Post-Hemorrhagic Hydrocephalus — Monitoring and Tapping Reservoir — Clinical Pathway: ICU

Post-Hemorrhagic Hydrocephalus in Pre-Term Infants Clinical Pathway — N/IICU

Monitoring and Tapping Reservoir

Reservoir Tapping Protocol

Monitoring
  • Weekly brain US (Mon)
  • Daily clinical assessments
    • Anterior fontanelle (full, bulging, tense)
    • Cranial sutures (split or not)
When to Tap
  • Tap in the presence of any one of the following:
    • Increase in FOR or FTHR on brain US/MRI/CT scan
    • Bulging anterior fontanelle (above bone)
      • Must be assessed when baby is calm and head is elevated
    • Mid-sagittal suture split > 2 mm or
    • Clinical signs of high pressure
  • If criteria not met, HOLD tapping until next assessment
  • If unsure whether to tap or not, consult neurosurgery
Tapping Supplies
  • 25 gauge butterfly or smaller
  • 10 cc syringe
  • Sterilize with chlorhexidine or povidine/iodine
Tapping Guidelines
  • In general, tap a total of 10 mL/kg at 2 mL/kg/min
  • If not able to aspirate, call neurosurgery
  • Neurosurgery will leave specific recommendation in Care Coordination Note
Consider converting to permanent CSF shunt if requires tapping more than once every 2 days
Follow any specific neurosurgery recommendations

Non-pharmacologic Support Protocol for Neonates/Infants Undergoing Reservoir Tapping

Prior to the Procedure

  • If infant is greater than 30 weeks adjusted age, place topical lidocaine cream to tap site and cover with Tegaderm for 20-30 minutes prior to beginning procedure. Refer to CHOP Formulary for dosing recommendations.
  • Dim lights and decrease ambient noise near infant’s bedspace.
  • Swaddle infant in a flexed, midline supine or sidelying position, with hands near face.
  • Positioning aides or blanket rolls may be used to facilitate positioning.
  • Allow for period of rest for infant prior to beginning procedure.
  • Gather all necessary supplies.
  • Identify second caregiver to support infant during procedure. (Second caregiver will be responsible for supporting infant only, i.e. providing facilitated tucking/hands-on containment and supporting pacifier.
  • Administer sucrose 2 minutes prior to beginning procedure (if appropriate, as per Nursing Standard 13:1). Consider pacifier dip in human milk if less than 30 weeks gestation, or ineligible to receive sucrose.
  • Offer pacifier.

During the Procedure

  • Prepare infant for procedure with soothing voice and gentle touch.
  • With hands and forearms, reinforce tucking. Infant’s legs should be tucked up to belly, with back rounded. Promote hand clasping or grasping of your fingers.
  • Continue to offer pacifier, and repeat sucrose, if eligible, every 2 minutes, up to 2 times during procedure.
  • Communicate infant’s tolerance and endurance to provider throughout procedure. Pace to infant’s tolerance, using physiologic and behavioral indicators, such as HR > 20% above baseline, bradycardia, prolonged desaturations, prolonged intense crying, stress cues, as able.

Following the Procedure

  • If parent available, holding of infant for at least 30 minutes following procedure is preferable.
  • If parent not available, assist infant’s recovery by settling the infant in their preferred position, continuing to support tucking of limbs to trunk, and offering pacifier as desired. Support infant in this fashion until return to baseline.
  • Allow for at least 30 minutes of undisturbed rest with lights dim following procedure.