Paediatric craniofacial surgery open procedures : standard operating procedure

• Total calvarial remodelling (TCR)
• Skull vault expansion procedures
• Fronto-orbital advancement and remodelling procedures (FOAR)
• Midface advancement and remodelling procedures
• Correction of orbital dystopia

(Hayward et al 2004)

Majority of craniofacial cases will be extubated in recovery prior to admission to PICU for close observation post-op.

Airway and Breathing

Some children may have complex airways secondary to underlying syndrome or secondary to hardware placed during surgery (Sharma 2013).

Risk factors should be highlighted on handover to PICU fellow, Consultant and bedside nurse and contingency plan with anaesthetist and surgeons regarding hardware in the event of emergency re-intubation. NB. appropriate equipment should be available at the bedside to facilitate this.

Cardiovascular

Craniofacial surgery can be associated with large blood loss volumes, children may return from theatre with an arterial line and central line in-situ. Cardiovascular status should be monitored closely (Mathijssen 2015).

All children will have a dressing in-situ, some children may also have a pressure bandage. If there is bleeding through the dressing, the neurosurgeon should be informed. Mild staining is acceptable.

Most children will also return with a sub-galeal (scalp) drain in-situ which will be stitched in place, this is usually on suction (however occasionally, at the surgeon’s discretion, it may be left on free drainage). If there is uncertainty as to whether a drain should be on suction you should clarify with the surgeon their requirement.

Close monitoring of drain losses should be observed. sub-galeal drain losses are approximate however it will be easy to identify if a patient is bleeding a lot. Initial drain losses are usually approximately 3-5mls/kg/hr. If there are large drain losses then consider repeating the Haemoglobin (Hb) and replacing drain losses with packed red cells.

FBC, U&E, coagulation profile and blood gas should be performed on admission, and aim to keep the haemoglobin (Hb) > 70g/l Where there is significant blood loss in theatre, Vitamin K/FFP/Cryoprecipitate may be required to normalise coagulation profile.

It is not uncommon for children to be tachycardic post operatively, usual troubleshooting should be employed to consider pain/blood loss/blocked catheter/pyrexia.

Central Nervous System and Neurological Assessment

One rare complication of craniofacial surgery is a possibility of cerebrospinal fluid (CSF) leak. This may be observed as a leak of clear fluid from the nostrils. If concerned then contact the neurosurgical registrar for advice. (Betances, Mendez & Das 2021)

Neurological observations should be documented regularly to assess the conscious level using Glasgow Coma Scale (GCS). An uncommon but important complication of craniofacial surgery is haematoma formation (scalp/extra/sub-dural), therefore neurological observation is paramount.

Baseline neurological observations on admission

15 minutes for the 2 hours (usually in recovery)

30 minutes for the next 2 hours

Every hour for next 4 hours

2 hourly for the next 6 hours

4 hourly thereafter

Pupillary reaction may be difficult or impossible to assess due to bruising and swelling of eyes and face following surgery. However if possible pupillary response to light and pupillary size should be observed and recorded.

To reduce incidence of swelling the child can be nursed slightly head above bed at 30-45 degrees incline (Blake & Bradshaw 2015)

Pain Management

Adequate post-op pain relief is imperative to aid recovery, typical pain management involves a combination of opioid and first line pain relief (Srivatsa et al 2021)

NCA/PCA for first 12- 24hours (continuous infusion). It is usual to discontinue the NCA on discharge from PICU with commencement of adequate analgesia (see below) on admission to the ward

Regular IV paracetamol +/- Ibuprofen at discharge

Fluid balance

70% maintenance plasmalite (+/-5% dextrose), until tolerating adequate oral intake (Srivetsa et al. 2021)

Patient should have a urinary catheter on admission to PICU which is removed prior to discharge to ward 3a unless specified.

Vomiting is not uncommon post-operatively due to effects of anaesthetic – PRN ondansetron should be prescribed, however, remain mindful that vomiting can be associated with raised ICP.

Antibiotics

The first dose of antibiotics is usually given in theatre. The first line antibiotic is usually cefuroxime (the alternative Teicoplanin for those with an allergy to cefuroxime may be given). Two further doses post-operative doses of antibiotics is usually requested.

 For those patients undergoing complex midface surgery Co-Amoxiclav is prescribed for 5-7 days.

Steroids

There is no routine prescription of steroids in the post-operative period.

Morning bloods including FBC, U&E, Coagulation profile and arterial blood gas. Assess Hb prior to ward transfer and if appropriate a further transfusion packed red cells should be given.

Most children are discharged from PICU the day after surgery to ward 3a, following documented review from Craniofacial team.

The urinary catheter and arterial line are removed prior to discharge to the ward. Central venous catheter is left in-situ only if there is no reliable peripheral access.

Temperature, pulse and respiration (TPR) and neurological observations should continue 4 hourly.

Pain relief, NCA/PCA are normally stopped prior to discharge to ward with a prescription for regular IV paracetamol for 24 hours post-op which can then be transitioned to oral when tolerating diet and fluids with regular Ibuprofen. PRN oramorph for breakthrough pain relief should be prescribed and regular pain assessment scores obtained.

The patient is normally discharged to ward 3a with Neurosurgical ANP or ward GP trainee notified by PICU medical team.

Baseline observations and 4 hourly neuro observations

Regular IV Paracetamol for 24 hours, this can be transitioned to oral paracetamol when tolerating diet and fluids.

Regular oral Ibuprofen to be introduced when tolerating diet and fluids, regular pain scores to be assessed.

PRN oramorph if required for adequate pain control

Promote oral diet and fluids with titration of maintenance fluids in response to oral intake and of fluid balance documented

If vomiting continues ondansetron can be given as required.

Mobilise and nurse child upright as possible to reduce swelling (a buggy can be used in upright position for day time sleeping). Maximal oedema occurs between days 2-3 following surgery (Blake & Bradshaw 2015)

Child will be reviewed on ward by the neurosurgical ward round

Wound dressing will be removed

Sub-galeal drain usually removed by nursing staff

Continue to mobilise and nurse upright when awake

Swelling will become more apparent, eyes may be completely swollen closed

Continue with regular pain relief, paracetamol and ibuprofen supplemented with oramorph as required

The child should be bathed with hair wash with mild shampoo

Continue with regular pain relief

Child is usually discharged between day 5-7 post-op following Craniofacial review.

Parents will be given post-op wound care advice by Craniofacial CNS and contact numbers for ongoing support.

For children with complex needs and other specialties involved ensure that all specialties are happy with discharge plan.

Craniofacial CNS will contact family 2 weeks post-op to assess ongoing wound care

Follow-up at craniofacial clinic will routinely be 6 weeks post-op, 6 months post-op, 1 year post-op, then age 3, age 5, age 10 and age 15 for single suture craniosynostosis. For complex synostosis this will be determined as per clinical need following the initial post-op course.