Ventriculoperitoneal Shunt Placement

Stephanie BartkowiczCSULA/CSMC

The Patient• Baby Girl• 8 days old (born 5/15)

o Born at 38 weeks • No Known Allergies• Admitted to NICU after birth

• Diagnosis: Hydrocephalus • History: VP shunt placement 5/17

The Patient • BG’s diagnosis was confirmed by:

o Ultrasound

o Symptoms:• Enlarged head circumference• Irritability• Vomiting

• Parents waiting in NICU

Hydrocephalus • Excess accumulation of CSF in the

ventricles • Results in an abnormal widening and

expansion of the ventricular system • This widening creates potentially

harmful pressure on the tissues of the brain

• Normally, CSF flows through the ventricles, and exits into cisterns (reservoirs) at the base of the brain

• CSF is then reabsorbed into the bloodstream

Ventriculoperitoneal Shunt

• A catheter is placed into the ventricle

• It is then advanced, subcutaneously, behind the ear, down the neck, and through to the abdomen

• The excess CSF is released and absorbed by the peritoneal cavity

• There is typically a valve which prevents the fluid from moving in the wrong direction and only lets fluid drain when the pressure is too high

Pediatric Considerations

• Room temperature: 79.5° Fo Gaymar heating pado Heat lamp

• Patient’s weight on the whiteboard: 5lbs 9ounces (2.5kg)o Medicationso Bovie pad (smallest size)o Implants (VP catheters)

• Always remain by the patient’s side o Especially during intubation!

Anesthesia and Medication

• General Anesthesiao Weight confirmed by 3 team memberso Dose calculated by Anesthesia attending and residento Propofol for induction and maintenance o Desflurane inhalation maintenance

• Intubated

• Ancef o Intravenouso 30 minutes prior to incisiono Antibiotic prophylaxis

• Bupivacaine with Epinephrine o Diluted with 0.9% NaClo 10ml/10ml

Equipment and Instrumentation

Equipment:

• Gaymar heating pad• Heat lamp• Suction • Bovie

o Monopolar: 18 cut/18 coag• Grounded left abdomen

o Bipolar: 25

• Fluid warmer o 0.9% NaCl irrigation

Instrumentation:• Basic Craniotomy tray• Curette tray

Implants:• Ventricular catheter• Peritoneal catheter• Delta valve

Positioning• OR bed

o Leg board unlatched and kept downo Turned 90°

• Anesthesia at lateral side, surgeon at head, resident on opposing lateral side

• Modified Supine o Shoulder rollo Head turned to opposing side with donut o Arms at sideso Secured with foam and tape

Prepping• Clippers to remove hair surrounding burr hole site

o From right ear to crown • Betadine scrub and paint

o Heado Abdomen

Concluding the Procedure

• Procedure length: 1 hour 10 minutes • All counts correct• Closing sutures: 3-0 Vicryl PS2

o Purse string suture in peritoneum to secure catheter• Steri Strips

• Specimen:o Previous VP shunt reservoir removed Pathology o CSF Microbiology

• Patient was not extubatedo Discharged to NICU o Still under sedation when transferred o Report given to NICU nurse (incision sites noted)

Post-Operative Considerations

• Infection, infection, infection!

• Bowel perforation

• Bladder perforation

• CSF leaks

• Over drainage of CSF from ventricles

• Assess and monitor developmental milestones

References Alexander, E. L., Rothrock, J. C., & McEwen, D. R. (2015). Alexander's care of the patient in surgery (15th ed.). St. Louis, MO: Mosby/Elsevier.

Hammon, W. (n.d.). Evaluation and use of the ventriculoperitoneal shunt in hydrocephalus. Journal of Neurosurgery, 34(6), 792-795.

Keucher, T., & Mealey, J., (2009) Long-term results after ventriculoatrial and ventriculoperitoneal

shunting for infantile hydrocephalus. Journal of Neurosurgery 50(2), 179-186.