A ventriculoperitoneal (VP) shunt is a cerebral shunt that drains excess cerebrospinal fluid (CSF) when there is an obstruction in the normal outflow or there is a decreased absorption of the fluid. Cerebral shunts are used to treat hydrocephalus. In pediatric patients, untreated hydrocephalus can lead to many adverse effects including increase irritabilities, chronic headaches, learning difficulties, visual disturbances, and in more advanced cases severe mental retardation.. After placement, if it malfunction, excess CSF accumulated which can increase the intracranial pressure resulting in cerebral edema and ultimately herniation. These shunts drain the CSF into the peritoneal cavity, the atrium, or the pleura; thus, appropriately called ventriculoperitoneal, ventriculoatrial, and ventriculopleural shunts.
A shunt consists of a ventricular catheter that is connected to a valve and then connected to a distal catheter. The distal end of a VP shunt is placed in the peritoneal cavity. The main differences between shunts are the type of valve used, and whether the valve is programmable or not. Advances in the biotechnologies are leading to progressive changes in the shunt components. These advanced components are expected to reduce shunt malfunctions and optimize neurosurgical patient care.
The ventricles of the brain are a communicating network of cavities located within the brain parenchyma. The ventricular system is composed of two lateral ventricles, the third ventricle, the cerebral aqueduct, and the fourth ventricle. The choroid plexus in the ventricles produce CSF, which fills the ventricle and the subarachnoid space in a constant cycle of production and reabsorption. The CSF is then absorbed into the cerebral venous circulation through the Pacchionian (arachnoid)granulations. Any block or obstruction in this pathway will produce obstructive hydrocephalus and if permanent will require a shunt. Sometimes, these granulations become obstructed from blood products or high protein and will not function adequately producing communicating hydrocephalus.
Placement of a cerebral shunt and its location is determined based on the surgeon's preference. It may be placed through a frontal approach into the anterior horn of the lateral ventricles or though a parieto-occipital approach into the trigone or occipital horn of the lateral ventricle. The catheter placed into the cerebral ventricle is called the proximal shunt (ventricular catheter) implying proximity to the brain. The most preferred proximal shunt location is on the right lateral ventricle as any complication will not be associated with the dominant hemisphere. If there is asymmetry, then the larger ventricle is used. The distal catheter can be placed in the abdomen (peritoneal cavity), heart via a cervical venous access, chest cavity (pleura), or rarely into the ureter or the bladder if all previous sites have been used. In all cases, however, the distal end of the catheter can be located in any tissue with cells capable of absorbing the incoming CSF.
A subgaleal shunt is a temporary measure used in infants who are too small or premature to tolerate other shunts of have difficulty with peritoneal absorption. The surgeon forms a pocket beneath the subgaleal space and allows the CSF to drain from the ventricles, creating a fluid-filled swelling on the infant's scalp. As the child grows, these shunts are later converted to a permanent shunt type.
Most VP shunts are placed to treat the hydrocephalus. Disorders that typically requiring shunting include the following:
A VP shunt is placed in the operating room under general anesthesia by a neurosurgeon.
Equipment needed to perform the procedure includes:
Nurse (circulating and technical)
Brain magnetic resonance imaging (MRI) or computed tomography (CT) scan is reviewed for the planning of the shunt and the proper placement of the proximal catheter. All patients need appropriate preoperative workup and informed consent for surgery and general anesthesia. The patient is placed supine. For a parieto-occipital approach, the head is tilted to the contralateral side of the shunt placement. Preoperative antibiotics are given and the patient is dressed in sterile conditions.
Complications include the following:
In those cases of malfunction, the shunt has to be assessed for proper function. The following technique is used:
Complications of a shunt tap are:
Ventriculoperitoneal shunts are used to treat hydrocephalus and divert CSF from the lateral ventricles into the peritoneum. Tapping a shunt is performed for both diagnostic and therapeutic reasons (evaluate for infection or malfunction). A VP shunt is one of the high impact advances made in neurosurgical patient care.
Patients with shunts are evaluated for evidence of signs or symptoms related to complications or malfunction. Acute symptoms of malfunction/infection are: headache, lethargy, diplopia, nausea and vomiting, seizure, irritability, poor feeding, head enlargement when sutures are open, tense fontanelle, fever, neck rigidity. Shunt system has to be assessed manually for proper function and visible for evidence of redness or swelling along the shunt tubing. Shunt X rays are done to evaluate the integrity of the system. CT scan or MRI is done to evaluate the size of the ventricles.
VP shunt can be lifesaving, but the eventual outcome depends on the reason why the shunt was inserted. For benign disorders, most patients have a good outcome. However, for malignant tumors, the outcomes are usually poor; often these patients die from other causes unrelated to the shunt. The complication rates of VP shunts range from 2-20%. In addition, shunt revision is required in about 5-10% of neonates and young children.(Level V)
There is no question that VP shunts have saved many lives, but these devices are not without complications. The shunt has to be monitored for infection and malfunction. The abdomen has to be monitored for peritonitis secondary to shunt infection. While the neurosurgeon is always involved in the care of patients with hydrocephalus, it is important to consult with an interprofessional team that includes a pediatrician, and a general surgeon. Any unusual finding by the primary physician has to be immediately reported back to the neurosurgeon. The nurses are also vital members of the interprofessional group as they will monitor the patient's clinical signs and assist with the education of the patient and the family. In the postoperative period for pain, or for shunt infection; the pharmacist will ensure that the patient is on the right analgesics and appropriate antibiotics. The radiologist also plays a role in determining the cause of the malfunction. Without providing a proper history, the radiologist may not be sure what to look for or what additional radiologic exams may be needed. Before the patient is discharged, the family has to be educated on the early identification of shunt failure and how to monitor the child's improvement. In some cases, a home care nurse may be required to pay regular visits to ensure that the VP shunt is functioning without problems. (Level V)
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