VENTRICULOPERITONEAL SHUNT
Received Sep 20, 1999 · Event occurred Aug 9, 1999
Report 241343 · MDR key 241343
Device
Generic name
Ventriculoperitoneal Shunt
Manufacturer
Integra NeurocareModel number
*Catalog number
NL850-1391
Lot number
*
Product problems
- Break
- Replace
- Device Issue
- Malfunction
Patient
27 YR
- Headache
- High Blood Pressure/ Hypertension
- Surgical procedure, repeated
- Respiratory Distress
- Tachycardia
- Other (for use when an appropriate patient code cannot be identified)
- Nonresorbable materials, unretrieved in body
- Therapy/non-surgical treatment, additional
- Cognitive Changes
- Treatment with medication(s)
- Manual ventilation required
Narrative
Description of Event or Problem
A 27YO FEMALE ADMITTED THROUGH ER WITH COMPLAINT OF SEVERE HEADACHE AND PHOTOPHOBIA UNRELIEVED BY HOME MEDS. PT HAS A HISTORY OF HYDROCEPHALUS AND HAD A VENTRICULOPERITONEAL SHUNT LAST PLACED 08/11/89. WHILE THE SURGEON WAS TALKING TO THE PT ABOUT HER H/A SHE BECAME SOMNOLENT. SEVERELY HYPERTENSIVE WITH SYSTOLIC BP>200, TACHYCARDIC, AND HAD AGONYL RESPIRATIONS WHICH REQUIRED THE USE OF MANUAL VENTILATION. THE SURGEON INSERTED A SPINAL NEEDLE INTO HER SHUNT AND REMOVED SOME FLUID. THE PT BECAME RESPONSIVE, SHE WAS EMERGENTLY TAKEN TO OR WHERE HER OLD SHUNT WAS PARTIALLY REMOVED. THE DISTAL END OF THE CATHETER BROKE OFF AND WILL REMAIN IN THE CHEST WALL AND ABDOMEN. A NEW VENTRICULARPERITONEAL SYSTEM WAS IMPLANTED. THE PT WAS OBSERVED FOR TWO DAYS POST OP THEN DISCHARGED.