Recovery After Surgery for Nonsyndromic Craniosynostosis in Children

Postoperative Orders  

• ICU vs. standard care unit: Patients should be admitted to the PICU for one night. Patients who had minimally invasive surgery may go home the next day. Patients who had open procedures can usually be transferred to regular care the next morning.
• IVF and rate: There can be big fluid shifts during and after surgery, so care should be taken in the adjustment of fluids administered after surgery to reflect this concern. The formula for fluid replacement needs in infants is 4 ml/kg for the first 10 kg plus 2 ml/kg for the second 10 kg plus 1 ml/kg up to the patient’s weight.
• Medications and dosages including PRN drugs: Analgesia can be managed with acetaminophen, 15 mg/kg every 6 hours, or ibuprofen, 10 mg/kg every 6 hours. These may be alternated every 3 hours for pain. Alternatively, morphine, 0.1 mg/kg IV every 2 hours as needed for severe pain, and acetaminophen with codeine, 1 mg/kg codeine, PO every 3-4 hours as needed for moderate pain, can be used. Do not give plain acetaminophen while giving acetaminophen with codeine. Postoperative antibiotics are optional.
• Postoperative laboratory testing: Check immediate and 24-hour hemoglobin if blood loss was routine. Hemoglobin may drop to 6 or 7 mg/dl without hemodynamic symptoms.  Full hematological profiles and chemistries are not necessary unless a massive blood transfusion has occurred during surgery.
• Physical therapy and orthotics: Patients who undergo endoscopic procedures should be scheduled for helmet fitting by postoperative day 3 or 4. Swelling should be at a minimum.
• Discharge within several days: Patients can be discharged home once they are taking adequate liquid and some solids. They do not need to have their eyes open to go home. Patients who undergo open procedures will go home by days 3–5. Patients who undergo minimally invasive procedures may go home on days 1 or 2.

Postoperative Morbidity

• Fever expected: All patients have fever. Only 4 of 126 patients with postoperative fever had infections based on clinical grounds. Work up should not be pursued unless it is clinically warranted (21, 44).
• Swelling expected: Swelling after the minimally invasive procedure is minimal. Swelling after the open procedure is significant, and the family should be told that it is normal. Swelling is worse on postoperative day 2. If surgery has been performed on the forehead, the swelling will settle into the periorbital region including the eyelids. Commonly, patients cannot open their eyes for several days. The family must be made aware that postoperative swelling and fluid will fluctuate with position of dependence.

• Hyponatremia common: Iatrogenic causes or excessive fluid during surgery may be etiologies. Some studies suggest cerebral salt wasting instead of SIADH as another cause. The hyponatremia corrects rapidly by postoperative day 1 without intervention. Isotonic solutions should be used and the patient kept euvolemic (10, 31).