Patient had prior vp shunt (implanted for 14-15 years) removed, and replaced with new one; strata ii small placed.Per op note: proximal catheter replaced, free flow of csf identified, connected to medtronic strata valve set at 1.5, connected to peritoneal catheter and placed laparoscopically.Vancomycin powder placed in surgical bed, galeal closed with vicryl, and skin closed with monocryl.Discharged home on (b)(6) 2018.A few days later, the patient in ed with complaints of falls, dizziness, and incontinence.Ct shows dilation of the entire ventricular system; no significant change in position of right frontal ventriculostomy catheter.To operating room; proximal catheter explored and free flow of csf seen; no flow to abdomen seen.The valve and distal catheter replaced.Free flow of csf re-established (the strata ii reg used).The patient discharged to rehab on (b)(6) 2018.A few days later the patient had worsening cognition and decline in function noted.Subsequently, ct shows interval worsening in ventriculomegaly/hydrocephalus suggesting shunt malfunction.Neurosurgeon interrogated shunt valve and found it to be at an appropriate setting.The shunt was tapped and approximately 30 cc of clear cerebrospinal fluid was obtained.Aspiration of cerebrospinal fluid concludes that the shunt is working proximally with a distal malfunction.Because the patient had previously had a shunt revision where the distal component had failed, the surgeon decided to convert it into a ventricular pleural shunt.On (b)(6), patient went to operating room and had distal catheter trimmed and placed into pleural space (strata valve was not replaced at this time).On (b)(6), the patient exhibiting altered mental status.Ct done and shows signs of shunt malfunction again.The next day patient went to operating room.The distal catheter was removed and found to be functioning with brisk flow of csf.A new strata valve at 0.5 and the catheter was attached.The proximal catheter functioning and distal catheter replaced.Tunneled to appropriate site in neck and placed into right atrium via internal jugular vein.On (b)(6), patient with altered mental status in afternoon.Ct done and shows shunt malfunction.Shunt was tapped that showed clear csf easily withdrawn and sent for specimen.Shunt was externalized at jumpsite from neck at bedside.On (b)(6), shunt valve and catheter was removed and external ventricular drain (evd) placed into ventricular space.Free flow of csf was initially seen and drained at 5mmhg.
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