From the Guidelines
Complications of ventriculoperitoneal (VP) shunts are a significant concern and can be life-threatening, therefore, prompt evaluation and treatment are crucial to prevent permanent neurological damage or death. Complications of VP shunts include mechanical failures, infections, and functional issues. Mechanical complications involve shunt obstruction (most common), disconnection, migration, or fracture of components, typically requiring surgical revision [(1, 2, 3)]. Infections occur in 5-15% of cases, usually within the first few months after placement, and are commonly caused by skin flora like Staphylococcus epidermidis.
Treatment of Complications
- Treatment requires shunt removal, external ventricular drainage, and appropriate antibiotics (often vancomycin plus ceftazidime or meropenem) for 10-14 days [(1, 2, 3)].
- Overdrainage can cause subdural hematomas, slit ventricle syndrome, or intracranial hypotension with headaches, while underdrainage results in persistent hydrocephalus symptoms.
- Abdominal complications include peritonitis, pseudocyst formation, bowel perforation, or CSF ascites.
- Seizures may develop in 5-10% of patients.
Management of Shunt Malfunction or Superinfection
- Shunt malfunction should be managed with a single-staged surgical revision, while superinfection should be treated with shunt removal and replacement at a subsequent time as a second procedure [(1, 2)].
- A rational approach in a patient who is hemodynamically stable is to perform lumbar puncture to assess for infection and measure opening pressure to indirectly assess shunt function 3.
- Regular clinical monitoring is essential, with symptoms like headache, vomiting, altered mental status, fever, or abdominal pain potentially indicating shunt malfunction.
- Prompt evaluation with imaging (CT scan) and shunt series radiographs is necessary when complications are suspected, as delayed treatment can lead to permanent neurological damage or death [(1, 2, 3)].
From the Research
Complications of VP Shunt
- Infections are a common complication of VP shunts, with Gram-negative organisms being the most predominant cause of recurrent infections 4
- The resistance rates of these organisms to antibiotics such as third-generation cephalosporins and piperacillin-tazobactam are high, making treatment challenging 4
- Central nervous system tuberculosis, short duration of antibiotics, high cerebrospinal fluid protein and blood C-reactive protein levels, and prolonged use of prophylactic antibiotics are risk factors for recurrent infections 4
- Shunt malfunction is another complication, which can be due to various reasons such as blockage or kinking of the shunt tube 5, 6
- Shunt exposure is a rare but serious complication, which can be managed with prompt and accurate on-ward revision, including wound curettage, skin mobilisation, and resuture over the exposed part of the shunt 7
- Traumatic brain injury, emergency shunting, and prophylactic vancomycin as the sole antibiotic are independent predictors for shunt infection 6
- The 30-day all-cause mortality rate after VP shunt placement is around 6%, although none are directly procedure-related 6
Treatment Options
- Two-stage shunt replacement is an effective strategy for managing VP shunt infections, especially in patients with recurrent infections 4, 5
- Shunt removal without replacement is another option, particularly in patients who are not shunt-dependent 5
- Antibiotic treatment is crucial in managing VP shunt infections, with carbapenem being a commonly used antibiotic due to its effectiveness against Gram-negative organisms 4
- Empirical antimicrobial treatment with glycopeptide plus carbapenem is recommended, especially in patients with risk factors for recurrent infections 4