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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 additional involvement of Pediatric Critical Care and Pediatric Services (physician and nursing components). Although the Pediatric service is expected to provide bedside monitoring and treatment according to the guidelines below, it is essential that differences from the expected course, any deterioration in the patient's condition, or substantive changes in therapy be discussed 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 the subgaleal 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). When the dura has been disrupted, there is an additional risk of subdural hematoma that similarly may result in elevated ICP. This is rarely seen because of the open communication between the epidural and subgaleal spaces achieved by the cranioplasty. 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 altered level of consciousness that might indicate elevated ICP and detection of poor perfusion that might indicate loss of blood from the vascular space. In addition, the increased ability to monitor patients in the PICU allows safer analgesia to be provided in those patients unable to tolerate enteral medications. Physiological Monitoring Cardiovascular and neurological function must be assessed at least hourly until postoperative day # 1. Heart rate, pulse oximetry, and respiration should be monitored continuously. When patients 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 for this assessment. Typically, patients return from the OR with bladder catheters in place. Urine output should be monitored hourly as oliguria may provide the earliest indicator of hypoperfusion. Appropriate orders should be entered to notify the Pediatric House staff for: 1. HR, BP, or RR outside the appropriate range for age 2. Urine output less than 0.5 ml/kg/hr for more than 1 hour

3. Hct < 35% or a decrease in Hct of more than 5% between subsequent measurements for 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 in hematocrit, and deficits in coagulation function. Patients should have the following laboratory tests ordered: 1. Immediately after return from the OR: Point of Care electrolytes and Hct, Lab PT, PTT and CBC 2. Hct hourly for hours 1 - 6 (STAT with point of care), q4h at 10, 14, 18 hours, then daily 3. 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 chest radiograph 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 day except when there is a drain in place. This study is aimed at examining the surgical repair as well as detecting any intracranial bleeding if it is present. The study should be done as early as possible on the morning of postoperative day 1 as the results of this test can influence disposition decisions. The study may be ordered at the time of admission to the PICU. For patients 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/l K+ is the preferred solution as long as there is adequate urine output. Consider removing 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 should never 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. If Hct <30% in the first 12 hours, consider this an urgent situation. If the patient has tachycardia, hypotension or hypothermia (<36.5 axillary or <36.8 rectally), PRBCs should be pushed as fast as tolerated and without the 5% test dose. Analgesia should be provided as needed with acetaminophen (10-15 mg/kg q4h) po/pr. If acetaminophen alone is inadequate, codeine may be added in those

patients tolerating enteral feeding. Morphine may be used after approval by the Neurosurgery team in those patients whose discomfort is otherwise poorly controlled or who are unable to tolerate codeine enterally. It is important to recognize that neonates have delayed clearance of narcotics and that narcotics blunt the ability to assess neurological 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, neurosurgery should 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 and acceptable cardiovascular and neurological function and when their perceived risk of decompensation is small. Such patients typically: 1. Are easily arousable, alternating between wakefulness and sleep. The Modified GCS should be > 14 (although it may be difficult to judge pupillary responses because of swelling). 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 of assessment may be decreased to every 4 hours.

Revised June 2011