Role of Transesophageal ECHO in Ventriculoperitoneal Shunt Surgery for a Child with Dandy–Walker Malformation: A Case Report

Background: Dandy–Walker malformation (DWM) is a congenital malformation, characterized by enlargement of the posterior fossa, cystic dilatation of the fourth ventricle, and agenesis/hypoplasia of the vermis. We would like to report the role of transesophagealecho (TEE) for confirming the position of distal tip during ventriculoatrial (VA) shunt insertion.

Case Description: A 2-year-old boy weighing 7.5 kg was admitted with diagnosis of DWM with shunt dysfunction following a cystoperitoneal shunt and was planned for insertion of VA shunt. Since, the child had features of raised ICP, an intravenous access was secured after applying the EMLA cream. Standard monitors were applied, the child was intubated after fentanyl, propofol, and atracurium using 5-size uncuffed tube. Anesthesia was maintained with propofol infusion till the insertion of VA shunt to avoid further increase in ICP. TEE probe (pediatric) was inserted for confirming the optimal position of the distal tip and to detect air embolism. Child was hydrated well with 20 mL/kg of RL to make the internal jugular vein prominent and to avoid air entrainment while inserting the distal tip into the atrium. All catheters were flushed with saline and 10-degree head down was given while inserting the distal tip. The distal tip was placed at the mid atrial level and its correct placement was confirmed by transesophageal echo.

Conclusion: Accurate placement of distal tip of the VA shunt is crucial to ensure long-term shunt function, prevention of cardiac arrhythmias, and myocardial damage. TEE is useful as it provides a real time image, enables continuous monitoring of tip, and occurrence of air embolism.

Publication History

Article published online:
25 March 2020