34.2.1 Location and Duration of Hospital Stay

After endoscopic skull base surgery (ESBS), patients are routinely monitored in the pediatric intensive care unit (PICU). In the first 24 hours after surgery, ICU care is necessary for neuromonitoring and close assessment of fluid balance and blood pressure. In addition, monitoring of fluid balance (in and out) and frequent serum electrolyte balance is necessary in cases involving manipulation of the pituitary gland and/or stalk to help identify early signs of hormonal dysfunction (diabetes insipidus [DI] and syndrome of inappropriate antidiuretic hormone [SIADH]). Whenever possible, the patient should be extubated immediately following postsurgical imaging (noncontrasted CT immediately performed after surgery), facilitating his/her neurologic assessment. In patients who require mechanical ventilation, we generally stop the sedation to complete a neurologic examination every hour.

The patient should be transitioned to a general surgical floor when neurologic examination, fluid balance, and endocrine function are determined to be stable. This typically occurs on the first or second postoperative day but varies with pathology, surgical approach, and comorbidities. ¹ Similarly, the overall length of stay is dependent on healing time of the surgical site and endocrine control, with lengths of stay ranging from 3 to 7 days in uncomplicated cases. ¹ Complications can greatly extend length of stay.

34.2.2 Pain Control

The objective of pain management following ESBS is to obtain maximum patient comfort while maintaining appropriate responsiveness to ensure a reliable neurologic assessment. The use of oral acetaminophen as a primary analgesic supplemented with narcotics when necessary is the mainstay of treatment. Intravenous narcotic medication is reserved for refractory pain. While adequate pain control is the goal, progressive headaches that do not respond to increasing doses of narcotic analgesics must be thoroughly and closely evaluated for potential risk of cerebrospinal fluid (CSF) leak with concomitant pneumocephalus, and other possible intracranial complications as such as hemorrhage and vasospasm. ²

Narcotics may induce nausea/vomiting and constipation, possibly causing an increase in intracranial pressure (ICP), displacement of the skull base reconstruction, and subsequent CSF leakage. Therefore, narcotic analgesia must be employed judiciously, administering the lowest dosage possible. Stool softeners and nonstimulant laxatives are routinely utilized in the postoperative setting for this purpose.

Nonsteroidal anti-inflammatory drugs are avoided in the postoperative period to minimize the risk of bleeding complications. Nonpharmacologic pain control strategies such as distraction have also shown efficacy in management of acute pain in the pediatric patient; therefore, therapeutic recreation, child life, or similar services can be utilized for this purpose. ³

34.2.3 Diet

Following surgery, the patient’s diet should be routinely advanced to the least restrictive diet as soon as possible. Following posterior fossa intervention with concern for alteration in function of lower cranial nerves, clinical assessment of the safety of swallow is performed before advancing the diet.

Fluid intake monitoring is necessary in patients with DI to prevent significant hyponatremia or dehydration while their medical management is optimized.

34.2.4 Monitoring

Continuous telemetry and pulse oximetry monitoring is utilized in the immediate postoperative period and during the length of stay in the ICU to ensure any changes in hemodynamic stability are quickly identified. Arterial line blood pressure monitoring is typically utilized intraoperatively and continued for the first 24 hours after surgery. After the first postoperative day, the arterial line is removed unless needed for frequent blood draws (as in the case of frequent sodium monitoring), and blood pressure monitoring is continued with cuff pressures. Upon transfer to the postsurgical floor, hemodynamic monitoring should be continued with vital sign measurements every 4 to 6 hours.

Neurologic status is typically assessed every hour in the first 24 hours after surgery and every 4 to 6 hours thereafter. Accurate assessment of neurologic status in the pediatric patient can be challenging due to stranger anxiety, fear of discomfort, and uneasiness in an unfamiliar setting. Patience during this process, establishing rapport, and utilizing examination aids to maintain the patient’s interest are helpful. For example, a small toy with a flashing light can capture the patient’s interest and enable complete visual field examination.

As in adults, sedating medications that could mimic a compromised neurologic condition should be avoided in most pediatric patients following ESBS. In rare instances, patients can become so agitated that they compromise their own postoperative outcome due to straining and Valsalva-like activity. Should this be the case, judicious use of short-acting sedatives is selected, and limitations of the examination are documented.

34.2.5 Imaging in the Acute Period

In the immediate postoperative period, a noncontrasted CT scan is obtained to rule out intracranial complications such as hematoma, subarachnoid bleeding, tension pneumocephalus, or dilated ventricles. This is repeated as needed to follow any finding or to rule out a possible postoperative CSF leak. Postoperative CSF leaks can present with increased pneumocephalus, illustrating the importance of obtaining a baseline scan for comparison. ⁴ Patients who require a staged procedure undergo a CT scan with image guidance protocol (axial fine-cut images [1-mm cuts or thinner] with cuts extending from the vertex to the maxillary incisors).

MRI is also obtained within the first 24 hours (to avoid artifact) to assess neurovascular integrity and adequacy of resection in patients with malignancies, recurrent tumors, and other select pathologies. As a secondary but significant gain, the MRI allows assessment of the multilayer reconstruction and flap placement (▶ Fig. 34.1; ▶ Fig. 34.2).

34.2.6 Nasal Precautions

After ESBS, it is imperative to avoid blind instrumentation of the nose. Clear communication to the nursing staff is necessary to prevent nasal suctioning, placement of nasal trumpets, or placement of nasogastric feeding or other nasal tubes. These interventions could potentially compromise the skull base repair and precipitate a CSF leak or even injure the brain or other neurovascular structures. ⁵ In addition, the patient should be instructed to avoid activities that generate positive or negative pressure in the nose, as pressure changes can lead to pneumocephalus and unnecessarily challenge a skull base repair early in the healing period. Nose blowing and sneezing with mouth closed are avoided for the first 4 to 6 weeks after surgery. Clear explanation to the pediatric patient and his/her caregivers regarding the rationale behind these restrictions and consequences of these behaviors can help improve compliance. Nasal saline should be provided as a replacement for nose blowing.

The use of straws has been debated in the postoperative period due to concern for generation of negative pressure. However, the pressure generated by straw use is similar to that generated during respiration, and the negative pressure with straw utilization is created in the oral cavity with minimal transfer to the nasopharynx. Therefore, straw use is permitted in the postoperative setting.

34.2.7 Activity

Activity level after ESBS is dependent on the extent of skull base defect and type of repair employed.

High-Flow Cerebrospinal Fluid Leak

If a high-flow CSF leak, defined by communication of the operative defect with the ventricular system or more than one cistern, is encountered and repaired (▶ Fig. 34.3), positioning measures as in low-flow CSF leak and the use of stool softeners are employed, but activity is further limited with restriction to bed/chair rest for 3 to 5 days. After the packing/drain securing the repair is removed and the repair is noted to be intact, activity is slowly advanced to mirror that of low-flow CSF leak repair patients.

Related posts:

27 Closure Techniques for the Pediatric Skull Base: Vascularized Flaps 28 Closure Techniques for the Pediatric Skull Base: Multilayer Closure 29 Closure Techniques for the Pediatric Skull Base: Gasket Seal 31 Closure Techniques for the Pediatric Skull Base: Lumbar Drains 30 Closure Techniques for the Pediatric Skull Base: Bilayer Button 32 Complication Management in Pediatric Endonasal Skull Base Surgery

Stay updated, free articles. Join our Telegram channel

Join