reprogramming guide for pressure adjustment for a codman hakim programmable valve in a patient of normal pressure hydrocephalus with special advice in relation to posture adjustment i.e.,sitting and lying duration

My mother Mrs. Bela Mitra,73 years  was a patient of Normal Pressure Hydrocephalus with pituitary adenoma (size 1.5 cm) and was having problem in gait,urinary incontinenance and dementia. She was operated with codman Hakim programmable VP shunt (without Siphon guard (Model:- Micro Valve with RICHAM Reservoir and Unitized Distal Catheter) on 3.4.2009 at CMC Hospital, Vellore,India. During operation it was noted that at 200 mm pressure the CSF drainage was slow. So,neurosurgeon adjusted the pressure at 180 mm during operation.Post-operatively she responded well within a week regarding her gait,cognition and urinary incontinenance. But after one week she detoriated after coming back to Dhanbad. She was unable to swallow orally and became drowsy. So, a CT scan of brain was done in my hospital (Central Hospital,Dhanbad) as per suggestion of our neurosurgeon. On CT scan features of overdrainage of CSF was noted with subdural effusion and chin ventricles and accordingly the pressure was readjusted to 200 mm and then she improved again by walking,talking and swallowing and also urinary incontinence. But remaining well for approximately one month, she again showed features of NPH. So the pressure was again readjusted to initial 190 mm for 5 days and as there was no remarkable improvement she was again readjusted to 180 mm. But again she showed features of overdrainage and consequently pressure was readjusted to 200 mmm with which she remained well for another 25 days and after that again showed features of NPH. Then naturally pressure was initially adjusted to 190 mm for 5 days at which she showed some improvement but not full as it was with 200 mm. The pressure was readjusted to 180 mm for 2 days with which again showing gross overdrainage. Naturally, now she was readjusted to 200 mm on 20.07.09 with which she is improving gradually in respect of alertness, gait and swallowing solid and liquid both except water.


Thanking You.
With Regards,
Dr.P.K.Mitra

[Nassim Abi Chahine, MD]

Ok so soon after she got well she should be adjusted to 110

[mitrapradeep]

Respected Sir,

I am really grateful to you for your suggestion regarding my mother to adjust the pressure at 110 and as per your suggestion I am proceeding accordingly. Now, I have reduced the pressure to 130 (done on 09.09.09) gradually from 200 in last 15 days. My mother is also improving with your valuable advice and I have a plan to reduce the pressure to 110 in another 4-5 days. Hope  you will also help me in future with yopur valuable advice regarding my mother and I shall remain grateful to you Sir forever. I request you if you kindly send your contact number if possible for better communication in future and obilige me.

Thanking You.
With Regards,
Dr.P.K.Mitra
Paediatrician
Central Hospital, Dhanbad
India.

[Nassim Abi Chahine, MD]

Dear Doctor Mitra, I am so glad to hear your mother's good news. I am sure that she will regain her strengh and I wish her long life.
please look up to my e mail on my personal CV:

http://en.wikipedia.org/wiki/User:Nassim_Abi_Chahine

so thats how you send me your e-mail and then I will re-send you my phone number for any quick contact
Sincerly

[mitrapradeep]

Respected Sir,
With reference to your mail in neurosurgery forum dated.20/09/09 I am really thankful to you Sir for your quick response.I am glad to inform you that I have reduced the pressure of my mother to 110 on 13/09/09 as per your valuable advice in your earlier reply through neurosurgery forum dated. 31/08/09. I am also glad to inform you that my mother is improving in respect of alertness and strength and she is able to sit with support but she is sleepy after sitting for a short period. But at present she is unable to speak and stand and also having urinary incontinence with difficulty in swallowing water (but able to swallow hot milk and tea).So I request you for your  valuable advice regarding my mother whether to reduce the pressure setting further or anything special you like to advice in this case.
Hope you will again  show me your kind gesture and advice me for my mother further so that she can speak and stand.I also request you to kindly send me your contact number for better communication in future.
Eagerly waiting for your early reply.

Thanking You.
Yours Sincerely,
With Regards,
Dr.P.K.Mitra
Paeditrician
Central Hospital
Dhanbad-826005, India.
Phone:[phone](R)
           09430152301 (Mobile)

[Nassim Abi Chahine, MD]

Dear Dr.Mitra
Your mother response is so kind, in this letter I would like to inform you that the minimum adviced pressure should not be inferior to 105 mmH2O.
Be patient to meet her best results after around 3 months from our level fixation. This is cardinal to know that the brain of a woman in her age will positively answer some time after your full care with an extreme slugishness.
I can not promise you that she will speak fluently again ! but interestingly she will regain her gait.
The cause of this state is probably a frequent change in the CSF pressure.

Two very important direction you should be tight to; control the Sodium (and less strict the Potassium) levels, if you find any disturbance start to correct on a basis of coorection in serum means change in interstitium after around 5-7 days in the case of sodium (normal serum level 135-145 is found to be 121-129 in electro interstitial scan)
Point 2: keep her in her initial environment, I mean in her room with her colors and atmosphere, because that will help us more  during the reconvalescence period.

And if you accept my last suggestion about her feeding; try to keep her far from drinking liquids (better solid food for the next month), an intravenous hydration is my preferable way of substituting. So you can add 1 ampoule calcium gluconate, vitamin B complex, or even sodium every second days during six-12 hours.

tolterodine tartrate or oxybutynin are very supportative for the urinary incontinence

Please substitute her with: Vimpozine, Citicholine, Caffeine, Olmifon. Start with whatever you find in your country.
And please google out my contact to prevent conflict of interest, and thank you for your trust and your confidence. Always welcome.
Dr Nassim
Medhelp