Parental recognition of shunt failure: a prospective single-institution study

Clinical article

Restricted access

Object

Because there is no gold standard for preoperative diagnosis of shunt failure, understanding the sensitivity, specificity, and predictive values of symptoms, signs, and diagnostic tests enables practitioners to make logical clinical decisions. Parents of children with shunts undergo educational instruction to enable them to recognize shunt failure. The authors prospectively investigated parental ability to recognize shunt failure.

Methods

Data were prospectively collected on 205 consecutive encounters in 153 children with shunted hydrocephalus presenting to the emergency department or clinic, or as an inpatient consultation, to the Children's Hospital of Alabama between April and October 2010. Regardless of the complaint, all parents were asked if they believed the shunt was in failure. Six children were excluded from analysis because a parental response was lacking. Using the Shunt Design Trial definitions, shunt failure was diagnosed intraoperatively or ruled out if the child did not undergo shunt revision within 1 week of presentation. Sensitivity, specificity, predictive values, and accuracy were calculated using the parental response and shunt failure diagnosis. Secondarily, parents were compared based on their experience with shunt failure in their children; experienced parents were defined as having experienced at least 3 shunt failures. Post hoc analysis evaluated diagnostic test characteristics among hydrocephalus causes and compared parental recognition of shunt failure to head CT and shunt series diagnostic test characteristics. Parents also completed a standardized shunt failure survey regarding their shunt teaching education and symptom tracking.

Results

Children enrolled were a mean age of 6.9 years old, 92 (46%) of the encounters were with male patients, and most patients were Caucasian (69%) and had undergone an average of 2.8 previous shunt revisions. Seventy-one children (36%) were diagnosed with shunt failure. Parental response diagnostic test characteristics were: positive predictive value (PPV) of 41%, negative predictive value (NPV) of 79%, sensitivity of 83%, specificity of 34%, and accuracy of 52% for shunt failure. Sixty-three parents were considered experienced and responded with a PPV of 29%, NPV of 92%, sensitivity of 94%, specificity of 23%, and accuracy of 41%. One hundred thirty-six parents were considered inexperienced and responded with a PPV of 48%, NPV of 75%, sensitivity of 80%, specificity of 41%, and accuracy of 57%. When statistically compared, experienced parents had significantly lower PPV (29% vs 48%, respectively; p = 0.035) and accuracy (41% vs 57%, respectively; p = 0.049) than inexperienced parents. On post hoc analysis, parental recognition of shunt failure was inferior to head CT and shunt series diagnostic tests with a lower specificity (20% vs 88%, respectively; p < 0.0005), PPV (44% vs 84%, respectively; p < 0.0005), NPV (61% vs 85%, respectively; p = 0.006), and accuracy (47% vs. 85%, respectively; p < 0.0005).

Conclusions

The overall parental response had the greatest value in ruling out shunt failure, reflected in the high NPV, particularly in experienced parents. The head CT and shunt series provide more favorable diagnostic test characteristics than the parental response. Although educational interventions have decreased shunt-related deaths, parents have difficulty differentiating shunt failure from alternative diagnoses.

Abbreviations used in this paper:IVH = intraventricular hemorrhage; NPV = negative predictive value; PPV = positive predictive value.

Article Information

Address correspondence to: Robert P. Naftel, M.D., Division of Neurosurgery, University of Alabama at Birmingham, 510 20th Street South, FOT 1062, Birmingham, Alabama 35294-3410. email: naftel@uab.edu.

Please include this information when citing this paper: DOI: 10.3171/2011.12.PEDS11291.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A diagram of the 199 encounters in the study. Parents were asked whether they believed the shunt was in failure, and their response was recorded as “yes” or “no.” Patients were either diagnosed as in shunt failure or not in shunt failure, yielding true positives, false positives, false negatives, and true negatives.

  • View in gallery

    A bar chart depicting parental responses to the educational resource question on the parent survey. Parents were asked: “How helpful were these educational resources in learning about shunt failure: teaching from neurosurgery staff, past experiences with shunt failures, self education, and primary care physician.” Answer responses were scored in a Likert format (scale 1–4).

References

  • 1

    Acakpo-Satchivi LShannon CNTubbs RSWellons JC IIIBlount JPIskandar BJ: Death in shunted hydrocephalic children: a follow-up study. Childs Nerv Syst 24:1972012008

    • Search Google Scholar
    • Export Citation
  • 2

    Barnes NPJones SJHayward RDHarkness WJThompson D: Ventriculoperitoneal shunt block: what are the best predictive clinical indicators?. Arch Dis Child 87:1982012002

    • Search Google Scholar
    • Export Citation
  • 3

    Chern JJMacias CGJea ACurry DJLuerssen TGWhitehead WE: Effectiveness of a clinical pathway for patients with cerebrospinal fluid shunt malfunction. Clinical article. J Neurosurg Pediatr 6:3183242010

    • Search Google Scholar
    • Export Citation
  • 4

    Drake JMKestle JRMilner RCinalli GBoop FPiatt J Jr: Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 43:2943051998

    • Search Google Scholar
    • Export Citation
  • 5

    Fleiss JL: Statistical Methods for Rates and Proportions ed 2New YorkWiley1981

  • 6

    Garton HJKestle JRDrake JM: Predicting shunt failure on the basis of clinical symptoms and signs in children. J Neurosurg 94:2022102001

    • Search Google Scholar
    • Export Citation
  • 7

    Iskandar BJMcLaughlin CMapstone TBGrabb PAOakes WJ: Pitfalls in the diagnosis of ventricular shunt dysfunction: radiology reports and ventricular size. Pediatrics 101:103110361998

    • Search Google Scholar
    • Export Citation
  • 8

    Iskandar BJTubbs SMapstone TBGrabb PABartolucci AAOakes WJ: Death in shunted hydrocephalic children in the 1990s. Pediatr Neurosurg 28:1731761998

    • Search Google Scholar
    • Export Citation
  • 9

    Kim TYBrown LStewart GM: Test characteristics of parent's visual analog scale score in predicting ventriculoperitoneal shunt malfunction in the pediatric emergency department. Pediatr Emerg Care 23:5495522007

    • Search Google Scholar
    • Export Citation
  • 10

    Kim TYStewart GVoth MMoynihan JABrown L: Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department. Pediatr Emerg Care 22:28342006

    • Search Google Scholar
    • Export Citation
  • 11

    Likert R: A technique for the measurement of attitudes. Arch Psychol 22:1551932

  • 12

    Mater AShroff MAl-Farsi SDrake JGoldman RD: Test characteristics of neuroimaging in the emergency department evaluation of children for cerebrospinal fluid shunt malfunction. CJEM 10:1311352008

    • Search Google Scholar
    • Export Citation
  • 13

    Rocque BGLapsiwala SIskandar BJ: Ventricular shunt tap as a predictor of proximal shunt malfunction in children: a prospective study. J Neurosurg Pediatr 1:4394432008

    • Search Google Scholar
    • Export Citation
  • 14

    Tuli SDrake JLawless JWigg MLamberti-Pasculli M: Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 92:31382000

    • Search Google Scholar
    • Export Citation
  • 15

    Walker HKHall WDHurst JW: Clinical Methods: The History Physical and Laboratory Examinations ed 3BostonButterworths1990

  • 16

    Wilson JMGJungner G: Principles and Practice of Screening for Disease GenevaWorld Health Organization1968

  • 17

    Zorc JJKrugman SDOgborn JBenson J: Radiographic evaluation for suspected cerebrospinal fluid shunt obstruction. Pediatr Emerg Care 18:3373402002

    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 115 115 10
Full Text Views 67 67 0
PDF Downloads 171 171 0
EPUB Downloads 0 0 0

PubMed

Google Scholar