“INFECTED SHUNT IN

HYDRANENCEPHALY PATIENT”

Presentasi Kasus Ilmu Bedah Saraf

Oleh: dr. Monalisa
Pembimbing: dr. Sonny Giat Raja Saragih, Sp.BS
IDENTITAS PASIEN

Nama : an. M
Usia : 1 tahun 3 bulan
Jenis kelamin : Perempuan
Alamat : Jl. SM. Tsyafiuddin No.23 34/00
Agama : Kristen
Suku : Dayak
ANAMNESIS

Keluhan Utama : Keluar selang dari pusar

Riwayat Penyakit Sekarang :
Pasien datang ke IGD RSUD Dr. Abdul Aziz (16/7/18)
dengan keluhan keluar selang dari pusar sejak 5 hari yang
lalu. Keluhan tersebut didahului dengan keluarnya darah
beserta nanah dari pusar yang terjadi 1 minggu yang lalu.
Pasien juga mengeluhkan batuk dan pilek sejak 2
minggu. Tidak ada keluhan muntah, demam maupun
kejang. Keluhan BAB dan BAK disangkal. Terdapat luka di
belakang telinga kiri sejak 1 minggu yang lalu namun
belum pernah dilakukan perawatan luka sebelumnya.
Riwayat Penyakit Dahulu :
Pasien sempat dirawat inap 2 minggu yang lalu di RSUD
Abdul Aziz dengan keluhan batuk dan pilek yang disertai
dengan demam yang hilang timbul dan di diagnosa
dengan bronkopneumonia.
Menurut pengakuan ibu pasien, sejak dalam kandungan
pasien sudah terdeteksi memiliki cairan berlebih pada
kepala. Hal ini diketahui saat ibu pasien melakukan
pemeriksaan antenatal care di dokter spesialis
kandungan. Saat pasien berumur 7 hari dilakukan
pemasangan VP Shunt pada tubuh sisi kanan pasien.
 Namun karena terjadi infeksi berulang pada tempat
pemasangan VP Shunt beberapa bulan setelah pemasangan,
maka dilakukanlah revisi VP Shunt ke bagian sisi kiri tubuh
pasien. Revisi VP Shunt telah dilakukan 4 bulan yang lalu.
Riwayat Persalinan :
Pasien merupakan anak ke 3. Tidak terdapat kelainan pada
kedua saudara pasien. Ibu pasien mengaku tidak menderita
sakit berat selama mengandung dan hanya mengkonsumsi
obat penambah darah yang diperolehnya dari bidan. Pasien
lahir cukup bulan, langsung menangis dengan BBL/PB/LK/LD
berturut-turut 3800gr/54cm/43cm/35cm melalui persalinan
normal yang dibantu oleh bidan. Tidak terdapat penyulit
selama persalinan.
Pemeriksaan Fisik
KU : lemah, tampak sakit ringan
Kesadaran : Compos mentis
Status Neurologis: E4M6V5

HR: 100x/menit
RR: 32x/menit
TTV
Suhu: 37,3 ͦc
SpO2: 98-99%

BB: 7.100 gr
Antropo
metri TB: 74cm
LK: 48cm  Makrocephali
Pemeriksaan Fisik
• Kepala: • Mulut: bibir kering • Cor: Bunyi jantung I
Macrocephali, (-), bibir sianosis (-), dan II reguler,
regio temporal mukosa merah Murmur (-), Gallop
tampak luka (+), muda (-)
darah (+), pus (+), • Leher: trakea • Abdomen: supel,
krusta (+) ditengah, Bu (+), tampak
• Mata: Sunset pembesaran KGB (-) selang shunt dari
Fenomenon CA-/-, • Thoraks: umbilikal sepanjang
SI -/- pergerakan dada ± 7cm
• Hidung: bentuk simetris, Rh +/+, • Ekstremitas:
normal, nafas retraksi (+) hangat, CRT < 2
cuping hidung (-) subcostal, detik
• Telinga: bentuk intercostal
normal, eritema (-),
fistel (-), abses pre
dan retro (-)
Diagnosis

• Infected Shunt
1

• bronkopneumonie
2
Terapi

IVFD D5 10 tpm

Inj Ronem 250mg/8jam

Inj Ranitidine 2x 10mg

Infus PCT 70mg/8jam

Ambroxol syr 3x1/2 cth

Pro OP Removal Shunt (19/7/18)

 Follow Up Pasien Selama
Perawatan
Tanggal S O A P

17/7 - GCS = 15 Infected shunt IVFD D5 10 tpm

E4M6V5 Bronkopneumonia Inj Ronem 250mg/8jam
KU = Tampak sakit ringan HP 1 Inj Ranitidine 2x10mg
Inf PCT 3x100mg
Ambroxol syr 3x ½ cth
Pro Removal Shunt (19/7)

18/7 - GCS = 15 Infected shunt IVFD D5 10 tpm

E4M6V5 Bronkopneumonia Inj Ronem 250mg/8jam
KU = Tampak sakit ringan HP 2 Inj Ranitidine 2x10mg
Inf PCT 3x100mg
Ambroxol syr 3x ½ cth
Pro Removal Shunt (19/7)

19/7 - GCS = 15 Infected shunt IVFD D5 10 tpm

E4M6V5 Bronkopneumonia Inj Ronem 250mg/8jam
KU = Tampak sakit ringan HP 3 Inj Ranitidine 2x10mg
Inf PCT 3x100mg
Ambroxol syr 3x ½ cth
Pro Removal Shunt hari ini
 Tanggal S O A P
20/7 - GCS = 15 POH 1 Post Removal IVFD D5 10 tpm
E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
KU = Tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
Inf PCT 3x100mg
Ambroxol syr 3x ½ cth

21/7 - GCS = 15 POH 2 Post Removal IVFD D5 10 tpm

E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
KU = Tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
Inf PCT 3x100mg
Ambroxol syr 3x ½ cth

22/7 - GCS = 15 POH 3 Post Removal IVFD D5 10 tpm

E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
KU = Tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
Inf PCT 3x100mg
Ambroxol syr 3x ½ cth

23/7 Batuk (+) GCS = 15 POH 4 Post Removal IVFD D5 ¼ NS 10 tpm

E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
KU = Tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
Pulmo : Rh+/+ Inf PCT 3x100mg
Ambroxol syr 3x ½ cth
Dat S O A P
e
24/7 Batuk (+) GCS = 15 POH 5 Post Removal IVFD D5 ¼ NS 10 tpm
E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
KU = Tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
Pulmo : Rh+/+ Inf PCT 3x100mg
Ambroxol syr 3x ½ cth

25/7 Demam (+) GCS = 15 POH 6 Post Removal IVFD D5 ¼ NS 10 tpm

Batuk dan E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
sesak (+) KU = Tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
HR = 160x/menit Inf PCT 3x100mg
RR = 42x/menit Nebu Ventolin 0,5cc/8jam
T = 37,3 ͦc Chest Fisioterapi
SpO2 82%95% Ambroxol syr 3x ½ cth
Pulmo: Retraksi Subcostal
(+), intrecostal (+), Rh+/+
26/7 Demam (-) GCS = 15 POH 7 Post Aff Shunt a/i IVFD D5 ¼ NS 10 tpm
Sesak (+) E4M6V5 Infected shunt Inj Ronem 250mg/8jam
Batuk (+) KU = Tampak agak sesak Bronkopneumonia Inj Ranitidine 2x10mg
T = 37,2 ͦc Inf PCT 3x100mg
Konsul dr. SpA Pulmo: Retraksi Subcostal Nebu Ventolin ½R+2cc NaCl/8jam
(+), intrecostal (+), Rh+/+ PCR syr 3x1cth
Salbutamol 0,7mg
Ambrozol 7mg 3x1 pulv
CTM 0,5mg
Chest Fisioterapi
Date S O A P

27/7 Batuk (+) GCS = 15 POH 8 Post Removal IVFD D5 ¼ NS 10 tpm

Demam (+) E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
Sesak (-) KU = tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
T = 37,7 ͦc Inf PCT 3x100mg
Pulmo: Retraksi Subcostal Nebu Ventolin ½R+2cc NaCl/8jam
dan intrecostal (+) minimal, PCR syr 3x1cth
Rh+/+ Puyer batuk 3x1 pulv
Chest Fisioterapi
28/7 Batuk (+) GCS = 15 POH 9 Post Removal IVFD D5 ¼ NS 10 tpm
Demam (-) E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
Sesak (-) KU = Tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
T = 36,7 ͦc Inf PCT 3x100mg
Pulmo: intrecostal (+) Nebu Ventolin ½R+2cc NaCl/8jam
minimal, Rh+/+ PCR syr 3x1cth
Puyer batuk 3x1 pulv
Chest Fisioterapi

29/7 Batuk (+) GCS = 15 POH 10 Post Removal IVFD D5 ¼ NS 10 tpm

Demam (-) E4M6V5 Shunt a/i Infected shunt Inj Ronem 250mg/8jam
Sesak (-) KU = Tampak sakit ringan Bronkopneumonia Inj Ranitidine 2x10mg
T = 36,3 ͦc Inf PCT 3x100mg
Pulmo: intrecostal (+) Nebu Ventolin ½R+2cc NaCl/8jam
minimal, Rh+/+ PCR syr 3x1cth
Puyer batuk 3x1 pulv
Chest Fisioterapi
Date S O A P

30/7 Batuk (+) GCS = 15 POH 11 Post Removal BLPL

Demam (+) E4M6V5 Shunt a/i Infected shunt Cefixime syr 2x ½ cth
Sesak (-) KU = tampak sakit ringan Bronkopneumonia Salbutamol 0,7mg
T = 37,7 ͦc Ambrozol 7mg 3x1 pulv
Pulmo: Retraksi Subcostal CTM 0,5mg
dan intrecostal (+) minimal, SanvitaB syr 1x1 cth
Rh+/+
 Pemeriksaan Laboratorium

16/6 20/6
Hb 13,0 12,6
Lekosit 15.300 11.400
Trombosit 116.000 130.000
Ht 42,2 41,1
Jumlah 5,24 5,10
eritrosit
Hitung Jenis mid cell: 7
Lekosit granulosit: 38
limfosit: 55
Golongan darah: B
HBsAg: Non Reaktif
HIV: Non Reaktif
 Hasil Lab Dahulu

10/7 29/6 8/6

Hb 7,9 9,3 14,4
Lekosit 20.000 24.400 42.900
Trombosit 212.000 222.000 203.000
Ht 25,6 32,1 48,9
Jumlah 3,18 3,96 5,87
eritrosit
Pemeriksaan Ct scan 03/07/2018
Hasil Pemeriksaan CT Scan
Kepala dengan Kontras
Membandingkan dengan CT scan kepala tanggal 21-11-2017, saat ini:
CT-Scan kepala irisan Axial sejajar Orbita Meatal Line tanpa dan dengan
kontras: Sulci cerebri dan gyri di regio fronto-temporo-parieto-
oksipital bilateral dan fissura Sylvii kanan kiri tidak tervisualisasi,
tertekan oleh cairan ventrikel lateral bilateral terutama kanan.
Cerebellum kesan dalam batas normal.
Ventrikel IV menyempit
Sella dan parasella tidak tampak lesi
Kedua orbita, sinus paranasal dan mastoid kanan-kiri tidak tampak
kelainan.
Tulang-tulang kesan intak
Tampak struktur dengan densitas logam dengan ujung distal di
intraventrikel lateral kiri dan ujung proksimal di luar intrakranial
Kesimpulan:
Dibandingkan dengan CT Scan kepala tanggal 21-11-
2017, saat ini relatif stqa. Gambaran hidrocephalus
obstruktif bilateral luas yang menekan sulci dan gyri
pada lobus fronto-temporo-parieto-oksipital bilateral
dengan terpasang shunt dengan ujung distal pada
ventrikel lateral kiri dan ujung proksimal di regio
temporo-oksiptial kiri. Cerebellum kesan dalam batas
normal.
Follow Up Pasien Setelah
Pulang 8/8/2018 (POH 28)

O : CM, KU tampak sakit ringan S:-

HR : 131x/menit BB : 7,3 kg
RR : 48x/menit PB : 72,1cm A : Post Removal Shunt,
T : 36,5 ͦc LK : 48,5 cm Bronkopneumonia

Kepala: Luka operasi kering, P : Cotrimoxazole syr 2x1 cth

fontanella cekung SanvitaB syr 1x1cth
Mata: Sunset Fenomenon, CA -/- PCT syr 3x1cth
, SI-/- (Salbutamol 0,8mg+Ambroxol
Pulmo: SNV+/+, Rh+/+ 8mg+CTM 1mg) 3x1 pulv
TINJAUAN PUSTAKA
Ventrikuloperitoneal Shunt

 Common neurosurgical procedure

 Complication rates remain considerably high
 VPS failure  11–25% within the first year
 significantly higher number of shunt revisions and
replacements among pediatric patients compared to
adults
 In one study of 64 pediatric patients followed over 15
years, only 15.5% of patients did not require a revision
Infected Shunt

 Second most common cause of shunt malfunction

 8–15% VPS placement
 Risk factors for shunt infection as reported by multiple
studies, include
 young age (premature neonates)
 post operative CSF leak
 glove holes during shunt handling
 African American race
 previous shunt infections
 etiology of intraventricular hemorrhage
Infected Shunt

 Majority occur within  first few weeks to several

months after VPS placement
o Early shunt infections are often due to inoculation
during shunt insertion
o Late infections have been traced to instances of
peritonitis, abdominal pseudocyst, bowel perforation
and hematogenous inoculation.
Infected Shunt

 Shunt malfunction due to any cause may present with

 Nausea
 Vomiting
 headache and
 Fever (more common in patients with shunt infection)
 McClinton et al  fever and > 10% neutrophils in the
ventricular fluid
specificity of 99%, a positive predictive value of 93%,
and a positive test probability of 92% predicting
shunt infection.
Infected Shunt

 Culture of the CSF  important  causative organisms

and choosing the appropriate specific antibiotic therapy.
 Noetzel et al  demonstrated that 92% of samples of
aspirated shunt fluid yielded the causative organism as
compared for
 30.4% of blood cultures and
 66.7% of lumbar puncture samples
suggesting that shunt tapping is an efficient means
of diagnosis when there is a high index of suspicion for
infection.
Infected Shunt

 common causative organisms  Staph epidermidis,

Staph aureus and gram negative rods
 Staph epidermidis and Staph aureus  common skin
flora, and infection typically occurs during shunt
placement due to contamination from the skin
 usually present relatively early after shunt placement.
 McGirt et al  a previous shunt infection with S. Aureus
significantly increased the likelihood that a subsequent
shunt infection would yield S. aureus as the causative
organism
Infected Shunt

 Standard therapy  typically involves removal of the

infected hardware and initiation of intravenous
antibiotic therapy.
 Shurtleff et al  conducted a study of 31 VPS infections
caused by S. epidermidis in which some patients received
complete shunt removal with systemic antibiotic therapy
(100% cure rate ) and others received systemic antibiotic
therapy alone (9% cure rate).
Infected Shunt

 After the infected shunt is removed, an external

ventricular drain (EVD) must be placed while
intravenous antibiotics are administered. The EVD must
then remain in place until the infection is cleared and a
new shunt can safely be implanted.
 Treatment  a lengthy process that involves week to
month-long admissions in the hospital
 Preventing shunt infections are of  to cut costs and
reduce morbidity
Infected Shunt

 Other effective means of reducing the rate of shunt

infections include use of
 use perioperative antibiotics,
 optimizing sterile technique, and
 reducing the time of the procedure.
 Rotim et al  rate of shunt infection dropped from
17.9% to 8%.
 “A meta-analysis of the literature between 1960
and 1999 performed by Schreffler et al.(2002)
found that complete removal of the infected shunt
with EVD placement and antibiotic administration
is far superior to immediate replacement with a
new shunt or use of antibiotics alone”
Daftar Pustaka
[1] C.P. Bondurant, D.F. Jimenez, Epidemiology of cerebrospinal fluid shunting,Pediatr.
Neurosurg. 23 (1995) 254–259.
[2] Farid Khan, Muhammad Shahzad Shamim, Abdul Rehman, Muhammad Ehsan
Bari,Analysis of factors affecting ventriculoperitoneal shunt survival in pediatric
patients,Childs Nerv. Syst. 29 (2013) 791–802.
[3] F. Khan, Rehman, S. Shamim, M.E. Bari, Factors affecting ventriculoperitoneal shunt
survival in adult patients, Surg. Neurol. Int. 6 (2015) 25.
[4] Y. Wu, N.L. Green, M.R. Wrensch, S. Zhao, N. Gupta, Ventricluoperitoneal
shuntcomplications in California: 1990 to 2000, Neurosurgery 61 (2007) 557–562.
[5] Reddy GK, Bollam P, and Caldito, G. Long term outcomes of ventriculoperitonealshunt
surgery in patients with hydrocephalus. World Neurosurg. 01.96: 404–410.
[6] J.J. Stone, C.T. Walker, M. Jacobson, V. Phillips, H.J. Silberstein, Revision rate
ofpediatric ventriculoperitoneal shunts after 15 years, J. Neurosurg. Pediatr. 11 (2013)
15–19.
[7] M.J. McGirt, J. Leveque, J.C. Wellons, A.T. Villavicencio, J.S. Hopkins, H.E.
Fuchs,Cerebrospinal fluid shunt survival and etiology of failures: a seven year
institutionalexperience, Pediatr. Neurosurg. 36 (2002) 248–255.
[8] C.S. Stein, W. Guo, Have we made progress in preventing shunt failure? A critical
analysis, J. Neurosurg. Pediatr. 1 (2008) 40–47.
[9] R.V. Patwardhan, A. Nanda, Implanted ventricular shunts in the United States: the
billion-dollar-a-year cost of hydrocephalus treatment, Neurosurgery 56 (1) (2005)
139–144. [10] T.D. Simon, M. Hall, J. Riva-Cambrin, J.E. Albert, H.E. Jefferies, B.
LaFleur, J.M. Dean, J.R.W. Kestle, Infection rates following initial cerebrospinal fluent
shunt placement across pediatric hospitals in the United States, J Neurosurg. Pediatr.
4 (2009) 156–165.
[11] A.V. Kulkarni, J.M. Drake, M. Lamberti-Pasculli, Cerebrospinal fluid shunt infection: a
prospective study of risk factors, J. Neurosurg. 94 (2001) 195–201.
[12] K. Rotim, P. Miklic, J. Paladino, A. Melada, M. Marcikic, M. Scap, Reducing the
incidence of infection in pediatric cerebrospinal fluid shunt operations, Childs Nerv.
Syst. 13 (1997) 584–587.
[13] M. Puff, D. Alexandru-Abram, M. Muhonen, Ventriculoperitoneal Shunt Complication:
A Review, Interdisciplinary Neurosurgery. 13(2018) 66-70.