Piatt Joseph H
Division of Neurosurgery, Nemours Neuroscience Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware; and Department of Neurological Surgery and Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania.
J Neurosurg Pediatr. 2014 Aug;14(2):179-83. doi: 10.3171/2014.5.PEDS1421. Epub 2014 Jun 13.
Cerebrospinal fluid shunts are the mainstay of the treatment of hydrocephalus. In past studies, outcomes of shunt surgery have been analyzed based on follow-up of 1 year or longer. The goal of the current study is to characterize 30-day shunt outcomes, to identify clinical risk factors for shunt infection and failure, and to develop statistical models that might be used for risk stratification.
Data for 2012 were obtained from the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) of the American College of Surgeons. Files with index surgical procedures for insertion or revision of a CSF shunt composed the study set. Returns to the operating room within 30 days for shunt infection and for shunt failure without infection were the study end points. Associations with a large number of potential clinical risk factors were analyzed on a univariate basis. Logistic regression was used for multivariate analysis.
There were 1790 index surgical procedures analyzed. The overall rates of shunt infection and shunt failure without infection were 2.0% and 11.5%, respectively. Male sex, steroid use in the preceding 30 days, and nutritional support at the time of surgery were risk factors for shunt infection. Cardiac disease was a risk factor for shunt failure without infection, and initial shunt insertion, admission during the second quarter, and neuromuscular disease appeared to be protective. There was a weak association of increasing age with shunt failure without infection. Models based on these factors accounted for no more than 6% of observed variance. Construction of stable statistical models with internal validity for risk adjustment proved impossible.
The precision of the NSQIP-P dataset has allowed identification of risk factors for shunt infection and for shunt failure without infection that have not been documented previously. Thirty-day shunt outcomes may be useful quality metrics, possibly even without risk adjustment. Whether important variation in 30-day outcomes exists among institutions or among neurosurgeons is yet unknown.
脑脊液分流术是治疗脑积水的主要手段。在过去的研究中，分流手术的结果是基于1年或更长时间的随访进行分析的。本研究的目的是描述30天分流结果，确定分流感染和失败的临床危险因素，并开发可用于风险分层的统计模型。
从美国外科医师学会的国家外科质量改进计划-儿科（NSQIP-P）获取2012年的数据。包含脑脊液分流术插入或修订的索引手术程序的文件构成了研究集。30天内因分流感染和无感染的分流失败返回手术室是研究终点。对大量潜在临床危险因素的关联进行单因素分析。多因素分析采用逻辑回归。
共分析了1790例索引手术程序。分流感染和无感染的分流失败的总体发生率分别为2.0%和11.5%。男性、术前30天使用类固醇以及手术时的营养支持是分流感染的危险因素。心脏病是无感染的分流失败的危险因素，初次分流插入、第二季度入院以及神经肌肉疾病似乎具有保护作用。年龄增加与无感染的分流失败之间存在弱关联。基于这些因素的模型解释的观察变异不超过6%。构建具有内部有效性用于风险调整的稳定统计模型被证明是不可能的。
NSQIP-P数据集的精确性使得能够识别先前未记录的分流感染和无感染的分流失败的危险因素。30天分流结果可能是有用的质量指标，甚至可能无需风险调整。各机构或神经外科医生之间30天结果是否存在重要差异尚不清楚。
