Nursing Care

Placement of growing rods/VEPTR

Lengthening TGR/VEPTR

Length of stay

4–7 days

^aASU – <23 h

Length of surgery

4–5 h

30–60 min

Pre-op labs

CBC, basic chemistry, nutrition panel, T and S, MRSA screen, UA, urine C and S (neuromuscular patients)

MRSA screen

Pre-op tests

PA and lat spine, side bending, traction; CT of the thorax, MRI entire spine, PFT, EKG

PA and lat spine

Tubes placed

2 IVs, Foley catheter, ET tube, central or arterial line, Hemovac, chest tube (VEPTR)

1 IV, ET tube

Pain meds post-op

Dilaudid/MSO4, OnQ, Ativan/Valium

Marcaine in surgery, oxycodone, Tylenol, Zofran for nausea

Return to school

2–4 weeks

3–7 days

^aAmbulatory surgical unit

54.7.1 Preoperative Testing: Initial Surgery

Thorough preoperative planning, teaching, and testing are important for surgery and recovery and to reduce the risk of complications. Preoperative testing can be completed 1–3 weeks before surgery, in most cases.

Preoperative testing usually includes lab work: complete blood count (CBC), type and screen (T and S), and methicillin-resistant Staphylococcus aureus (MRSA) screen. Other labs including basic chemistry, coagulation, nutritional panel, urinalysis (UA), and urine culture and sensitivity (C and S) are usually driven by the patient’s disease process and need.

Radiological examinations include posterior-anterior (PA) and lateral views of the entire spine (AP sitting if the patient is unable to stand), supine right and left maximum bending views, and a traction radiograph before or after the patient is anesthetized. Magnetic resonance imaging (MRI) of the entire spine should be obtained (if it was not completed prior) to rule out intraspinal abnormalities such as tethered cord, congenital components, Arnold-Chiari malformation, or syrinx [10]. The MRI may need to be obtained under sedation or general anesthesia as many of the patients are very young and/or unable to cooperate or hold still for extended period of time. Computed tomography (CT) scan of the thorax assists in assessing for thoracic insufficiency [11].

Consultations and tests from other medical services such as cardiology or pulmonary may be necessary depending on the child’s comorbidities. Surgery may need to be postponed if the patient is not medically cleared for surgery until the cause is determined and treated.

To prevent surgical site infections (SSI), the OCHSPS National Children’s Network developed and utilized a preventative SSI protocol. This consists of MRSA screen (and treatment with mupirocin if warranted), preoperative bathing at home the night before surgery with Dial soap or chlorhexidine, use of chlorhexidine wipes in the pre-op area, antibiotic selection and timing in the operating room with re-dosing schedule, and use of ChloraPrep to prepare the surgical site.

54.7.2 Preoperative Testing: Lengthening Procedures

Most cases are usually considered outpatient; therefore, no lab work except for MRSA nasal screen is necessary; however, this will be up to the individual surgeon’s discretion based on comorbidity issues.

54.8 Perioperative Care

54.8.1 Growing Rods or VEPTR: Initial and Complex Revision Surgery

Once the child is asleep, an endotracheal tube, two large-bore intravenous lines, an arterial central line, and a Foley catheter are placed. After the surgery is completed, a Hemovac, Jackson-Pratt, or chest tube may be placed.

Patients having growing rods placed are positioned prone, usually on a Jackson table. A folded blanket with a gel pad under the thighs keeps the knees free. Two to three blankets with a gel pad are placed under the lower legs to keep toes free and knees flexed. Arms are abducted and the elbows are flexed 90°. Padding or a folded blanket placed under each arm protects the elbows and arms.

Patients having VEPTRs inserted are positioned in the lateral decubitus position with the thoracic area prepped and draped free.

After the initial placement of the growing rods or VEPTR, the orthotist can mold the patient for a TLSO in the operating room while the child is under anesthesia. This allows time for the brace to be completed by the time the patient is ready for discharge.

The nursing care before and after the initial insertion of growing rod(s) or VEPTR is very similar to the nursing care after a posterior spinal fusion. The patient may recover in the pediatric intensive care unit (PICU) or on a patient division, depending on the comorbidity of the patient or at the discretion of the surgeon.

54.8.2 Growing Rods, VEPTR: Lengthening Procedures

Surgical lengthening of the TGR or VEPTR is completed approximately every 6 months. The perioperative care is simpler than the initial placement. Since the procedure is short and there is usually very little blood loss, preoperative lab work or other special tests are usually not necessary except for the MRSA nasal screen. The surgical site infection protocol is also utilized. Only one IV is required along with an endotracheal tube. A Foley catheter is not needed. Positioning in the operating room is the same as with the placement. Injection of ¼–½% Marcaine in the surgical incision after closure makes a significant difference with pain management. Occasionally, one dose of morphine may be needed in the postanesthesia care unit (PACU). Oxycodone and Tylenol are started at home the evening after surgery.

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