2. 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
3. The Patient
• BG’s diagnosis was confirmed by:
o Ultrasound
o Symptoms:
• Enlarged head circumference
• Irritability
• Vomiting
• Parents waiting in NICU
4. 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
5. 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
6.
7. Pediatric Considerations
• Room temperature: 79.5° F
o Gaymar heating pad
o Heat lamp
• Patient’s weight on the whiteboard: 5lbs 9ounces (2.5kg)
o Medications
o Bovie pad (smallest size)
o Implants (VP catheters)
• Always remain by the patient’s side
o Especially during intubation!
8. Anesthesia and Medication
• General Anesthesia
o Weight confirmed by 3 team members
o Dose calculated by Anesthesia attending and resident
o Propofol for induction and maintenance
o Desflurane inhalation maintenance
• Intubated
• Ancef
o Intravenous
o 30 minutes prior to incision
o Antibiotic prophylaxis
• Bupivacaine with Epinephrine
o Diluted with 0.9% NaCl
o 10ml/10ml
9. 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
10. Positioning
• OR bed
o Leg board unlatched and kept down
o Turned 90°
• Anesthesia at lateral side, surgeon at head,
resident on opposing lateral side
• Modified Supine
o Shoulder roll
o Head turned to opposing side with donut
o Arms at sides
o Secured with foam and tape
11. Prepping
• Clippers to remove hair surrounding burr hole site
o From right ear to crown
• Betadine scrub and paint
o Head
o Abdomen
12. 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 extubated
o Discharged to NICU
o Still under sedation when transferred
o Report given to NICU nurse (incision sites noted)
13. Post-Operative Considerations
• Infection, infection, infection!
• Bowel perforation
• Bladder perforation
• CSF leaks
• Over drainage of CSF from ventricles
• Assess and monitor developmental milestones
14. 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.
