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inserted perpendicular to the skull through the burr hole to a depth of no more than cm H2 O After the stylet is removed, fluid should drain spontaneously and should be allowed to so until flow slows down The patient’s condition should stabilize sufficiently for transport to an operating suite or tertiary care institution Another method of temporarily relieving a lumen obstruction is to flush a small amount of sterile saline through the clogged tubing in an attempt to dislodge the obstruction This method can be used for distal or proximal obstructions, with the caveat that instilling a few more milliliters into the ventricles may in fact worsen the patient’s condition If this procedure is performed with a double-bubble device, the reservoir that is not being used must be compressed to allow the fluid to go in only one direction In an infant with an open fontanel, the physician can aspirate fluid through a direct ventricular puncture ( Fig 135.6 ) This procedure also carries a significant risk of parenchymal injury should be performed only when prompt surgery is impossible FIGURE 135.6 Ventricular tap through open fontanel Infection The reported incidence of CSF shunt infections ranges between 5% and 10% and depends on the center performing the study and the criteria used to define infection The majority of infections are perioperative in nature Recent advances have reduced the rate of infection, including allowing fewer operating room personnel, soaking the shunt in antibiotics before insertion, and administering