From the Guidelines
Complications of ventriculoperitoneal (VP) shunts can be life-threatening and require prompt evaluation and treatment, with a focus on preventing shunt failure, infection, and other mechanical issues that can impact morbidity, mortality, and quality of life. When evaluating patients with VP shunts, it is essential to consider the potential for shunt failure, which may be associated with superinfection by bacteria or other microorganisms, as noted in the 2016 IDSA clinical practice guideline for the treatment of coccidioidomycosis 1. Some key complications to consider include:
- Shunt obstruction, disconnection, migration, fracture, and over-drainage leading to subdural hematomas
- Infection, which occurs in 5-15% of cases, typically presenting within the first few months after placement, with Staphylococcus epidermidis and Staphylococcus aureus being the most common pathogens
- Abdominal complications, such as peritonitis, pseudocyst formation, bowel perforation, and rarely CSF ascites
- Shunt malfunction symptoms, including headache, nausea, vomiting, altered mental status, and visual disturbances Treatment of VP shunt complications often requires surgical revision for mechanical issues or shunt removal with external ventricular drainage and antibiotics for infections, with antibiotic regimens typically including vancomycin plus a third-generation cephalosporin or meropenem for empiric coverage, adjusted based on culture results, and continued for 10-14 days, as recommended by the 2016 IDSA guideline 1. Regular follow-up with neurosurgery is essential for patients with VP shunts to monitor for these potential complications, as early detection can prevent serious neurological sequelae. In cases where shunt infection is suspected, a shunt tap to sample the CSF for infection, as well as to evaluate the patency and function of the shunt apparatus, can be considered, taking into account the possibility of introducing a shunt infection or causing a malfunction with this intervention, as noted in the 2016 IDSA guideline 1. Exploration of the non-functioning shunt is done by evaluating proximal and distal flow intraoperatively, so that revision can be tailored to the particular area of failure, and in some instances, the shunt can be completely replaced if the failure is due to clogging secondary to highly proteinaceous fluid, as recommended by the 2016 IDSA guideline 1.
From the Research
Complications of VP Shunt
- Infection is a common complication of ventriculoperitoneal (VP) shunt surgery, with a high incidence despite routine administration of perioperative antibiotics 2
- The risk factors for postoperative shunt infection include prematurity, age less than one month, and duration of surgery of 90 min or more 2
- Bacterial ventriculoperitoneal shunt infections can be caused by various bacteria, including Acinetobacter species, Pseudomonas species, and coagulase-negative Staphylococcus (CoNS) 3
- The sensitivity of antibiotics such as piperacillin-tazobactam and meropenem for Gram-negative bacteria has decreased significantly over time, making it essential to consider alternative antibiotics 3
Types of Complications
- Shunt infection: can be caused by various bacteria and can be treated with antibiotics, but in some cases, shunt removal may be necessary 2, 3, 4
- Shunt malfunction: can be diagnosed using a practical algorithm that includes clinical symptoms, computed tomography, and plain radiography 5
- Ventricular catheter obstruction/damage/displacement, valve damage, and distal catheter obstruction/damage/displacement are common causes of shunt malfunction 5
Treatment of Complications
- Antibiotic-impregnated ventriculoperitoneal shunts can reduce the incidence of shunt infection compared to standard shunts 6
- Two-stage shunt replacement (TSSR) is the most effective strategy for treating VP shunt infections, especially when the patient is shunt dependent 4
- Shunt removal, particularly TSSR, remains the optimal choice of treatment for VP shunt infections and does not increase morbidity 4