VP SHUNT placement

Question 1

Main reason to place a shunt

Answer 1

There are many conditions where it is necessary to shunt cerebral spinal fluid (CSF) from the ventricles in the brain to another body cavity where it can be absorbed.
▪ Most common condition is hydrocephalus. This is when there is dilation of ventricular system due to obstruction of CSF flow

Question 2

Causes for placement of VP shunt EXPLAIN

Answer 2

because of their size and indirectly by causing edema in surrounding tissue as well and by causing an obstruction in CSF flow (common in tumors involving the 3rd ventricle), Intracranial hematoma, blood in CSF as manifested by subarachnoid hemorrhage may lead to obstruction of CSF reabsorption at the arachnoid villi and Infection (e.g., meningitis, encephalitis) can lead to edema or obstruction of CSF flow

Question 3

Preparation the surgery VP placement

Incision

Answer 3

Patient put into correct position with cranial and abdominal incision in same plane
Scalp shaved (usually over the frontal or parietal region), the continuous surgical field created from head to abdomen

Question 4

STEP of the VP shunt procedure

Answer 4

1. Cranial incision is made over the region of cannulation of ventricle and a burr hole is made in the cranium
2. A subgaleal pocket is created for the valve, usually behind the ear
3. Other incision made in the abdomen, and the dissection is carried down the level of the peritoneum
4. Catheter is then passed subcutaneously from the abdominal incision to the cranial incision with a special tunneling instrument
5. Valve is connected to the catheter and placed in the subgaleal pocket
6. Ventricular catheter is then inserted into the ventricle and a small amount of CSF is drained to check placement and patency
7. Catheter is then connected to the valve and CSF flow is checked
8. The distal end is then placed into the peritoneal cavity and all wounds are closed

Question 5

VP shunt surgery time

Answer 5

Estimated Time: 1 hour

Question 6

VP shunt surgery POSITIONING and LINE PLACEMENT AND WHY

Answer 6

Supine position w/head turned to contralateral side, w/bolster under shoulder of operative side
• Lines placed at the left side of the patient, because patient will be turned 90-180 degrees away from the anesthetist
• Put lines on the side that will be closest to the anesthetist and extend circuit out as far as it goes
• Patient will be prepped from head down to abdomen. May sure everything is out of the way
• Pad pressure points
• Tape and pad eyes

Question 7

VP shunt EBL

Answer 7

EBL: 5-25 mL

Question 8

VP shunt IV ABT and Line needed

Answer 8

Preop:
IV: 18-20 g
Antibiotic: Ceftriaxone 1-2 g IV

Question 9

VP shunt hemodynamics monitoring

Answer 9

• Arterial line sometimes required for further hemodynamic monitoring
• Central line may be necessary depending on patient’s hemodynamic status
• With everything we do, we want to be conscious of CMRO2, CBF and increasing ICP

Question 10

VP shunt, consideration for patients with hydrocephaly

Answer 10

Patients with hydrocephaly often have other congenital anomalies-so providers should assess the airway very carefully
• Patients are commonly children: check to see if on any anticonvulsant medications because of ability to alter drug metabolism

Question 11

VP shunt surgery INDUCTION

NORMAL, why propofol

Answer 11

Lidocaine: 50-100 mg
Propofol (1-2 mg/kg) or if significant cardiac history Etomidate (0.3-0.6 mg/kg)-both have ability to decrease cerebral blood flow. Want to do slow smooth induction to avoid hypertensive and hypotensive episodes
Rocuronium (0.6-1 mg/kg)

Question 12

SPECIFIC induction VP SHUNT :ETOMIDATE

Answer 12

Etomidate (0.3-0.6 mg/kg)-both have ability to decrease cerebral blood flow. Want to do slow smooth induction to avoid hypertensive and hypotensive episodes

Question 13

VP shunt Maintenance:
What GAS?
Which NDNMB
TEMPERATURE, maintain how and why?

Answer 13

• Isoflurane ≤ 1% or Sevoflurane < 2% (< 1 MAC is goal) inspired with 50:50 N2O/O2 mixture.
• May need to give additional doses of rocuronium 0.2 mg/kg throughout surgery to maintain paralysis
• Maintain normal temperature in children. But slight hypothermia can aid in decreasing ICP.

Question 14

VP SHUNT If ↑ ICP is issue during surgery, medications to ↓ ICP include: First choice

Answer 14

• Mannitol 25 or 50 grams IV given with 20-40 mg of Lasix IV

Question 15

VP SHUNT If ↑ ICP is issue during surgery, medications to ↓ ICP include: OTHER THAN MANNITOL
and their actions

Answer 15

• Lasix 20-40 mg IV alone if patient cannot tolerate increase in intravascular volume from Mannitol
• Corticosteroids: stabilize capillary membranes and decrease CSF production
• Acetazolamide decreases CSF production

Question 16

Emergence of VP shunt

Answer 16

• Give prophylactic antiemetics like ondansetron 4-8 mg/IV or dexamethasone (8-12 mg/IV)
• Elevate head of bed to approximately 30 degrees-to reduced aspiration risk and it aids in venous and CSF drainage
• Perform neurological assessment as soon as the patient can follow commands-the goal is to assess neurological status while the patient is still in operating room
• Surgeon wants to assess patient immediate postoperative so they can intervene if needed
• Will be safer and easier to do CT scan if patient is still asleep if this is an issue

Question 17

Sugammadex VP SHUNT surgery

Answer 17

• Shallow block reversal: 2 mg/kg
• Deep block reversal (1-2 post tetanic counts): 4 mg/kg
• Rescue block reversal: 16 mg/kg

Question 18

VP shunt POST OP Predicted pain: 
and TREATMENT (FOM)

Answer 18

4-6:
Ofirmev 15 mg/kg for patients <50 kg and 1000 mg for patients> 50 kg
Fentanyl 25-50 mcg IV PRN
Meperidine 10-20 mg IV for post-operative shivering
Will go to a floor in hospital, patient usually needs to stay flat for 24 hours

Question 19

Potential complications of VP SHUNT (BISHI)

Answer 19

Infection- ABT, fluid resuscitation