Recovery for Cerebral Arteriovenous Malformations in Children

Postoperative Orders

• PICU: Patients should be sent to the PICU after surgery as they will likely require a high level of postoperative care.
• Vital signs: Maintain continuous blood pressure, heart rate, and oxygenation monitoring; maintain strict monitoring of inputs and outputs.
• Blood pressure: Keep normotensive to slightly (<5%) hypotensive to reduce risk of perfusion breakthrough in high-flow lesions.
• Fluids: Isotonic IV fluids (usually normal saline) at maintenance levels. Keep patient euvolemic.
• CSF drainage: If present, we recommend keeping an external ventricular drain at 20 cm above external auditory meatus and monitor output.
• Diet: NPO
• HOB: Bed rest, HOB at 30 degrees.
• Nursing: Maintain age-appropriate normotension and oxygenation. Repeat neurological examination hourly and report changes.
• Medications: These include antihypertensives (e.g., nicardipine, labetalol, and hydralazine), antiepileptics, stool softener, multivitamin, and pain management. Avoid aspirin, nonsteroidal anti-inflammatory drugs, and any long-acting sedating agents unless specific orders are indicated to the contrary.

Postoperative Morbidity

• Perfusion breakthrough: Normal perfusion pressure breakthrough is a phenomenon thought to occur after resection of high-flow AVMs in which the blood previously transmitted through the AVM is redirected to smaller, normal vasculature after the AVM has been removed. The vessels may have been chronically, maximally vasodilated to adapt to competing flow, with subsequent loss of cerebral vasoreactivity. They are unable to handle the increased flow, resulting in brain swelling, increased ICP, seizure, neurological dysfunction, or hemorrhage (100). The problem may be minimized by staged preoperative embolization and rigorous blood pressure control postoperatively.