Is replacement of ventriculo(peritoneal) (VP) shunt justified in an 8-year-old child with hydrocephalus who underwent ventriculoperitoneal (VP) shunt placement in 2016?

From the Guidelines

The replacement of a ventriculoperitoneal (VP) shunt in an 8-year-old child with hydrocephalus who received the initial shunt in 2016 is justified only if there are specific clinical indications present, such as shunt malfunction or infection, as recommended by the 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis 1. These indications include shunt malfunction (evidenced by recurrent symptoms of increased intracranial pressure such as headaches, vomiting, visual disturbances, or altered mental status), shunt infection (presenting with fever, redness or drainage at the shunt site, or meningeal signs), growth-related issues requiring shunt lengthening, or mechanical problems with the shunt components.

Key Considerations

• Routine replacement without clinical indications is not recommended.
• If replacement is needed, the procedure would typically involve removing the malfunctioning components and placing new sterile hardware, often using the same entry sites.
• The decision should be based on clinical assessment, imaging findings (CT or MRI showing enlarged ventricles compared to baseline), and possibly shunt tap results if infection is suspected, as suggested by the 2016 IDSA guideline 1.
• Prophylactic antibiotics (commonly cefazolin 25-50 mg/kg IV) are administered before the procedure.
• The risks of shunt revision include infection, bleeding, neurological injury, and anesthesia complications, which must be weighed against the benefits of treating the underlying problem.

Procedure Approach

• For shunt malfunction without infection, a single-stage revision is recommended 1.
• For shunt infection, a two-stage approach is recommended, where the infected shunt is removed and a replacement is placed at a subsequent time 1.

From the Research

Replacement of Ventriculo(peritoneal) (VP) Shunt

The question of whether replacement of a ventriculo(peritoneal) (VP) shunt is justified in an 8-year-old child with hydrocephalus who underwent VP shunt placement in 2016 can be considered based on several factors and evidence from medical studies.

Factors Influencing Shunt Replacement

• Shunt Malfunction: Symptoms mimicking other common pediatric conditions can make timely diagnosis of shunt malfunction challenging 2.
• Imaging Modalities: Various imaging modalities such as MRI, CT, X-ray Shunt series, or Optic Nerve Sheath Diameter (ONSD) ultrasound are used to evaluate shunt malfunction, each with its sensitivity, specificity, and likelihood ratios 2.
• Previous Studies: The use of local shunts like the Malawi shunt has been explored, showing satisfactory function in 80% of cases immediately after insertion, with complications including blockage, abdominal wound rupture, shunt disconnection, and infection 3.
• Complications and Considerations: Unique cases, such as pleural effusion in a child with a VP shunt and congenital heart disease, highlight the need to consider CSF extravasation as a cause of pleural effusions in children with VP shunts 4.
• Abdominal Operations: Children with VP shunts can safely undergo abdominal operations with minimal risk of shunt infection or malfunction, even when the GI or GU systems are opened 5.
• Ventricular Morphology: Evaluation of ventricular morphology using CT or MRI can provide useful clinical information in suspected CSF shunt malfunctions, though historical patterns may not always be conclusive 6.

Considerations for Replacement

• The decision for replacement should be based on clinical judgment, considering symptoms, imaging results, and the child's overall condition.
• Given the child's age and the time elapsed since the initial shunt placement (2016), any decision for replacement would need to consider the current functional status of the shunt, any signs of malfunction, and the potential risks and benefits of the procedure.

Key Points

• Replacement of a VP shunt is a significant procedure that should be considered carefully based on clinical evidence and the child's specific situation.
• The use of appropriate imaging modalities and consideration of the child's medical history, including any previous complications or unique conditions, are crucial in making this decision.
• Consultation with a neurosurgeon and a multidisciplinary team is essential to determine the best course of action for the child's specific case.