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Care of Patients following Cranioplasty for Cranial Synostosis

Care Team:

This surgical procedure is most frequently performed in a collaborative approach by

Pediatric Neurosurgery and Plastic Surgery. Postoperative care requires the additionalinvolvement of Pediatric Critical Care and Pediatric Services (physician and nursingcomponents). Although the Pediatric service is expected to provide bedside monitoring andtreatment according to the guidelines below, it is essential that differences from the expectedcourse, any deterioration in the patient's condition, or substantive changes in therapy bediscussed with the Neurosurgery and Plastic Surgery Services as soon as possible.

Postoperative Care:

The major risks during the postoperative period are twofold:

1.

The most common and potentially serious problem is extravasation of blood into thesubgaleal space beneath the scalp which can lead to intravascular volume depletion and

shock. This problem is particularly exacerbated in smaller patients in whom a greater

proportion of the circulating blood volume may extravasate unobserved.

2. Rarely, epidural hematoma can lead to elevated intracranial pressure (ICP). Whenthe dura has been disrupted, there is an additional risk of subdural hematoma thatsimilarly may result in elevated ICP. This is rarely seen because of the opencommunication between the epidural and subgaleal spaces achieved by thecranioplasty.

Accordingly, patients are monitored at least overnight in the Pediatric Intensive Care Unit

following cranioplasty. The purpose of monitoring in the PICU is to ensure detection of alteredlevel of consciousness that might indicate elevated ICP and detection of poor perfusion thatmight indicate loss of blood from the vascular space. In addition, the increased ability to monitorpatients in the PICU allows safer analgesia to be provided in those patients unable to tolerateenteral medications.

Physiological Monitoring

Cardiovascular and neurological function must be assessed at least hourly until postoperativeday # 1. Heart rate, pulse oximetry, and respiration should be monitored continuously. Whenpatients return from the OR with arterial cannulae, BP should also be monitored continuously.The patient's level of consciousness should be assessed at least hourly. For most of these

patients (nonverbal), the Modified Glascow Coma Scale is the most appropriate instrument forthis assessment. Typically, patients return from the OR with bladder catheters in place. Urineoutput should be monitored hourly as oliguria may provide the earliest indicator ofhypoperfusion.

Appropriate orders should be entered to notify the Pediatric House staff for:

1. HR, BP, or RR outside the appropriate range for age2. Urine output less than 0.5 ml/kg/hr for more than 1 hour

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3. Hct < 35% or a decrease in Hct of more than 5% between subsequent measurementsfor the first 24 hours.4. Cool extremities and mottled skin or other signs of poor tissue perfusion.5. Deterioration in level of consciousness

Laboratory Monitoring

Transfusion and volume repletion in the OR can result in electrolyte abnormalities, changes inhematocrit, and deficits in coagulation function. Patients should have the following laboratorytests ordered:

1. Immediately after return from the OR: Point of Care electrolytes and Hct, Lab PT,PTT and CBC2. Hct hourly for hours 1 - 6 (STAT with point of care), q4h at 10, 14, 18 hours, then daily3. One unit of PRBCs should be kept in the PICU blood refrigerator for the first 24 hours.

Imaging

If patients have a central venous catheter placed in the OR, they should have a chestradiograph after arrival in the PICU to confirm proper positioning and to rule out a pneumothorax(a known complication of subclavian venous catheter placement).

Patients may have computerized tomography (CT) on the morning of the first postoperative dayexcept when there is a drain in place. This study is aimed at examining the surgical repair aswell as detecting any intracranial bleeding if it is present. The study should be done as early aspossible on the morning of postoperative day 1 as the results of this test can influencedisposition decisions. The study may be ordered at the time of admission to the PICU. Forpatients with a ventricular drain in place, CT should be scheduled for after the drain removal.

Postoperative therapy

IVF should provide maintenance fluid and electrolytes. D5 l/2 NS with 20 mEq/lK+ is the preferred solution as long as there is adequate urine output. Considerremoving K+ if urine output falls below 0.5ml/kg/hr.

Coagulation abnormalities should be corrected with blood products. Specifically,elevations in INR (>1.8) should be treated with FFP (10ml/kg). Thrombocytopenia(plts < 75) should be treated with platelet transfusion (10ml/kg). Platelets shouldnever be pushed.

PRBCs transfusions (15cc/kg) should be provided as necessary to keep the Hct> 35% until the first postoperative morning (18 hours) and >30% thereafter. IfHct

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patients tolerating enteral feeding. Morphine may be used after approval by theNeurosurgery team in those patients whose discomfort is otherwise poorlycontrolled or who are unable to tolerate codeine enterally. It is important torecognize that neonates have delayed clearance of narcotics and thatnarcotics blunt the ability to assessneurological function.If administered,morphine should be used at a reduced dose (0.05mg/kg) and, for this patient

population, only in the PICU. If urgent administration is necessary, neurosurgeryshould be advised of this within a few minutes of its administration.

Oral feeds may be provided ad lib once patients emerge from anesthesia.

IVF rates should be reduced when oral feeds are tolerated.

Transfer of patients from the PICU to the floor

Patients will be transferred from the PICU to the appropriate floor when they have stable andacceptable cardiovascular and neurological function and when their perceived risk ofdecompensation is small. Such patients typically:

1. Are easily arousable, alternating between wakefulness and sleep. The Modified GCSshould be > 14 (although it may be difficult to judge pupillary responses because ofswelling).

2. Have normal BP and a HR < 120% of the upper limit of normal for age.3. Have normal (> 0.5- 1 ml/kg/hr) urine output.4. Have a head CT that shows no evidence of intracranial bleeding or a drain in place

without excessive drainage (head CT can be done from the floor if drain remaining).

Frequent monitoring should continue on the floor after transfer although the frequency ofassessment may be decreased to every 4 hours.

Revised June 2011