If your child has a shunt, it may become infected. If your child has an infection in the cerebrospinal fluid (CSF), the infection can travel into the shunt. The bacteria (germs) can then stick to the shunt and grow. If your child's shunt becomes infected, your child will need the following treatments:
- surgery (an operation) to take out the infected shunt
- antibiotics to clear the infection from the CSF
- a second operation to put in a new shunt once the infection is clear
Problems caused by an infected shunt
- The CSF becomes thicker, so it does not flow as well through the shunt.
- The bacteria can travel and grow in the CSF, causing a type of meningitis infection.
- The bacteria can travel down the shunt into the abdomen (belly) and cause an infection there.
Surgery is needed for an infected shunt
Antibiotics can stop infection in the CSF. But since the shunt is not a living thing, antibiotics cannot reach all of the bacteria stuck to it. Even if the infection in the CSF clears up, it may come back if the shunt stays infected. Therefore, we need to remove the shunt and give your child antibiotics until all of the infection in the CSF has gone. Then, a new shunt is inserted.
Signs of a shunt infection
In a baby with a shunt, the following signs may mean an infection:
- fever
- poor feeding or loss of appetite
- vomiting (throwing up)
- neck stiffness
- sleepy (hard to wake up) or not as awake as usual
- large head (your family doctor can measure this)
- bulging "soft spot" (fontanelle) on the top of the head
- seeming irritable (cries easily or without reason)
- redness or puffiness of the skin on top of the shunt tubing and at incision (cut) sites
- abdomen (belly) pain
- fluid leaking from the shunt incision sites
- seizures
- noticeable scalp veins
- slowness at reaching milestones (for example, slow to roll over, slow to sit)
- "sunset" eyes, when the eyes appear to be always looking down and are not able to look up
In a child, the following are also possible signs of infection or other shunt problems:
- headaches
- nausea and vomiting
- fever
- neck stiffness
- tiredness (sleeping more than usual, difficult to wake up, does not want to play as usual)
- seeming irritable
- changes in personality, behaviour, or school performance
- loss of coordination
- seizures
- changes in vision
- redness or puffiness of the skin on top of the shunt tubing and at incision (cut) sites
- abdomen (belly) pain
- fluid leaking from the shunt incision sites
Shunt infections are very dangerous. If your child has any of these symptoms, take your child to your local emergency department right away.
Diagnosing shunt infection
Imaging tests check for blockage, leakage and infection
If the doctors think your child's shunt may be infected, they will do imaging tests to learn more. Imaging tests give pictures of the inside of your child's body. The following are some tests the doctors may order:
- The doctors may use a
CT scan,
MRI or
ultrasound to check the
ventricles (fluid chambers) of the brain to look for blockage of flow through the shunt. Ultrasound may also be used to look for infection in the abdomen.
- Doctors may order a "shunt series," which is a series of X-ray pictures that can show if the shunt is disconnected or broken.
- A CSF flow study may also be ordered. This test uses a dye to show the flow of CSF through the shunt. The test can reveal blockage or a leak.
If your child has trouble keeping still for a test, they may need medicine so that they sleep during the CT scan or MRI.
Lab tests check for infection
The medical team may take a sample of your child's CSF and send it to the lab to see if there is an infection. This is usually done by doing a shunt tap. A shunt tap means the doctor or a specially trained nurse uses a small needle to take a small amount of CSF out of the shunt reservoir. A shunt reservoir is a small area along the shunt where a sample of CSF can be easily taken.
An infected shunt is treated with surgery and antibiotics
Your child will need to stay in hospital while we treat the shunt infection. The following steps are used to treat a shunt infection:
- First, your child will need an operation to remove the infected shunt and put in a temporary drainage device.
- Next, your child will take antibiotics to help clear the infection. These antibiotics are put directly into your child's blood using an intravenous (IV) line.
- After your child's infection has cleared, they will have a second operation to put in a new shunt. The second operation usually takes place about one to two weeks after the first operation.
The first operation to remove the shunt
Your child will be given a general anesthetic or sleep medicine to make sure they sleep through the operation.
The surgeon makes incisions (cuts) on your child's head and removes the old shunt tubing. Then the surgeon makes a new cut and gently puts an external ventricular drain (EVD) into the ventricle. An EVD drains CSF directly out of the body. This means that instead of the CSF draining into your child's abdomen, it drains outside your child's body. The CSF collects in a sterile bag that hangs beside your child's bed. New CSF will still form in the brain and move around your child's brain and spinal cord as before.
The operation to take out the infected shunt and put in the EVD takes about one hour.
After the EVD is put in
After the operation, your child will spend one to two hours in the Post Anesthetic Care Unit (PACU) to recover from the anesthetic. Then your child will go back to the Neurosurgical Unit.
While your child has an EVD in place, the nurse will check the drain to make sure the CSF is draining properly every hour. The drain collection system is put in a special position so that it controls the pressure inside the brain just like the shunt did. It is therefore important not to move your child by yourself. Only the nurse or doctor should change the position of the drain, or the position of your child. While your child has the EVD in place, they must stay on the nursing unit or be accompanied by a nurse.
Every two to three days, the nurse will also take a sample of CSF using the EVD. The lab will test this sample for infection. These results will help the doctor to decide when the infection has cleared.
Managing pain after the operation
Your child may experience some pain at the operation site. The nurse will give your child medicine by mouth about every four hours. This should control the pain. If it does not control the pain, speak to your child's nurse.
Your child may also learn other ways to control pain, such as blowing bubbles or relaxation breathing. Ask your nurse or Child Life specialist to help you and your child to learn how to do this.
Your child's doctor will tell you how much your child can move around, sit or walk after surgery.
Intravenous (IV) antibiotics to clear the infection
Your child will have an intravenous line (IV) in place. An IV is a tube that goes directly into your child's vein. We will give your child antibiotics through the IV to help clear the infection. Your child will need the IV for as long as the EVD is in place.
If your child needs antibiotics for more than two weeks, we may talk to you about your child having a PICC line put in place. A PICC line is a special IV that is used when medication has to be given for a long period of time.
The second operation to put in a new shunt
The operation to remove the EVD and put in a new shunt takes about one to two hours. It is performed once the infection has cleared, usually about one to two weeks after the first operation. The surgeon may decide to place the new shunt on the other side.
Your child is brought down to the operating room. Your child will be given a special "sleep medicine" called general anesthetic to make sure that your child sleeps through the operation and does not feel any pain. The operation usually takes between one and two hours.
The area from the head to the abdomen (belly) is scrubbed with a special soap. The surgeon makes incisions (cuts) on the head and abdomen and removes the EVD. Then the surgeon inserts the new shunt.
The ventricular (top) end of the tube is placed in a ventricle (fluid space) in the brain. The tube is then tunnelled below the skin to an area of the body where the fluid can be absorbed. One area is the lining of the abdominal cavity, called the peritoneum. Less often, the shunt is connected from the brain to the lining of the lungs (pleural space) inside the chest (a ventriculo-pleural shunt) or veins draining into the heart (ventriculo-atrial shunt).
The surgeon then closes the incisions using either stitches or staples.
Your child may need to stay in the hospital for a few days after the operation to recover.
Longer-term: as your child grows to adulthood
A child with hydrocephalus needs to see a doctor often to make sure the shunt is working properly. Several members of the team will help and guide you as your child grows and develops. You should encourage your child to become involved in this ongoing process.
Following up after the operation
Removing the staples or sutures
How your child's staples or stitches are taken out depends on the type of staple or stitch that was used. Your neurosurgeon or nurse practitioner will tell you what type of stitches were used.
- If your child has staples or stitches that need to be taken out, your family doctor will need to do this. The stitches should be taken out about seven to 10 days after the operation. Staples should be removed about 10 days after the operation. Your surgeon or nurse will tell you when they need to come out.
- If staples were used, you will be given a special remover to take to your family doctor.
- If your child has the kind of stitches that dissolve on their own, you can see your family doctor to have the incision line checked, but the stitches will not need to be taken out.
Follow-up clinic visit
Your surgeon will see your child in a follow-up clinic visit about six weeks after you go home. The appointment may be made for you when your child is discharged. If not, you can call the neurosurgery clinic at the hospital to make an appointment yourself.
If you have any questions
Any medical questions you may have can be answered by your surgeon. Be sure to write down your questions before you meet the surgeon. Other questions can be answered by your nurse or by a Nurse Practitioner.
Your child's neurosurgeon is:
Your child's nurse practitioner is:
Their telephone number is:
When to see a doctor
It is possible that the shunt will stop working properly after you go home. Sometimes the tube can become blocked, come apart, break or become infected again. If your child gets another shunt infection, they will need to come back to the hospital right away.
If the shunt is not working properly or is infected, call for medical help right away
Your child needs medical attention right away if you see any signs or symptoms of a shunt problem.
Signs that the shunt is not working or is infected are listed above. Your child may have the same signs they first had before the shunt was put in, or your child may have new signs.
If your child has any of these symptoms, call 911 or your local emergency services right away. Shunt malfunctions or infections that are not treated promptly and appropriately can lead to coma and possibly death.
For more information, please see Shunt revisions and Hydrocephalus and treatment.