Fujimura R, Lober R, Kamian K, Kleiner L
Department of Neurosurgery, Dayton Children's Hospital, Wright State Boonshoft School of Medicine, Dayton, Ohio, United States.
Surg Neurol Int. 2018 Mar 1;9:51. doi: 10.4103/sni.sni_444_17. eCollection 2018.
Programmable ventricular shunt valves are commonly used to treat hydrocephalus. They can be adjusted to allow for varying amounts of cerebrospinal fluid (CSF) flow using an external magnetic programming device, and are susceptible to maladjustment from inadvertent exposure to magnetic fields.
We describe the case of a 3-month-old girl treated for hydrocephalus with a programmable Strata II valve found at the incorrect setting on multiple occasions during her hospitalization despite frequent reprogramming and surveillance. We found that the Vocera badge, a common hands-free wireless communication system worn by our nursing staff, had a strong enough magnetic field to unintentionally change the shunt setting. The device is worn on the chest bringing it into close proximity to the shunt valve when care providers hold the baby, resulting in the maladjustment.
Some commonly used medical devices have a magnetic field strong enough to alter programmable shunt valve settings. Here, we report that the magnetic field from the Vocera hands-free wireless communication system, combined with the worn position, results in shunt maladjustment for the Strata II valve. Healthcare facilities using the Vocera badges need to put protocols in place and properly educate staff members to ensure the safety of patients with Strata II valves.
可编程心室分流阀常用于治疗脑积水。使用外部磁性编程设备可对其进行调节，以实现不同量的脑脊液（CSF）流动，并且容易因意外暴露于磁场而出现调节不当的情况。
我们描述了一名3个月大女童的病例，她因脑积水接受了可编程Strata II阀治疗。在住院期间，尽管进行了频繁的重新编程和监测，但该分流阀多次被发现处于错误设置。我们发现，护理人员佩戴的心语通徽章（一种常见的免提无线通信系统）产生的磁场强度足以意外改变分流阀的设置。当护理人员抱起婴儿时，该设备佩戴在胸部，使其靠近分流阀，从而导致调节不当。
一些常用的医疗设备产生的磁场强度足以改变可编程分流阀的设置。在此，我们报告心语通免提无线通信系统产生的磁场，结合其佩戴位置，会导致Strata II阀的分流调节不当。使用心语通徽章的医疗机构需要制定相关协议并对工作人员进行适当培训，以确保使用Strata II阀患者的安全。
