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Neuraxial Anesthesia in Children With Ventriculoperitoneal Shunts

Longhini, Anthony B. MD*; Cheon, Eric C. MD*; Hajduk, John BS*; Bowman, Robin MD; Birmingham, Patrick K. MD*

doi: 10.1213/ANE.0000000000003312
Pediatric Anesthesiology

Neuraxial anesthesia has been demonstrated to be safe and effective for children undergoing subumbilical surgery. There is limited evidence regarding the safety of neuraxial anesthesia in pediatric patients with a ventriculoperitoneal shunt. We evaluated a series of 25 patients with indwelling ventriculoperitoneal shunts for complications within 30 days of any procedure performed with a neuraxial technique. One patient required a ventriculoperitoneal shunt revision 5 days after a lumbar catheter placement. The neurosurgeon determined the revision to be likely unrelated to the patient’s lumbar catheter. Concerns about the use of neuraxial anesthesia in patients with an indwelling ventriculoperitoneal shunt may be overstated.

From the Departments of *Anesthesiology

Neurosurgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois.

Published ahead of print February 14, 2018.

Accepted for publication December 19, 2018.

Funding: None.

The authors declare no conflicts of interest.

A. B. Longhini and E. C. Cheon contributed equally to this work and share first authorship.

Reprints will not be available from the authors.

Address correspondence to Anthony B. Longhini, MD, Department of Anesthesiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611. Address e-mail to

Children with a ventriculoperitoneal shunt (VPS) for hydrocephalus occasionally present for nonneurological surgery. An anesthesiologist may use neuraxial anesthesia for surgery in children; however, a child with a VPS confers an unclear risk–benefit proposition that is contested between providers. Concerns include the potential risk for a neuraxial anesthetic to cause shunt malfunction or infection as well as increasing epidural pressure. Despite this, the opioid and general anesthetic-sparing benefits of neuraxial anesthesia may facilitate a faster return to baseline mental and neurological status. This is especially relevant to patients with a VPS, who often present with other major neurological and respiratory comorbidities. Reductions in postoperative apnea and emesis secondary to neuraxial anesthesia are also potentially beneficial.

Caudal epidural anesthesia has been demonstrated to be safe and effective for subumbilical surgery in children.1 An observational study from the Pediatric Regional Anesthesia Network database evaluated 18,650 children who received caudal single-shot blocks and found a 1.9% (95% CI, 1.7%–2.1%) incidence of complications and no cases of temporary or permanent sequelae, with an estimated incidence of 0.005% (95% CI, 0% to 0.3%).2 The potentially increased infectious risk of neuraxial catheters must also be considered. An additional Pediatric Regional Anesthesia Network database cohort of 307 neonates with neuraxial catheters had no reports of deep infection among a 0.3% (95% CI, 0.08%–1.8%) incidence of serious complications.3 There is limited evidence regarding the safety of neuraxial anesthesia in pediatric patients with an indwelling VPS.4 Hypothetical risks of intracranial pressure changes and infection leading to shunt malfunction have been described.5 The injection of local anesthetic into the epidural space causes a transient increase in epidural, cerebrospinal fluid (CSF), and intracranial pressure. A malfunctioning shunt would not compensate for the increased CSF pressure and could lead to potentially injurious elevations of intracranial pressure.

There are previous case series of patients undergoing single-shot caudal epidural (n = 6) and spinal anesthesia (n = 5) without anesthetic complication.6,7 Length of follow-up was not defined in these reports. We sought to analyze a large group of patients with 30-day postoperative follow-up to identify any VPS malfunction or infection after neuraxial anesthesia. We hypothesized that neuraxial anesthesia is safe in patients with a VPS.

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This retrospective study was approved by the Ann & Robert H. Lurie Children’s Hospital of Chicago institutional review board (2015–654), and the requirement for written informed consent was waived by the institutional review board. The medical records of children with a VPS who underwent subumbilical surgery with neuraxial anesthesia from January 2006 to June 2017 were reviewed. The primary outcome was VPS malfunction requiring surgical revision by postoperative day (POD) 30. The secondary outcome was unplanned readmission within POD 30. All patients had a preoperative VPS assessment consisting of a 6-point screening questionnaire conducted before the day of surgery. Any recent revision or symptoms of VPS malfunction on the questionnaire prompted further evaluation by the neurosurgery service. Caudal injections were performed with sterile gloves, mask, and chlorhexidine skin preparation per our standard institutional practice for all patients.

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During the reviewed time period, a total of 12,880 neuraxial anesthetics were performed, with 26 administered to patients with an indwelling VPS. All patients had normally functioning shunts preoperatively, as determined by neurosurgical evaluation. Fourteen patients (56%) had previous shunt revision procedures.

We reviewed data from 25 patients undergoing 26 procedures with a variety of neuraxial techniques, comorbidities, and surgical procedures (Table). Intraoperative antibiotics were administered to all patients who underwent lumbar (n = 9) or caudal (n = 2) catheter placement and 8 of the 14 patients (57%) who received single-shot caudal blocks. One patient who underwent an epidural blood patch did not receive prophylactic antibiotics for the procedure but was receiving vancomycin for positive CSF cultures. Antibiotic administration was determined by the surgeon and based on the planned operation, rather than presence or absence of a VPS. Catheters remained in situ for a median of 3 days (range, 2–5 days). Patients were admitted for 1 or more days after 20 of 26 procedures. In the 6 outpatient procedures, the average length of stay in the postanesthesia care unit was 51 ± 20 minutes, and overall time to discharge was 131 ± 25 minutes.



One patient had a VPS malfunction that required surgical revision during admission on POD 5 after lower extremity orthopedic surgery with a lumbar catheter. The operative report noted a mechanical obstruction of the distal intra-abdominal VPS catheter. Three patients were readmitted within POD 30. Reasons for readmission included an exacerbation of chronic lung disease and gastroenteritis on POD 16, dehydration on POD 25, and bradycardia not associated with VPS malfunction on POD 27. These 3 readmitted patients were evaluated by the neurosurgery service and were determined not to have VPS malfunction or infection.

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Our small series demonstrates a 4% incidence of VPS malfunction and 0% incidence of infection in the 30 days after neuraxial anesthesia. Prior smaller series reporting the use of neuraxial anesthesia in children with VPS found no complications. These authors cautioned the anesthesiologist to ensure a properly functioning VPS and no systemic or local infection before proceeding with neuraxial anesthesia in this special population. Veyckemans and Scholtes5 recommend performing epidural injection very slowly in patients with VPS to avoid potential increases in intracranial pressure. Increased intracranial pressure should be considered, in addition to intravascular injection, if the patient has hemodynamic changes after injection. One patient in our series had a VPS malfunction within 30 days of neuraxial anesthesia that required a surgical revision. The patient was an 11-year-old boy with cerebral palsy and sickle cell trait who underwent lower extremity osteotomies under general anesthesia with a lumbar catheter. He was found to have altered mental status due to hydrocephalus and underwent a VPS revision on POD 5 during his index hospital stay. Neurosurgical opinion was that the VPS malfunction was unrelated to the neuraxial technique. There were no cases of VPS infection related to neuraxial techniques. The 3 additional readmissions were unrelated to anesthesia or VPS complications. Our findings suggest that a VPS should not be an absolute contraindication for neuraxial anesthesia. To our knowledge, this is the largest reported series of pediatric patients undergoing neuraxial anesthesia with VPS.

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Name: Anthony B. Longhini, MD.

Contribution: This author helped collect and analyze the data, and prepare the manuscript.

Name: Eric C. Cheon, MD.

Contribution: This author helped design the study, collect and analyze the data, and prepare the manuscript.

Name: John Hajduk, BS.

Contribution: This author helped design the study, collect and analyze the data, and prepare the manuscript.

Name: Robin Bowman, MD.

Contribution: This author helped design the study and prepare the manuscript.

Name: Patrick K. Birmingham, MD.

Contribution: This author helped design the study and prepare the manuscript.

This manuscript was handled by: James A. DiNardo, MD, FAAP.

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