New Hydrocephalus Pathway Offers Potential to Improve Outcomes

As part of our new Neonatal Neurocritical Care Program within the CHOP Newborn/Infant Intensive Care Unit (N/IICU), we recently developed a pathway to standardize the approach to preterm infants with evolving hydrocephalus after intraventricular hemorrhage (IVH). Support from The Children’s Hospital of Philadelphia’s Office of Clinical Quality Improvement was instrumental in the development of this pathway by providing quality improvement expertise and resources for Web publishing.

After a year-long process that included review of evidence in the literature and peer practice at other institutions, the pathway was recently published on the CHOP website. Many elements of the pathway have been adapted from the approach used in neurosurgical research networks or hydrocephalus management trials. At its core, the pathway standardizes measurements of ventricular size to head size and suggests criteria for intervention. It specifies the use of the fronto-occipital ratio and the fronto-temporal horn ratio to determine the severity of hydrocephalus. More details about these measures are provided in the pathway. Furthermore, recommended timing of surveillance with head ultrasound and a protocol for tapping the reservoirs is outlined, and transfer recommendations are included for referring sites.

“Placement of reservoirs to relieve worsening hydrocephalus in preterm infants too small for a shunt is a management strategy at peer institutions that seems safe and offers potential to improve outcomes,” says Greg Heuer, MD, PhD, director of Fetal and Neonatal Neurosurgery at CHOP. “I wanted to make this treatment available to preterm infants in the CHOP N/IICU and the referring network.”

Together with attending neonatologist John Flibotte, MD, and Annie Giaccone, MD, attending neonatologist and associate medical director of CHOP’s Neonatal Outreach Program, the team reviewed best practices around timing of interventions and tapping of the reservoir.

“Safety was the major focus of our review, and it seems that, with a consistent approach, infection is not a major issue in centers with enough volume,” says Flibotte. “Impact on long-term outcomes is less clear, but in infants with clearly evolving hydrocephalus that will require a shunt, this seems to be the best approach.”

The team will monitor infants for complications, including reservoir malfunction and infection. Infants on the pathway will be followed through CHOP’s Neonatal Follow-up Program for long-term outcomes.

Eight infants with evolving hydrocephalus after IVH have been transferred to CHOP and managed according to pathway recommendations over the past several months (see “Case Study”). Thanks to a strong relationship with Neurosurgery and the commitment of Heuer and the N/IICU, we look forward to ongoing collaboration around the management of these infants. With standardized care, we hope to participate in multicenter research efforts in the future to further our understanding of how best to manage this challenging condition.