Recovery From Surgery for Brainstem Gliomas in Children

Postoperative Orders 

• Ventilatory support: Ventilatory support is critical in the first 24-72 hours after surgery. When surgery involves the medulla, it is particularly important, as these patients have impaired ventilatory drive resulting in a very high risk for CO2 retention followed by respiratory collapse and infarction within the operative bed. Patients should remain intubated postoperatively, with ventilator weaning and extubation considered only if the patient has demonstrated a stable respiratory drive for at least 24 hours.
• EVD clamped unless documented hydrocephalus: If an EVD was left in place postoperatively, it can remain clamped if there is no immediate concern for development of hydrocephalus. Thereafter, it can serve as a rescue drain should there be neurological deterioration. After a period of observation with normal ICP levels, the drain can be removed. In the case of postoperative hydrocephalus, it should be left open to drain at 5 cm above the tragus with ICP and output recorded hourly.
• Steroid taper: Steroids are tapered over a period of 5–7 days postoperatively.
• Advance diet cautiously: Care should be taken in the introduction of oral intake.   These patients are at high risk for silent micro-aspiration and resultant respiratory difficulties, particularly in the case of cervicomedullary tumors. Formal swallow evaluation should be obtained if there is any concern for difficulty with airway protection BEFORE their diet is advanced.
• Oncology consultation: If not already involved, Oncology should be consulted to arrange long-term follow-up and begin planning of adjuvant therapy if needed.
• Physical and occupational therapy: There should be early consultation with physical and occupational therapy to evaluate the patient’s disabilities and needs so that steps can be taken for arranging support or placement if needed.
• MRI imaging with and without contrast: Imaging should be obtained in the first few days after surgery to evaluate the extent of resection and provide a new baseline for future comparison. Imaging should be obtained sooner if there is concern for a new neurological deficit.

Postoperative Morbidity

The patient may experience transient or permanent worsening of neurological symptoms in the immediate postoperative period that require special monitoring and intervention.

• Poor respiratory drive: Poor respiratory drive can occur, especially in patients with tumors involving the medulla. Early placement of a tracheostomy for airway management should be considered in patients with decreased or absent central respiratory drive that does not resolve in the first 48–72 hours. 
• Difficulty swallowing: In addition to diminished respiratory drive, patients can experience difficulty swallowing and choking on food. A feeding tube should be placed in cases where strong evidence of silent or frank aspiration is encountered. Typically, this is only a temporary need.