Recovery From Surgery for Supratentorial High-Grade Gliomas in Children

Postoperative Orders 

• ICU: The child should recover in the ICU.  If the child is extubated, stable over the ensuing 12–24 hours, and hemodynamically stable, consideration should be given to transfer out of the ICU.
• VS: Blood pressure will be monitored continuously via arterial catheter. If the catheter is dislodged or becomes non-functioning, frequent cuff pressures are acceptable. Pulse oximetry will be used to verify adequate oxygenation.
• BP parameters: With the exception of a child who has suffered an inadvertent arterial injury during surgery, blood pressure should be normalized and allowed to fluctuate physiologically, with assurance that hydration and hematocrit/hemoglobin are optimized.
• IVF and rate: Maintenance fluids based on weight without dextrose are important to maintain adequate hydration and physiological electrolyte levels (0-10 kg, 10 ml/kg/hour; 11-20 kg, 40 ml/hour+2 ml/kg/hour; and > 20 kg, 60 ml/hour+1 ml/kg/hour).
• Ventilator support: Unless there is concern for increased ICP or there has been prolonged surgery with large fluid shifts that may compromise respiratory drive or pulmonary function, extubation should be considered at the end of surgery. If intubation is required, normal pCO2 and adequate oxygenation should be the goal, with progressively less ventilator support as the child awakens, working towards extubation.
• ICP parameters: ICP, if monitored, should be controlled to allow for pressures less than 20 mmHg. Most such monitoring is by ventricular catheter, placed either before surgery or directly in the ventricle at the end of surgery. These catheters are typically set to drain at specific pressures, but transduced pressures 3–4 times per hour are helpful in determining trends.
• CSF drainage parameters/drainage bag setup: If there is an EVD, the decision can be made to allow it drain or to keep it clamped. If clamped, it should be transduced to a monitor allowing for ICP monitoring. If the intention is to drain, it should be clamped until ICP is maintained about the desired threshold, depending on the child between 10–15 mmHg, then opened to continuous drainage.
• Diet: In the extubated child who is otherwise awake with a secure airway and adequate swallowing, the diet can be advanced immediately after surgery as tolerated. Depending on scheduling and patient cooperation and tolerance, NPO status may be required ahead of post-operative MRI for purposes of sedation.
• HOB, positioning, activity, bathing: The HOB after supratentorial craniotomy should be at least at 30 degrees. Avoidance of prolonged pressure directly on the incision will prevent breakdown or added discomfort. Depending on the extent of surgery and immediate postoperative condition, the child may start mobilizing the following day, depending on age, but sitting up, sitting in a chair, standing, and eventually walking if able. With the exception of a child with an EVD, bathing may begin the day after surgery, washing the incision with soap and water daily.
• Medications and dosages including PRN drugs: If there is no drain or EVD, three postoperative doses of antibiotics (typically cefazolin 30 mg/kg iv every 8 hours) are given. In addition, anticonvulsants, if needed, should be continued from the pre- or peri-operative periods. Acetominophen (15 mg/kg per mouth/rectum every 6 hours as needed) as well as morphine (0.05 mg/kg iv every 2 hours as needed) can be ordered for pain. Steroids (dexamethasone) may be given, the dose depending on patient age, weight, and level of concern for edema, swelling, or immediate postoperative neurological examination.
• Laboratory studies: Postoperative electrolyte and hematological studies should be ordered, particularly if there have been large fluid shifts or intraoperative bleeding, in which case coagulation studies may also be warranted. Anticonvulsant levels should also be checked if anticonvulsants are being given.
• Radiology studies: Routine postoperative MRI for evaluation of surgical resection and potential complications should be performed in the first 24 hours. If there is a sense of urgency because of a sudden change in neurological or hemodynamic status, or because of unexpected immediate postoperative issues, a CT should be done urgently. If there is concern for vascular injury or potential vasospasm, formal catheter angiography may be considered.
• Consultations: The intensivists will aid in the care of the patient immediately after surgery in the ICU. The oncology team should also be aware of the child in order to begin the process of meeting the family and the child.

Postoperative Morbidity

The postoperative course of children undergoing surgery for HGGs depends on the extent and location of surgery, intraoperative issues and complications, and postoperative complications. Surgery in eloquent cortex may lead to expected neurological deficit, such as aphasia, visual loss, or weakness. Urgent attention to such expected problems may not be necessary, depending on the surgeon’s experience and confidence in the examination. Other postoperative problems may not be anticipated. The following is a list of potential issues in the immediate or later postoperative period and their management:

• Unexpected lethargy or coma: Children with unexpected lethargy or coma should be emergently imaged by CT to rule out a space-occupying lesion such as a hematoma, newly developed hydrocephalus, or stroke. Depending on the findings, the child may require osmotic diuretics, emergent placement of an EVD, or a return to surgery to remove a hemorrhage or decompress the brain with a craniectomy if necessary. If there is no evidence for increased ICP, bloodwork to evaluate electrolyte and anticonvulsant status should be obtained, and EEG should be considered to rule out subclinical seizures.
• Unexpected weakness, sensory, visual, or speech deficit: If the patient is otherwise awake and alert, an imaging studying, preferably MRI, should be obtained to evaluate not only the extent of resection, but to rule out a focal hematoma or stroke. In the awake patient, acute surgical intervention is rarely required, and glucocorticoids, hydration, and maintenance of physiological electrolyte levels could be helpful.
• Spinal fluid leakage from the incision: Should the ventricle have been entered at surgery, the risks for postoperative CSF leak is higher. Even if this is not the case, and there is not evidence for preoperative hydrocephalus or postoperative symptoms of increased ICP, an image should be obtained to verify the absence of hydrocephalus. If hydrocephalus is present, ventricular drainage or ETV should be considered. Ultimately, permanent CSF diversion may be required. Over-sewing the site of leakage is important, but likely not definitive. In the child without hydrocephalus, over-sewing the site of leakage may be adequate. Prolonged postoperative antibiotic administration may be considered.
• Postoperative seizures: Seizures after surgery for cortical lesions are not unexpected but should be evaluated by appropriate bloodwork, radiological studies, and EEG. Persistent seizures should be treated with benzodiazepines, and antionvulsants should be started or supplemented. Status epilepticus may require intubation to secure the airway.
• Infections: Infections typically present at least 1 week after surgery and are not an immediate postoperative concern. The child with an EVD placed well before surgery may indeed develop meningitis/ventriculitis. This can be determined by CSF sampling. If an infection occurs, appropriate antibiotics should be started, and consideration should be made to change the catheter. Wound infections, otherwise, may be treated with IV antibiotics, but persistent fevers and concerns for a deeper infection will require CSF (if there is no EVD), an enhanced CT or MRI to look for empyema or abnormal enhancement, and possible surgery for debridement of the brain and perhaps removal of the bone flap if necessary.
• Complications of positioning (decubitus ulcers, skull fractures, CSF leak): Issues because of positioning, such as pressure ulcers, or rigid fixation, such as skull fracture, CSF leak, or epidural hematoma, should be treated appropriately.