A year-old boy was admitted with chest wall infection around the implanted ventriculoperitoneal shunt VPS catheter of 5 days. He had received a right-sided, medium pressure, whole-length VPS for hydrocephalus, following tubercular meningitis at the age of 3 years.
Hydrocephalus - Diagnosis and treatment - Mayo Clinic
Seven years, 9 months following VPS implantation, he was admitted with shunt tract infection at the chest area for 5 days. He had neither fever nor features of meningitis, raised intracranial pressure, or peritonitis. His clinical examination and radiological investigations revealed that the VPS catheter was disconnected at the cranial site, and it was migrated downward up to the upper chest. He was managed well with the removal of the entire VPS catheter. The removed peritoneal catheter along with the shunt chamber was loaded with fecal matter and was presumed that the peritoneal catheter was within the colon.
His postoperative recovery was excellent. This is a rare case of VPS catheter disconnection, shunt migration, and silent bowel perforation by peritoneal catheter, and all the above-mentioned complications were detected in a child at the same time and were managed well with the removal of the entire VPS catheter. Ventriculoperitoneal shunt VPS insertion for the treatment of hydrocephalus is associated with several complications, including infections, mechanical failure, obstruction, bowel perforation with or without extrusion through natural orifices, nonvisceral perforation, shunt migrations, and shunt disconnection.
A year-old boy was admitted with infected ulcers in the chest wall around the implanted VPS catheter for 5 days [ Figure 1 ]. At the age of 3 years, a right-sided, medium pressure, whole-length VPS Chhabra slit n spring hydrocephalus shunt system was implanted for hydrocephalus following tubercular meningitis.
Five years, 8 months following VPS implantation, he was admitted with vague abdominal pain for 2 weeks, and malfunctioning of peritoneal part of the VPS catheter was detected. He was managed well with exteriorization of peritoneal part of the VPS catheter and followed by delayed revision of peritoneal part of the VPS catheter.
Seven years, 9 months following VPS implantation 25 months after revision of peritoneal part of the VPS catheter , he was admitted again with shunt tract infection at the chest area for 5 days. His clinical examination revealed that there were multiple infected ulcers around the VPS catheter in the chest area. VPS catheter proximal to the chamber was also seen protruding out for few centimeters from the chest wound [ Figure 1 ]. On palpation of the VPS catheter, the part of the shunt from the cranial to the upper chest was missing. Abdominal examination revealed two healed abdominal scars in the right hypochondrium [ Figure 1 ], and the rest of the abdominal examination was normal.
Digital anal examination was normal and only loaded fecal matter was noted. Other systemic examination was normal. Skiagram of the head showed that the ventricular part of the VPS catheter with a connector was seen, and the chamber and the rest of the shunt catheter were not visualized [ Figure 2a and b ]. Skiagram of the chest and abdomen revealed that the VPS chamber was migrated downward and seen at the upper chest area. This skiagram also revealed that there was coiling of part of the peritoneal catheter in the upper part of the abdominal cavity [ Figure 3 ].
There were no fluid levels or free gas shadow under the diaphragm. Ultrasonography examination of the abdomen revealed that there was no fluid collection within the peritoneal cavity, and peritoneal part of the VPS catheter was seen in the peritoneal cavity. Computed tomography CT scan of the head delineated the ventricular catheter with the connector well in place, and the tip of the ventricular catheter was lying at anterior horn of the left lateral ventricle without ventricular dilatation [ Figure 4 ].
The shunt chamber and upper part of the shunt catheter were missing in cranial CT. The VPS catheter was disconnected from the connector that was used to connect the ventricular catheter to the chamber of the VPS catheter and which was also migrated downward. His hemoglobin, total and differential white blood cells counts, platelets counts, urea, creatinine, bilirubin, and electrolytes values were within normal limits.
He was managed with the removal of the entire VPS catheter under sedation. The VPS chamber along with the peritoneal catheter was removed easily from the chest area [ Figure 5a ]. During the removal of the VPS chamber and peritoneal catheter, it was observed that the chamber and the entire peritoneal catheter were loaded with fecal matter, and it was presumed that the peritoneal catheter was within the large bowel [ Figure 5b ], although digital rectal examination felt to palpate the catheter.
The ventricular catheter along with the connector was removed through a separate scalp incision and was removed with some difficulty. Peritoneal pseudocysts and hernias are other possible complications. Any sign of infection must be reported to the provider as soon as possible. Broad-spectrum antibiotics should be initiated to cover aerobic and anaerobic bacteria until culture results become available. Precautions such as limiting the number of people in the operating rooms, performing shunts as the first case in operating rooms, meticulous skin preparation, prophylactic antibiotics, avoiding CSF leaks, double gloving during surgery, and antibiotic-impregnated catheters may potentially reduce infections.
However, this will prolong hospitalization and impact cost associated with VP shunt placement. Incidence of shunt failure is high in the first 6 months after shunt placement. Malfunction can also occur from shunt disconnection, displacement, or migration. Catheter migration to intracranial spaces, pulmonary vasculature, intestines, mouth, or the urethra has been reported subsequent to catheter disconnection or fracture.
Sharma et al 41 describe malnourishment, anemia, sepsis, and a thin cortical mantle as causes of shunt migration. In addition, excessive neck movements, dilated ventricles with negative suctioning pressure, or a positive intra-abdominal pressure may be responsible for the migration. If there is a problem with the pressure gradient, the pressure can be changed noninvasively, if magnetically programmable valves are used.
It is important to teach the parents to avoid contact with extremely strong magnetic fields including magnetic resonance imaging, as magnetic fields can change the programming of CSF flow. Excessive drainage of CSF is seen in children shunted early in life, which may be evident by a sunken fontanel, increased urine output, and increased sodium loss. Complications associated with overdrainage is certainly a problem, and antisiphon devices may help prevent this.
In addition to the major complications described, bleeding can also occur as a complication of VP shunt placement. Routine care of the infant, care of the shunt sites, and specific shunt-related information should be part of the discharge teaching.
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Parents should be given a copy of the medical report, a list of resources, follow-up plan, and information on whom to contact in case of emergency. Continued care is required for the proper healing of a newly placed VP shunt. Caregivers should know that all visible staples or stitches will be removed within 1 to 2 weeks, and that the head should not be showered or shampooed until those staples or stitches are removed.
The surgical wound should not be submerged or soaked before it is completely healed. Once the swelling from surgery goes down, a raised area will remain visible. Parents should be taught to protect these areas and that when the hair grows over, it is usually unnoticeable.
Nursing Care of Infants With a Ventriculoperitoneal Shunt
Tylenol may be administered for pain. They should know the signs and symptoms that indicate shunt failure or infection and must call their assigned clinic if any issues are suspected. Strong magnetic fields should be avoided to prevent malfunction of externally programmable valves. Knowledge of the type of shunt system is essential, particularly during emergencies, when manipulation of the pressure valve is crucial. Although the likelihood of a cell phone interfering with the settings of the valve is minimal, caregivers should be aware to keep cell phones and other magnetic devices away from the implanted shunt and notify the care team in case of magnetic resonance imaging.
Multimodal training using audiovisual aids may help achieve better understanding in parents who are overwhelmed with the care of the infant. A summary of teaching points for parental education is given in Table 4. Practicing nurses must receive continuing education on newer devices and related changes in practice. For example, nurses should be aware of newer procedures such as ETV, devices such as magnets to change pressure, or programs or applications to change pressure noninvasively.
Nurses should be equipped to teach parents on care of infants with special attention to devices. As more preterm infants survive with complications such as IVH and consequent HC, that may require surgical interventions and long-term care, nursing educators should prepare students to care for these infants by including these topics in the curriculum. Nursing-specific parental education materials can be created by collaborative efforts between educators and bedside clinicians. Nurses must take leadership roles in developing interdisciplinary resources for families caring for infants with HC and VP shunt placement.
Research should explore existing guidelines and develop new evidence-based guidelines on care of children with shunts and emerging methods of conservative management. Current literature lacks evidence on nursing care of infants with HC and VP shunt placement. Nurse researchers could study consistency of current nursing practice on care of infants with HC and develop evidence-based guidelines to address this gap. Emerging technology to change pressure noninvasively or remotely should be researched.
In addition, exploring cost of long-term care can contribute to the health economics of this nation. Follow-up by a multidisciplinary team that includes nurses, rehabilitation specialists, neurologists, developmental specialists, pediatrician, and educational experts is critical for a positive outcome. The extent of the team will vary with comorbidities and development of the child. Success of shunts and incidence of complications vary from person to person; some recover completely and have a good quality of life.
Early diagnosis, timely treatment, regular follow-up, and continued care may offer an optimum outcome. Hydrocephalus, if identified and treated early, can result in positive neurodevelopmental outcomes in infants. A VP shunt is a common procedure performed in infants with HC, and proper monitoring and timely action by an interdisciplinary team are essential for the best results. However, complications occur even with careful management.
Teaching parents for continued home care, monitoring, and follow-up care improves long-term results in infants. The NICU nurses are in a pivotal position to guide families adapt to the new skills necessary to care for their infant with special needs. Although comorbidities may impact prognosis, careful monitoring and early recognition of symptoms by a nurse or an empowered parent are essential for positive outcomes.
If managed well, children with HC can have a productive life. Furthermore, prevention of complications and timely management can save costs associated with readmissions and shunt revisions and eliminate a high amount of distress in parents. Neilson N, Breedt A.
Download Complications of CSF Shunting in Hydrocephalus: Prevention, Identification, and
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Pediatric hydrocephalus in east Africa: prevalence, causes, treatments, and strategies for the future. World Neurosurg. National Hydrocephalus Foundation. Facts about hydrocephalus. Accessed May 29, Hydrocephalus Association. Hydrocephalus facts and stats. Brand MC. Part 2: examining the newborn with an open spinal dysraphism.