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LETTER TO EDITOR
Year : 2012  |  Volume : 6  |  Issue : 1  |  Page : 76-77

Anesthetic concerns in patients with abnormal migration of ventriculoperitoneal shunt


Department of Neuroanesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Tumul Chowdhury
Neurosciences Center, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.93062

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Date of Web Publication21-Feb-2012
 


How to cite this article:
Dube SK, Chowdhury T, Chaturvedi A. Anesthetic concerns in patients with abnormal migration of ventriculoperitoneal shunt. Saudi J Anaesth 2012;6:76-7

How to cite this URL:
Dube SK, Chowdhury T, Chaturvedi A. Anesthetic concerns in patients with abnormal migration of ventriculoperitoneal shunt. Saudi J Anaesth [serial online] 2012 [cited 2019 Dec 9];6:76-7. Available from: http://www.saudija.org/text.asp?2012/6/1/76/93062

Sir,

Ventriculoperitoneal (VP) shunt surgery is the most common procedure for the management of symptomatic hydrocephalus but associated with many complications. Here we report a case of abnormal migration of the VP shunt catheter, it's anesthetic concerns, and possible causations.

A 2-year-old child presented with gradually progressive swelling at the right fronto-parietal region for 5 months. He was in altered sensorium and had 3-4 episodes of generalized tonic-clonic seizure within 7 days. The child was diagnosed as a case of Down syndrome with global developmental delay and had a history of tuberculous meningitis with communicating hydrocephalus for which right VP shunt (Chhabra shunt) was inserted at the age of 18 months. The child was drowsy. All preoperative investigations were within the normal limit except hemoglobin (Hb, 8.0 g/dL). On examination there was a large pseudomeningocele (2.0 × 2.0 cm 2 ) at the previous shunt site. The shunt catheter was not palpable along its extracranial course. The chest and abdominal X-rays failed to demonstrate the catheter. However, a lateral X-ray of the skull showed a coiled shunt catheter inside the cranial cavity [Figure 1]. A diagnosis of intraventricular shunt migration was made and the child was scheduled for endoscopic retrieval of catheter and placement of left low pressure VP shunt. The child was premedicated with 0.1 mg of intramuscular glycopyrrolate. In the operation theater, a 20G intravenous line was secured and pulse oximeter, noninvasive blood pressure, and electrocardiogram were attached. General anesthesia was induced with IV fentanyl (20 μg), propofol (20 mg), and rocuronium (10 mg). After placing the head on cotton head rest, tracheal intubation was done with a 4.5 mm uncuffed polyvinyl chloride tube following mild hyperventilation (PCO 2 =35 mmHg). Anesthesia was maintained with oxygen plus nitrous oxide (1:1) ratio, sevoflurane (up to 1 minimal alveolar concentration) and intermittent blouses of fentanyl and rocuronium. Normothermia was maintained throughout the procedure. The procedure was uneventful and the patient's trachea was extubated on the next day. The patient was discharged after 5 days of surgery with no neurologic deficit.
Figure 1: A lateral X-ray of the skull showing a coiled shunt catheter inside the cranial cavity

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Complete migration of shunt is a rare event. Inadequate catheter length and not fixing the shunt firmly enough to peripheral tissues are the main causes of shunt migration. Cephalic migration of shunt can be due to lesser resistance of potential spaces (intraventricular or subgaleal), loose subcutaneous tissue, inadequate or loose fixation of the shunt chambers and catheters, upward movement of the peritoneal catheter secondary to flexion-extension movements of the patient's head or pressure difference between ventricle (negative pressure) and abdomen (positive pressure). [1],[2],[3] This kind of catheter migration can cause raised intracranial pressure (ICP) and pseudomeningocele formation. The patient-related factors include the age of the patient, severe and gross hydrocephalus with very thin cortical mantle, malnutrition, anaemia, sepsis, and repeated head movements. Many of these predisposing factors were present in our patient who had a gross head enlargement with very thin cortical mantle. This patient was also malnourished. The supine position in which the infants are nursed as well as the shorter distance between the ventricular and the peritoneal ends in these children facilitate proximal migration of the shunt. This complication may be avoided by firm anchoring of the connector sites to the periosteum, and avoidance of large burr holes and dural openings. Apart from the usual anesthetic considerations in case of pediatric patients, the main consideration in these patients are related to difficulty in positioning the head for intubation (when associated with large pseudomeningocele) and management of raised ICP secondary to ineffective cerebrospinal fluid (CSF) diversion. Inhalational agents have unfavorable effects on CSF dynamics in cases of raised ICP. Intravenous agents are preferable over inhalational agents in patients with raised ICP. [4] Careful planning of extubation should be done in these patients.

This case emphasizes preoperative careful examination of shunt site (cranial), palpation of thoracic, and abdominal site and thereafter meticulous planning of perioperative anesthetic management.

 
  References Top

1.Al Hinai QS, Pawar SJ, Sharma RR, Devadas RV. Subgaleal migration of a ventriculoperitoneal shunt. J Clin Neurosci 2006;13:666-9.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Acharya R, Bhutani A, Saxena H, Madan VS. Complete migration of VP shunt into the ventricle. Neurol Sci 2002;23:75-7.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Eljamel MS, Sharif S, Pidgeon CN. Total intraventricular migration of unisystem VP shunt. Acta Neurochir (Wein) 1995;136:217-8.  Back to cited text no. 3
    
4.Sakabe T, Matsumoto M. Effects of anesthetic agents and other drugs on cerebral blood flow, metabolism, and intracranial pressure. In: Cottrell JE, Young WL, Editors. Cottrell and Young's neuroanesthesia. 5 th ed. Philadelphia: Mosby Elsevier; 2010. p.78-94.  Back to cited text no. 4
    


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