Next up is Michael Yang, talking about Calgary Shunt Protocol and Adaptation of the Hydrocephalus Clinical Research Network, Shunt Protocol Reduces Risk of Shunt Infection in Children. Good afternoon. I would like to thank the AANS Scientific Committee for giving me this opportunity to present my research. I have no conflict of interest. I did this project in collaboration with Dr. J. Rupert Cameron. I don't mean to convince this crowd, but shunt infection continues to be a common complication after shunt surgery, and in large database studies, the shunt infection rate has been reported around 5 to 10%. With each shunt infection, it can cause a significant amount of morbidity and cost the healthcare system. The average cost to manage a shunt infection is around $30,000 U.S., and for the patient, it means the hospital admission for 14 days to 15 days, and this leads to about $239 million in total hospital charges in 2003. This is Alberta Children's Hospital, and it's where I'm from, it is a small to medium-volume tertiary pediatric neurosurgery center. The catchment area is about 2 million people. In 2011, we did a quality assurance study, and we found that our shunt infection rates were quite high, between 12 to 15%, higher than what is reported in the literature. So this prompted us to go into the literature to see whether we can find a strategy to try to reduce our shunt infection rate, and we found this paper by Dr. Kessler-Law, a person on behalf of the Hydrocephalus Clinical Research Network. In this study, they included four HCR and research centers and 11-step shunt protocol, and they showed a reduction of shunt infection of 3.15% from 8.8 to 5.7 after implementation of this shunt protocol. This is their shunt protocol listed on the right-hand side. However, due to logistical constraints in our institution, we weren't able to get vancomycin and gentamicin to the OR in time for injection into the reservoir. So we designed a very closely adapted protocol, and we termed it the Calgary Shunt Protocol. The two protocols are identical except for a few minor points. Obviously, we didn't inject antibiotics into the reservoir. However, we also hypothesized that waiting at least 30 minutes between giving preoperative antibiotics and skin incision will reduce shunt infection rates because the carbonylkinetic cephasone peaks at 30 minutes in the serum. We also maintained normal thermia throughout the case. Other than those, the two protocols were identical. This brings me to my primary research question, which is did the implementation of the Calgary Shunt Protocol improve shunt infection rates in Alberta Children's Hospital? And my two secondary goals were to answer whether can we externally validate the HCR shunt protocol in a non-HCR and small to medium neurosurgery center. We also wanted to know what components of our protocol drove the improvement in shunt infection rates. So we implemented the Calgary Shunt Protocol on May 23, 2013, and then we retrospectively looked at patients from January 2009 and used those as our control cohort with a sample size of 158 patients. From the implementation, we then prospectively looked at all patients underwent shunt surgery in our institution until December 2016, and this acted as our interventional cohort with a sample size of 110. We used the same inclusion and exclusion criteria as the Kesseldahl paper that I presented before, and we also used the strict definition, ACR definition of shunt infection, including shunt erosion and the presence of abdominal pseudocyst as an indication for infection. Our sample size was 268 patients with a median age of 14 months. The most common etiology for hydrocephalus is premature IVH, and the most common type of shunt surgery we did was a ventricular peritoneal shunt. So this is our shunt infection data. So prior to the implementation of the shunt protocol, so our control cohort, our average shunt infection rate was 12.7%. After implementation of our shunt protocol, this was significantly reduced to 2.7% with an absolute risk reduction of 10%. In terms of our protocol compliance, we had a 70% perfect compliance. We also wanted to know which components of the protocol actually drove the reduction in shunt infection rates, and we found that the act of just implementing a protocol, our protocol, reduced shunt infection rates, that was statistically significant. Using chlorhexidine skin preparation compared to iodine-based skin preparation solution also reduced infection rates by about 8%. Timing of preoperative antibiotics, we hypothesized that waiting 30 minutes would reduce infections. However, that was not found to be statistically significant. However, in a post-hoc analysis, waiting at least 20 minutes between preoperative antibiotics and skin incision was significant in reducing shunt infection rates. We took near-significant variables and those variables that needs to be adjusted into a multivariable logistic regression model. Only the implementation of the Calgary shunt protocol was independently associated with a reduction in shunt infection with an odd ratio of 0.19, and this was statistically significant. So in conclusion, the Calgary shunt protocol was effective in reducing shunt infections with an absolute risk reduction of 10% and a relative risk reduction of 79%. The success of our protocol suggests that the HCRN protocol is able to reduce shunt infection in non-HCRN small-to-medium pediatric neurosurgery centers. Protocol implementation was the only variable that was independently predictive of reduction in shunt infection. However, we think that chlorhexidine compared to proviadone skin prep and waiting at least 20 minutes also contributed to the overall protocol success. I'd like to thank Dr. J. Robert Cameron as well as my co-author and my funding agencies. Thank you very much. Thank you.

Calgary Shunt Protocol

Hydrocephalus Clinical Research Network

shunt infection

children

surgery complications