Recovery From Surgery for Hydrocephalus After Intraventricular Hemorrhage in Infants

Postoperative Orders 

• ICU vs. standard care unit: When the newborn is at a clinical status to tolerate the insertion of a ventriculoperitoneal shunt with minimal risk, he or she is fit to be transferred to a standard care unit.
• VS: Heart rate: 120 – 160/min; respiratory rate: 40 – 60/min; apnea alarms set to 20 sec; oxygen saturation: < 94% for infants younger than 32 weeks (danger of hyperoxia); – temperature: 36.5 – 37.50C
• BP parameters: In the ICU invasive blood pressure monitoring from an indwelling peripheral or umbilical arterial line is the preferred method for any unstable infant. Otherwise, blood pressure should be monitored noninvasively for all infants, taking care to use the correct cuff size.
• IV fluid and rate: Maintenance: 4 ml/kg/hour; NaCl 0.45% + 5% dextrose or NaCl 0.9%
• Ventilator support: Infants who have recently become independent may require a period of assisted ventilation. Some anesthetists would intubate for transfer purposes.
• ICP parameters: If an EVD was placed, the maximum ICP should be 12 mmHg. Otherwise, there should be close monitoring of anterior fontanelle tension and head circumference increase rate.
• CSF drainage parameters/drainage bag setup: CSF drainage is related to the setting of the bag. Aim for 2 ml/hour (maximum 5 ml/hour) for premature infants. This rate is usually achieved at a 5 to 2 cmH20 setting. Very careful nursing is needed with written instructions at bedside. The drain is clamped when the baby is transferred, fed, or cries for prolonged periods (e.g., punctures or other bedside procedures).
• Diet: Oral feeding (usually formulas) can restart 3–4 hours after an uncomplicated ventriculoperitoneal shunt insertion.
• HOB, positioning, activity, bathing: The head of the bed should be positioned from 0 to 30 degrees after ventriculoperitoneal shunt placement. If there is evidence of overdrainage (constantly sunken fontanelle or suture overriding), a Trendelenburg position can be chosen. Avoid prolonged pressure over shunt hardware due to the risk of decubitus ulcerations. Bathing may be begun with smooth massage 3 days postoperatively.
• Medications and dosages including PRN drugs: Antibiotics are rarely used postoperatively. Pain control: Morphine (IV 0.1 mg/kg) to an intubated infant; codeine (oral 1 mg/kg), paracetamol (oral 15 mg/kg) to a term baby.
• Laboratory studies: Routine postoperative laboratory tests. If an EVD or a ventricular access device has been placed, CSF samples should be taken 2 times/ week for microbiology and sensitivities (MC&S) and basic biochemistry studies (protein, glucose).
• Radiology studies: Cranial ultrasound scan (first postoperative day) and then one prior to discharge in cases of ventriculoperitoneal shunts. Some surgeons perform shunt series (x-rays) immediately after surgery for baseline or even a CT scan (67).

Postoperative Morbidity

• Usually none