VP Shunt Failure: Pre-Lab Notes

Neurologic Assessment in Peds 1. Level of Consciousness (LOC) Most sensitive measure of brain function and brain perfusion LOC = indicator of shock. 2. Pupillary Response to Light and Accomodation (CNIII function) Size and light response (in absence of opioids or ocular medication to dialate pupils). Helps delineate level of brain injury. 3. Response to Painful Stimuli Appropriate response vs abnormal response/posturing. 4. Muscle Tone Normal vs or -- equal or unequal. Glasgow Coma Scale (modified for peds) Remember, scale goes from 3 to 15. Inanimate objects have a GCS of 3. GCS < 8 is ominous sign. Treatment of ICP Mild ICP Increase HOB 15-30 degrees with head midline to facilitate CSF drainage and venous return from head. Maintain normothermia to the metabolic demands associated with fever. o Avoid shivering, which ICP. Minimize disturbances and agitation Maintain slightly elevated serum osmolality with Na++ 145-150. IV fluids of D5 0.9% NS Mannitol bolus prn. o Osmotic diuretic. o ICP occurs within 15 minutes. o Contrindicated with active intracranial bleed. Monitor intake and output hourly. Monitor labs q 6 hrs. Moderate to Severe ICP Institute all interventions used for mild ICP. Intubate patient to prevent hypercarbia and insure adequate O2 delivery. o Goals pH of 7.35. PCO2 at 30-35. Sedate patient with barbiturates, benzodiazepines, narcotics. Maintain mild hypothermia with core tem at 35-36 C. Use chemical paralysis to prevent shivering ( ICP). Maintain serum osmolality with serum Na++ around 150-155 using hypertonic saline (3%) and Mannitol boluses prn. Monitor ICP directly with ventrculostomy and drain CSF prn. Steroid use controversial but is still mentioned in the literature. Prevent seizures with adequate serum levels of anticonvulsants (usually Fosphenytoin and/or possibly Phenobarbital).

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Maintain adequate Cerebral Perfusion Pressure (CPP) using vasoactive med infutsions such as Dopamine, Epinephrine, and Norepinephrine. rd Prevent infection using 3 generation cephalosporin or broad specrum Vancomycin. Mouth care q 4 hrs + VAP precautions. Monitor and treat coagulopathies o pH Adequate circulating volume. Adequate ventilation (CO2=35). NaHCO3 sparingly. o PT Give FFP. o PTT Give FFP. o Factors Give Cryoprecipitate. Give Vitamin K. Early enteral nutrition to prevent sepsis. Monitor lab work, especially electrolytes & osmolality q 4 hrs. Monitor urine output and specific gravity q 1 hr. Watch for signs and symptoms of SIADH or D.I. Urine replacement and DDAVP for D.I. Hydrocephalus

Prognosis now is that most children with hydrocephalus will develop with relatively normal intelligence. However, the saying Once a shunt, always a shunt is fairly true. Hydrocephalus may eventually self arrest but at high morbitity & mortality.

Two Types of Hydrochephalus 1. Communicating 2. Noncommunicating Communicating Acquired hydrocephalus 1. Obstructive hydrocephalus due to presence of childhood tumors in midline posterior fossa region, pineal region, and rd suprasellar region / 3 ventricle. Remove the tumor and then place a shunt only if continued hydrocephalus is seen. 2. IVH (Intra Ventricular Hemorrhage) especially in premature infants < 1800 grams. 3. Post meningitic and post inflammatory hydrocephalus is usually due to obstruction at the basal cisterns. E Coli meningitis and Hemophilus influenza meningitis are most common infectious agents. Ventricular enlargement may resolve, may require a shunt, or may cause brain atrophy with hydrocephalus. Ex-vacuo more CSF than usual; CSF Noncommunicating Physical obstruction to CSF flow. Congenital malformations = 40% of cases. 1. Aqueductal stenosis is increased lateral rd th and 3 ventricles with normal sized 4 ventricle. Various styles of aqueductal stenosis: a. Atretic. b. Divided by membranes within the space. c. Two blind-end channels. d. Several other styles. th 2. Occassionally, the previously normal 4 ventricle may become secondarily stenotic in shunted hydrocephalus where its outflow is blocked and it cannot flow upward into the shunt. If symptomatic, a second VP catheter is placed and connected into the existing shunt above the valve to ensure equal flow.

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pressure is normal (NPH Normal Pressure Hydrocephalus).

3. Aqueductal stenosis is seen in Chiari malformation (brainstem distortion). st 4. Manifest in utero or by 1 3 months of age.

VP shunt has highest failure rate for infection and malfunction. Most common malfunction is proximal portion of shunt occluded with choroid plexus Difficult to clear May have bleed post-op Distal malformation may be R/T too short of a catheter or infection. 2-8% risk of infection for each shunt operation. 5-15% of all shunts can be expected to become infected over the life of the shunt. Signs and Symptoms of Meningitis Redness along shunt Septicemia Peritonitis Other Shunts VA Shunts Shunt nephritis unique complication to VA shunts. Signs and Symptoms include proteinuria, hematuria, and progressive decrease in renal function. Pleural effusion. Cardial tamponade. Endocarditis. Lost distal catheter in SVC or atrium. Signs and Symptoms of Shunt Failure 70% of all patients with VP shunt failure have pronounced symptoms of:. o Headache o Vomiting and lethargy o Drowsiness 30% present with subtle deteriorations: o Change in behavior o Fall off in school performance o Change in attention span o Change in behavior suchs as temper tantrums and daily HA Pumping of shunt helps delineate area of malfunction. If reservoir pumps easily, then does not refill readily means proximal occlusion. If reservoir difficult to pump, then there is a distal occlusion. Note: Nursing staff do not pump shunts. Signs and Symptoms of Increased ICP Bulging anterior fontanelle Splitting sutures Macewans crackpot sound to head percussion Setting-sun sign due to tectal compression o May also be diagnosed in teenagers and adults with chronic HA and large head with or without school problems Chiari Malformation, Type I & II Type I Usually without spinabifida or myleomeningocele Shunt first then posterior fossa decompression

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Type II Seen in 90% of patients with myleomeningocele and 70-80% of these patients have hydrocephalus Cysts block CSF flow and may require additional shunting of cyst as well as blocked ventricle. Porencephalic (within brain tissue adjacent to ventricle) Arachnoid (in subarachnoid space or in the ventricle) th Dandy-Walker cyst is a posterior fossa CSF cyst communicating with 4 ventricle which requires both cyst and ventricular shunt Medical management of hydrocephalus, especially in post-hemmorhagic states, includes: Diamox to carbonanhydrase, which significantly decreases CSF production. o Watch for metabolic acidisis as kidneys dump NaHCO3 with Diamox. Use of an external drain, daily lumbar punctures, or ventricular taps until determination of permanent shunt is clear. Lasix has also been shown to CSF production. See: http://www.crash.lshtm.ac.uk/ctscanlarge.htm for good images of CT scans of hydrocephalus.

Informational Images

Normal CT Scan (London School of Hygiene & Tropical Medicine, n. d.))

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Acute Subdural Haematoma Demonstrating Midline Shift (London School of Hygiene & Tropical Medicine, n.d.)

Ventriculoperitoneal (VP) Shunt placement (Lundeen, 2007)

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