Enhanced recovery after surgery in patients with normal pressure hydrocephalus undergoing ventriculoperitoneal shunting procedures

Objective: Patients with idiopathic normal pressure hydrocephalus (iNPH) who undergo ventriculoperitoneal shunt (VPS) placement often belong to an older demographic, putting them at increased risk of postoperative delirium and related complications. Recent literature documenting the use of Enhanced Recovery After Surgery (ERAS) protocols in various disciplines of surgery has shown improved clinical outcomes, faster discharge, and lower readmission rates. Early return to a familiar environment (i.e., discharged home) is a well-known predictor of reduced postoperative delirium. However, ERAS protocols are uncommon in neurosurgery, especially intra-cranial procedures. We developed a novel ERAS protocol for patients with iNPH undergoing VPS placement to gain further insight regarding postoperative complications, specifically delirium.Methods: We studied 40 patients with iNPH with indications for VPS. Seventeen patients were selected at random to undergo the ERAS protocol, and twenty-three patients underwent the standard VPS protocol. The ERAS protocol consisted of measures to reduce infection, manage pain, minimize invasiveness, confirm procedural success with imaging, and shorten the length of stay. Pre-operative American Society of Anesthesiologists (ASA) grade was collected for each patient to indicate baseline risk. Rates of readmission and postoperative compli-cations, including delirium and infection, were collected at 48 h, 2 weeks, and 4 weeks postoperatively.Results: There were no perioperative complications among the 40 patients. There was no postoperative delirium in any of the ERAS patients. Postoperative delirium was observed in 10 of 23 non-ERAS patients. There was no statistically significant difference between the ASA grade between the ERAS and non-ERAS groups.Conclusions: We described a novel ERAS protocol for patients with iNPH receiving VPS focusing on an early discharge. Our data suggest that ERAS protocols in VPS patients might reduce the incidence of delirium without increasing the risk of infection or other postoperative complications.