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Disclaimer
These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.
Aim
To guide the PCH ED with the assessment and management of ventriculoperitoneal shunt problems.
Definition
Ventriculoperitoneal (VP) shunt complications include blockage and infection. Early and prompt detection of shuntdysfunction is vital as delay can lead to markedly raised intracranial pressure, coning and death.
All patients withsuspected VP shunt dysfunctionshould be discussed with neurosurgery.
Background
VP shunts areinserted fortreatment of hydrocephalus. Hydrocephalus isnota single disease entity. It is either due to subnormal CSF re-absorption, obstruction along the flow pathways or very rarely increased production. It may be:
- Congenital (e.g. myelomeningocele, Dandy Walker syndrome, stenosis of the aqueduct of Sylvius) or
- Acquired (e.g. post meningitis, post haemorrhagic, obstruction due to tumour).
Treatment options include:
- Insertion of a CSF temporary diversion shunt (external ventricular drain) or a permanent diversion shunt (VP shunt) – the main treatment modality
- Endoscopic third ventriculostomy (internal diversion via perforating the floor of the third ventricle allowing CSF to flow from the 3rd ventricle directly to the cortical subarachnoid space).
Assessment1,2
The following signssuggest a dangerously elevated intracranial pressure which constitutes a neurosurgical emergency:
- Impaired or falling Glasgow Coma Scale
- Bradycardia
- Hypertension
- Papilloedema
- Sun setting eyes
Immediate mandatory referral to the on-call neurosurgery team via Switch or Vocera.
If, in the event of such an emergency, there is an issue in obtaining the neurosurgery team, contact the on call neurosurgery consultant for advice.
History
- Parents may knowthe usual symptomsfor their child in the event of a shuntblockage.Do not ignorethe concerns of the child’s parents or carers, particularly if they have had shuntdysfunction in the past.
History and symptoms may be variable
- Drowsiness
- Headache
- Vomiting
- Irritability.
The presence of drowsiness, headache and vomiting together make it very likely that the patient has shunt dysfunction.
Less commonly
- Seizures
- Any new neurological symptoms
- Abdominal problem (tenderness, distension or peritonism)
- Fever (suggestive of shunt infection)
- Lethargy
- Intermittent shunt dysfunction/blockage or low pressure may lead to a more protracted time course with chronic headaches
- Always suspect shunt dysfunction in any patient with a VP shuntandno alternative explanation for the presenting symptoms.
Examination
- Shunt evaluation (pressing the valve) is diagnostically unreliable and can potentially cause shunt dysfunction.Do not press the valve without prior discussion/direction from the neurosurgical team.
- Any abnormal shunt findings should be discussed with the neurosurgical team.
- Examine for new focal neurological signs.
- Examine for conscious state, pupillary size/reactivity, papilloedema.
- In a child with an open fontanelle, this should be soft and pulsatile.
- A sunken fontanelle may be due to low pressure.
- Fluid tracking along subcutaneous shunt tubing may indicate shunt blockage.
- Erythema, tenderness along shunt tubing and fever suggest infection.
- Examine shunt surgical wounds if implanted.
Investigations
Investigations that aid in diagnosis are:
- Brain CT – to detect ventricular size
- Enlarged ventricles may imply shunt obstruction.
- A scan showing obviously dilated ventricles whencomparedwith previous scans is a definite indication of shunt blockage/hydrocephalus.
- A 'normal' looking CT scan without a previous scandoes notreliably exclude the diagnosis of a shunt blockage/hydrocephalus. (as in slit ventricle syndrome)
- Consider ultrasound in an infant with an open fontanelle.
- Plain X-ray / shunt series – may demonstrate a disconnection.
- CSF sampling – this should only to be done by the neurosurgical team or after consultation with neurosurgery.
- Full blood picture (FBC) and C-reactive protein (CRP) may help in elucidating infection/ shunt dysfunction.
Differential diagnoses
- In any unwell child with a VP shunt, shuntdysfunction must be a differential and not excluded until proven otherwise –early consultationwith the neurosurgical team is advised if suspected.
Management3,4,5,6
- Maintain a low threshold for contacting the neurosurgery team for advice
- If blocked or infected, the shunt will require revision/removal – urgent consultation with the neurosurgical team is required.
- In the event that herniation (coning)is imminent and/or neurosurgical intervention will be delayed, institute steps to maintain / restore cerebral perfusion pressure including:
- Reducing brain bulk and cerebral blood volume:
- Anaesthesia
- Intubation
- Hyperventilation (End tidal Carbon Dioxide (ETCO2) 28-35mmHg)
- Mannitol 20%: IV bolus 1 gram/kg (equivalent to 5mL/kg) over 20 minutes3or
- Sodium chloride 3% (hypertonic saline): IV bolus 5mL/kg over 10-20 minutes.6
- Needling of the shunt and removal of cerebral spinal fluid. (always to be done by someone who is familiar with the procedure or under guidance from neurosurgery)
- Increasing cerebral perfusion pressure using inotropes such as anoradrenaline infusion.
- Reducing brain bulk and cerebral blood volume:
Advice on this support can be provided by contacting the PCH Paediatric Critical Care Unit.
| Child with CSF shunt who presents unwell | |
|---|---|
| No signs and symptoms of raised intracranial pressure (ICP) or no new neurological findings | Raised ICP or history comparable to a previous episode ofblocked shunt |
|
|
Nursing
Observations
- Record baseline observations heart rate, respiratory rate, blood pressure, oxygen saturations, temperature and neurological observations on the observation and response tool, neurological observations chart and the clinical comments chart.
- Minimum ofhourly neurological observations(including BP) along with general observations until definite diagnosis is made
- Any significant changes must be reported immediately to the medical team.
References
- Barnes NP, Jones SJ, Hayward RD, Harkness WJ, Thompson D. Ventricularperitoneal shunt block: what are the best predictive clinical indicators? Arch Dis Child 2002; 87:198-201.
- Watkins L, Hayward R, Andar U, Harkness W. The diagnosis of blocked cerebrospinal fluid shunts: a prospective study of referral to a paediatric neurosurgical unit. Childs Nerv Syst 1994; 10:87-90
- AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd Mannitol Updated July 2021 [Cited 9 December 2021] Available from: Mannitol - AMH Children's Dosing Companion (health.wa.gov.au)
- Stevens RD, Shoykhet M, Cadena R, Emergency Neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care 2015 23:S76-S82
- Brophy GM, Human T, Shutter L, Emergency Neurological Life Support: Pharmacotherapy. 2015 23:S48-S68
- Tasker R., Elevated intracranial Pressure (ICP) in children: Management [Internet] Uptodate; 2021. [cited 13 January 2022] Available from: Elevated intracranial pressure (ICP) in children: Management - UpToDate
| Endorsed by: | Drugs and Therapeutics Committee | Date: | Mar 2022 |
| Review date: | Jan 2025 |
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FAQs
Ventriculoperitoneal shunt problems? ›
Definition. Ventriculoperitoneal (VP) shunt complications include blockage and infection. Early and prompt detection of shunt dysfunction is vital as delay can lead to markedly raised intracranial pressure, coning and death. All patients with suspected VP shunt dysfunction should be discussed with neurosurgery.
What is the most common complication of VP shunt? ›The major complications of VP shunt are mechanical malfunction, placement failure, infection, CSF leak [3,5-7] with some reports of even intracerebral haemorrhage, though rare, and complications related with peritoneal catheter such as ileus, pseudocyst formation, and bowel perforation, resulting in shunt failure [3,5, ...
What are the two most common shunt complications? ›Some of the most common risks of CSF shunts include infection, shunt malfunction, and improper drainage.
What are the symptoms of ventriculoperitoneal shunt malfunction? ›A shunt is said to have failed when any complication of the treatment of hydrocephalus requires surgery. Symptoms of a cerebral shunt malfunction may be obvious, redness over the shunt, headache, sleepiness, vomiting, or visual changes. Symptoms may also be subtle, change in behavior, change in school performance.
What are the symptoms of overdrainage of a shunt? ›Over-drainage: When the shunt allows cerebral fluid to drain from the brain's ventricles more quickly than it is produced, the ventricles can collapse, tearing blood vessels and causing bleeding in the brain or blood clot, marked by severe headache, nausea, vomiting, seizure and other symptoms.
What is the most common cause of shunt failure? ›The principal causes of shunt malfunction are infection, occlusion, intracranial hemorrhage, and overdrainage. The risk of shunt failure is greatest within the first year of insertion, estimated to be 10% to 20%, depending on the underlying cause of the hydrocephalus.
How do you know if a shunt is failing? ›Conclusions: Vomiting, irritability, and sleepiness were the most common symptoms of shunt malfunction and false alarms for children ≤5 years. Most caregivers reported challenges differentiating malfunctions from their child's development.
How many years do shunts last? ›VP shunts are likely to require replacement after several years, especially in small children. The average lifespan of an infant's shunt is two years. Adults and children over the age of 2 may not need a shunt replacement for eight or more years. Shunt systems require frequent monitoring and follow-up.
How often should a VP shunt be checked? ›All younger patients with a shunt should probably be encouraged to seek a neurosurgical check up at least every three years, ideally at a dedicated hydrocephalus follow up clinic.
What are the red flags of hydrocephalus? ›Among adults 60 years of age and older, the more common signs and symptoms of hydrocephalus are: Loss of bladder control or a frequent urge to urinate. Memory loss. Progressive loss of other thinking or reasoning skills.
How often do VP shunts malfunction? ›
Shunt complications
The incidence of overall shunt malfunction was found to be 15.4%, while the incidence of shunt revision was 14.1%. Kaplan–Meier curve showed that shunt failure rates at 6 months, 1 year, and 6 years were 19/227 (8.4%), 25/227 (11.0%), and 35/227 (15.4%), respectively.
Staphylococcal species, especially coagulase-negative Staphylococcus and Staphylococcus aureus, account for almost two-thirds of all shunt infections. (10, 18) The most common infecting organism recovered from conventional aerobic cultures of CSF is Staphylococcus epidermidis.
What are the symptoms of overshunting VP shunt? ›If the overshunting is chronic, slit ventricle syndrome can result. This manifests as minor episodic headaches, nausea and vomiting, and ataxia. Infection of the shunt is another common complication that occurs most frequently in the first six months after placement and in infants under 3 months of age.
How should a VP shunt feel? ›During VP shunt surgery, the doctor placed two small tubes (catheters) and a valve under your skin. After surgery, your neck or belly may feel tender. You will probably feel tired, but you should not have much pain. For a few weeks after surgery, you may have headaches.
How do you assess VP shunt functioning? ›However, the use of ultrasound to assess shunt function has relied primarily on an assessment of flow, which is intermittent and of low magnitude, even in normally functioning shunts. Furthermore, this technique requires the injection of contrast agents into the CSF or the shunt cavity.
What should you avoid with a shunt? ›Any activity that involves being grabbed around the neck is not advised, as the shunt tubing in the neck can crack.
How serious is having a shunt put in? ›A shunt is permanent, but because it can malfunction, it may have to be repaired or replaced throughout a person's life. Other rare but serious problems can include infection and bleeding, usually within the first few weeks after the surgery.
Is VP shunt a high risk surgery? ›VP shunts are generally safe, but there are some risks during and after the surgery. There can be bleeding, or an infection can develop.