss is minimal in this operation. If less fluid escapes, the valve begins operating with satisfactory pressure. When the tubes are securely placed and appear to be working efficiently, contrast medium is inserted into the tube for the X-ray.
62
After this part of the procedure is completed, the tube is rinsed with physiological salt solution. At Jackson Memorial three valves are used in the neurosurgical department-the Holter, Pudenz and Hakin. The size of the patient has no bearing on the choice of valve; each valve is suitable for adults or children. The valve used depends upon the physician’s preference, and the protein content of the cerebro-spinal fluid. Dr. Reynolds, who uses the Holter almost routinely, states that his department finds itself constantly applying new uses to this valve. John Holter set out to create a device that would maintain constant pressure and prevent backflow, and in this he succeeded. Color-coded, the Holter offers a choice of
AORN Journal
PUDENZ VENTRICULO-ATRIAL SHUNT
NORMAL OPERATING POSITION
COMPRESSION FORCES F L U I D THROUGH CARDIAC TUBE Joan Eldon
a normal pressure valve calibrated to aatisfy most routine cases; medium pressure valve for advanced cases where the skull has been greatly distended; and the low pressure valve for draining accumulated sub-dural fluid into the venous system. Surprisingly, the head of the child with great distention is under less pressure than those not so far advanced. There are three kinds of jugular catheters and connectors in the Holter. Type A is a simple catheter made of silicone rubber, barium impregnated. It fits firmly at the entrance of the jugular vein. Type B is a two-piece structure with a small flexible portion which fits deeply in the atrium, reducing problems of growth, infection and thrombus. Type C has a reinforcing sleeve which can be moved to suit the changing needs of the patient .
March 1967
The nylon connector holds the jugular catheter in place, prevents collapse of the catheter when suture is placed around the vein, and permits stretching of the catheter or vein by activity or growth of the patient. The catheters at the ventricular end of the shunt are either straight or angular, and are chosen according to the thickness of the patient’s cortex. The Pudenz valve has four parts: the cardiac tube with multiple slit valves in the side wall near the tip; the ventriculaLrtube with side perforations; nylon connectors; and a flushing device. The ventricular and cardiac tips are radiopaque. The flushing device fits into a burr hole, and flushing is accomplished by puncturing its surface with a small needle and syringe at a 45 degree angle.
63
HAKIM-VALVE SYSTEM
VENTRICULAR CATHETER
TREPHINE OPENING
CARDIAC CATHETER
< \
OCCIPITAL APPROACH
TO RIGHT ATRIUM
TEMPORAL
.APPROACH
\
FRONTAL APPROACH
f
\ 64
Joan Eldon
AORN Journal
The Hakim valve, also color-coded, has special non-clogging features which make it appealing for use in patients with high protein in their cerebro-spinal fluid. The ventricular end is inserted with an introducing rod, which when withdrawn, leaves the catheter end curled. The slits are on the inner side of the curl, preventing clogging in implantation. The fluid runs through the tube and connector to an antechamber where pressure readings may be taken by inserting a hypodermic needle. Fluid samples can be obtained at the antechamber; if clogging orcurs, it can be located by checking fluid flows in either direction from this chamber. By squeezing this chamber, it acts as a pump. so that fluid is forced through, and dehris can be cleared. The valve has sapphire balls in stainless steel seats which have self-cleaning action, grinding debris into minute particles lwfore permitting passage into the cardiac catheter. Color-coding indicates the pressure-maintaining ability of the valve on the ventricular end, and the direction of the flow on the cardiac end. Enough cannot be said of the importance of handling this equipment carefully. The price of each valve is quite high, and each is an intricate mechanism. The Holter valve is packaged in fluid, and drying-out causes irreparable damage. There are variations to the three valves described herein. A modification of the P u denz is a “twin reservoir” which acts similarly to the antechamber of the Hakim, and can be used for injection of drugs, contrast material and irrigating fluid into either chamber of the system. It also has declogging action. can be used for recording pressures
and taking fluid samples. Not all shunts exit into the atrium. For non-communicating hydrocephalus is ventriculo-cisternal operation can be done which drains the ventricles, carrying the fluid past a valved pump to the basal cisterns where they can exit through the spinal canal. If this should prove unsuccessful, the transfer to the internal jugular is a simple transition. Replacement of a valve is hardly considered a complication, but rather a maintenance program for the hydrocephallic patient. Some physicians do this aribil rarily, others only as needed. Many factors can bring about a need for change: clogging by debris of the ventricular end; moving of the end of the catheter into a cleft in the ventricle; local inflammation causing a thrombosis on the cardiac end; withdrawal of the tubes from the atrium because of patient’s growth. Infective material is always a thr’eat to patency; there are recorded cases where the tube was sucked into the vascular system. Replacement of a non-functioning valve system is done as quickly as possible to prevent a build-up of pressure. “If I were to advise an OR nurse on her most important obligation in these cases,” says Dr. David Reynolds, “I would a,sk for meticulous technique.” Although septicemia is a less common complication than in the past, the danger is ever present, with staphylococcus albus the chief offender. At Jackson Memorial, the infection incidence was dramatically reduced by changing from heat to gas sterilization. With modern neurosurgical innovations, skilled physicians and talented surgical nurses, hydrocephalics are enjoying great hope for a normal life.
REFERENCES Ingraham, Franc, M.D. and Matson, Donald, 2. Workshop in Hydrocephalus held at Children’s M.D., Neurosurgery in Infancy & Childhood, Charles Hospital of Philadelphia, April 10, 1965. C. Thomas, Springfield, Illinois. 3. Neiirosirrgical News. 1.
March 1967
65
w.
Ruth Davis is a graduate of Conemaugh Memorial Hospital School of Nursing in Johnstown, Pennsylvania and has taken additional courses in nursing at both the Universities of Pittsburgh and Pennsylvania. Currently employed as a part time general duty nurse in the operating room at Jackson Memorial Hospital in Miami, Florida, Miss Davis has held a variety of positions in her nursing career including those of emergency room nurse, head nurse, assistant supervisor and night supervisor. In the last few years she has been engaged in free-lance writing for such publications as Health. the New York Times, London Express, and the Washington Post. Miss Davis wishes to thank Dr. David Reynolds, Chairman of the Department of Neurology at Jackson Memorial Hospital, and Mrs. Virginia Gary, head nurse of the department, for their help in writing this article.
Murch 1967
partment of Neurosurgery at Jackson Memorial Hospital, Miami, Florida, hydrlocephalus is far from a simple disease. It has many origins -congenital, postinfectious, posttraumatic, neoplastic, postoperative. Its etiology can lie in the brain tissues themselves, or in the vascular structures that nourish them. Secreted by the choroid plexus o f the lateral and other ventricles, the cerebrospinal fluid normally passes along the aqueduct of Sylvius to the fourth ventricle, then to the basal cisterns of the sub-arachnoid space. From there it follows narrow channels between the brain stem and tentorium, finally laking in the cerebral portion of the sub-arachnoid space. It also passes frlom the basal cisterns into the spinal canal where samples can be withdrawn by lumbar puncture. This transparent, slightly yellowish, watery fluid surrounds the brain on all sides, helping to support the organ’s weight and acting as a buffer. Obstruction of normal channels causes the ventricles to dilate, bringing an accompanying pressure atrophy of the cerebral tissue. Common points of obstruction are in the aqueduct of Sylvius and in the roof of the fourth ventricle, causing internal hydrocephalus, and around the mesencephalon where it passes through the narrow opening into the tentorium, causing communicating hydrocephalus. Formation of cerebro-spinal fluid is related to cranial metabolism, and its composition is not uniform throughout the brain chan-
59
Fig. 1 shows the cards and photos which describe the techniques and equipment used in the basic neuro setup at Jackson Memorial Hospital. These two devices aid those technicians who may be unfamiliar with the hospital’s routines.
nels, varying in chemical and protein content. Neither is its pressure constant, changing slightly with pulsations from each heart beat. Suspected hydrocephalic cases are diagnosed by air study via lumbar puncture. If this proves to be inconclusive and visualization of the aqueduct and fourth ventricle is not satisfactory, a ventriculography is performed to identify pathology. Many surgical techniques for controlling this condition have been employed before the valves were available to the neurosurgeon : ventricular drainage, ventriculocisternostomy, third ventriculostomy, choroid plexectomy. arachnoid ureterostomy, ventriculo-
60
ureterostomy and ventriculoperitoneostomy. Many adults living today can testify to their success, but the cases which did not survive, or lived on in mental retardation, pointed the need for a more efficient shunting device. Basically, the procedure involves inserting a catheter into the ventricle, permitting the fluid to flow outward to a valve which permits only one-way traffic, then proceeds downward through the jugular vein to the right atrium. Some physicians assume an attitude of permanency about this procedure, that “once a shunt, always a shunt.” Others are inclined to disagree, in the hopeful belief that sometimes the basic etiology will correct itself so
AORN Journal
F i g . 2 shows O R Technician Juanita McCune working with the basic neuro setup used at Jackson Memorial Hospital.
the by-pass device can be removed. Hydrocephalus is really a symptom, not a disease, and as previously stated, has many origins. Since preservation of intellect is a prime object in this procedure, once diagnosed, long delay before surgery is not tolerable. The basic setup for this procedure, outlined by Mrs. Virginia Gary, Head Nurse in Neurosurgery at Jackson Memorial Hospital is: instruments for trephining the skull, plus routine dissecting instruments for separating the neck vein from the surrounding tissue. Besides the valve and its components, Mrs. Gary includes a small pair of curved iris scissors for slitting the vein, a fine mousetoothed tissue forceps, blunted 16 gauge
March 1967
needle for injecting the tubes, 2 ml imd 10 ml. syringes, small bulldog clamp!j, two uterine dressing forceps for inserting the catheters, umbilical tape, right angle clamps, mastoid retractors, small rongeurs, currettes and bone wax. The setup includes Hypaque and syringes and, Mrs. Gary adds: “skin towels must be sewed in place, as clips interfere with X-ray visualization.” All shunting devices must be checked before implanting to insure efficiency of the valves and patency of the tubes. The problems of tube stickiness and narrowing of the lumen disappeared at Jackson Memorial when heat sterilization was replaced by gas. The patient is placed in supine position with the head rotated 45-60 degrees to the
61
HOLTER VENTRICULO-CAVAL SHUNT VALVE SI LlCO N E CATHETER
I N VENTRICLE
SUBCUTANEOUS PUMP
SILICONE TUBING
DIVIDED JUGULAR
SUPERIOR VENA CAVA Joan Eldon
left side. A pad is placed under the shoulders to extend the neck. A cassett must be placed under the patient’s chest for X-Ray verification that the tube is in the atrium. Mrs. Gary reminds the reader to keep the Mayo stand clear of the chest. She remembers a few roentograms that had to be “done over” because of the blunder of misplaced furniture. The operative site is outlined with methylene blue or gentian violet. It is important that cerebro-spinal fluid loss is minimal in this operation. If less fluid escapes, the valve begins operating with satisfactory pressure. When the tubes are securely placed and appear to be working efficiently, contrast medium is inserted into the tube for the X-ray.
62
After this part of the procedure is completed, the tube is rinsed with physiological salt solution. At Jackson Memorial three valves are used in the neurosurgical department-the Holter, Pudenz and Hakin. The size of the patient has no bearing on the choice of valve; each valve is suitable for adults or children. The valve used depends upon the physician’s preference, and the protein content of the cerebro-spinal fluid. Dr. Reynolds, who uses the Holter almost routinely, states that his department finds itself constantly applying new uses to this valve. John Holter set out to create a device that would maintain constant pressure and prevent backflow, and in this he succeeded. Color-coded, the Holter offers a choice of
AORN Journal
PUDENZ VENTRICULO-ATRIAL SHUNT
NORMAL OPERATING POSITION
COMPRESSION FORCES F L U I D THROUGH CARDIAC TUBE Joan Eldon
a normal pressure valve calibrated to aatisfy most routine cases; medium pressure valve for advanced cases where the skull has been greatly distended; and the low pressure valve for draining accumulated sub-dural fluid into the venous system. Surprisingly, the head of the child with great distention is under less pressure than those not so far advanced. There are three kinds of jugular catheters and connectors in the Holter. Type A is a simple catheter made of silicone rubber, barium impregnated. It fits firmly at the entrance of the jugular vein. Type B is a two-piece structure with a small flexible portion which fits deeply in the atrium, reducing problems of growth, infection and thrombus. Type C has a reinforcing sleeve which can be moved to suit the changing needs of the patient .
March 1967
The nylon connector holds the jugular catheter in place, prevents collapse of the catheter when suture is placed around the vein, and permits stretching of the catheter or vein by activity or growth of the patient. The catheters at the ventricular end of the shunt are either straight or angular, and are chosen according to the thickness of the patient’s cortex. The Pudenz valve has four parts: the cardiac tube with multiple slit valves in the side wall near the tip; the ventriculaLrtube with side perforations; nylon connectors; and a flushing device. The ventricular and cardiac tips are radiopaque. The flushing device fits into a burr hole, and flushing is accomplished by puncturing its surface with a small needle and syringe at a 45 degree angle.
63
HAKIM-VALVE SYSTEM
VENTRICULAR CATHETER
TREPHINE OPENING
CARDIAC CATHETER
< \
OCCIPITAL APPROACH
TO RIGHT ATRIUM
TEMPORAL
.APPROACH
\
FRONTAL APPROACH
f
\ 64
Joan Eldon
AORN Journal
The Hakim valve, also color-coded, has special non-clogging features which make it appealing for use in patients with high protein in their cerebro-spinal fluid. The ventricular end is inserted with an introducing rod, which when withdrawn, leaves the catheter end curled. The slits are on the inner side of the curl, preventing clogging in implantation. The fluid runs through the tube and connector to an antechamber where pressure readings may be taken by inserting a hypodermic needle. Fluid samples can be obtained at the antechamber; if clogging orcurs, it can be located by checking fluid flows in either direction from this chamber. By squeezing this chamber, it acts as a pump. so that fluid is forced through, and dehris can be cleared. The valve has sapphire balls in stainless steel seats which have self-cleaning action, grinding debris into minute particles lwfore permitting passage into the cardiac catheter. Color-coding indicates the pressure-maintaining ability of the valve on the ventricular end, and the direction of the flow on the cardiac end. Enough cannot be said of the importance of handling this equipment carefully. The price of each valve is quite high, and each is an intricate mechanism. The Holter valve is packaged in fluid, and drying-out causes irreparable damage. There are variations to the three valves described herein. A modification of the P u denz is a “twin reservoir” which acts similarly to the antechamber of the Hakim, and can be used for injection of drugs, contrast material and irrigating fluid into either chamber of the system. It also has declogging action. can be used for recording pressures
and taking fluid samples. Not all shunts exit into the atrium. For non-communicating hydrocephalus is ventriculo-cisternal operation can be done which drains the ventricles, carrying the fluid past a valved pump to the basal cisterns where they can exit through the spinal canal. If this should prove unsuccessful, the transfer to the internal jugular is a simple transition. Replacement of a valve is hardly considered a complication, but rather a maintenance program for the hydrocephallic patient. Some physicians do this aribil rarily, others only as needed. Many factors can bring about a need for change: clogging by debris of the ventricular end; moving of the end of the catheter into a cleft in the ventricle; local inflammation causing a thrombosis on the cardiac end; withdrawal of the tubes from the atrium because of patient’s growth. Infective material is always a thr’eat to patency; there are recorded cases where the tube was sucked into the vascular system. Replacement of a non-functioning valve system is done as quickly as possible to prevent a build-up of pressure. “If I were to advise an OR nurse on her most important obligation in these cases,” says Dr. David Reynolds, “I would a,sk for meticulous technique.” Although septicemia is a less common complication than in the past, the danger is ever present, with staphylococcus albus the chief offender. At Jackson Memorial, the infection incidence was dramatically reduced by changing from heat to gas sterilization. With modern neurosurgical innovations, skilled physicians and talented surgical nurses, hydrocephalics are enjoying great hope for a normal life.
REFERENCES Ingraham, Franc, M.D. and Matson, Donald, 2. Workshop in Hydrocephalus held at Children’s M.D., Neurosurgery in Infancy & Childhood, Charles Hospital of Philadelphia, April 10, 1965. C. Thomas, Springfield, Illinois. 3. Neiirosirrgical News. 1.
March 1967
65