Ventriculoperitoneal Shunt (Pediatric)
Patient phenotype
Hydrocephalus: post-IVH preemie, congenital (aqueductal stenosis, Chiari II/myelomeningocele), tumor, post-meningitis. Infants → adolescents. Often emergent for raised ICP.
Procedure
Burr hole in skull, ventricular catheter, subcutaneous tunneled to peritoneum, distal end in peritoneum. ~30-90 min. Supine, head turned.
Anesthetic plan
GETA. RSI if vomiting/AMS (raised ICP). Smooth emergence. Antibiotic prophylaxis (shunt infection devastating).
Setup
- ·Pediatric circuit, warmed
- ·PIV
- ·ETT (uncuffed or microcuff per age/weight)
- ·Forced air warmer
- ·Anti-emetic + dex
- ·Antibiotic on time (cefazolin ± vanc)
Biggest concerns by phase
Raised ICP — induction strategy
Vomiting + AMS = high ICP. Avoid hypercarbia (hyperventilate slightly). RSI with smooth induction. Avoid ketamine (raises ICP — controversial in modern practice). Lidocaine + propofol + roc.
Sudden ICP drop after CSF release
When ventricle entered, rapid CSF release → sudden BP swings, slow HR (Cushing's reflex resolution). Watch vitals through release.
Position — head turn + airway concerns
Head turned with tube taped contralateral. Confirm tube position post-positioning.
Smooth emergence + no vomiting
Coughing/vomiting raises ICP + stresses fresh shunt. Multimodal antiemetic (dex + ondansetron). Smooth emergence with remi.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
8-month-old with congenital aqueductal stenosis, head circumference > 99%ile, vomiting × 24h, fontanel bulging. VP shunt placement. Plan?
What an examiner probes for
- ▹RSI for full stomach (vomiting)
- ▹ICP-friendly induction (avoid hypercarbia)
- ▹Watch for Cushing's reflex resolution post-CSF release
- ▹Antiemetic emphasis
- ▹Smooth emergence
Sources
- Coté Peds Anesthesia 6e
- Cottrell Neuroanesthesia 6e Ch 22
Anatomy reference
Sourced reference images. 4 matches for "brain ventricle skull".
Browse the full image library →
