Paediatric craniofacial endoscopic strip craniectomy (ESC) with helmet therapy : standard operating procedure

Minimally invasive technique. Incisions will be smallest size to safely perform osteotomies, an endoscope is used for appropriate visualisation.

Strip craniectomy to completely release the affected fused suture to allow for mobilisation of the skull to provide optimal post-operative outcomes following the period of helmet therapy.

Radiology

For all patients a CT scan will be obtained in the pre-operative period.

All patients with the exception of single suture sagittal craniosynostosis will have a post operative CT on day 1. All CT requests should be non-contrast low dose protocol as standard, unless otherwise clinically indicated.

Immediate Post Op Care Plan – Ward 3A

The majority of patients undergoing ESC surgery for craniosynostosis will be nursed in Ward 3A post-operatively. However, some high risk patients with pre-existing airway or respiratory compromise, or other significant co-morbidity, will still require critical care support post-operatively. This will be agreed by the Consultant Surgeon and Anaesthetist in advance of the procedure and a critical care bed booked appropriately.

Ward Nurse Staffing Levels

Patients can be nursed in single room or four bed bay depending on clinical needs.

Handover

Recovery nurse will give a verbal handover to ward nurse with written instructions on the operation note.

Observations

Continuous Sp02 monitoring and a high level of observation for post-operative decline in Glasgow Coma Score or suggestion of intracranial bleeding.

Document HR, BP, Sp02, RR, Temp, CRT and GCS on PEWS chart

• On return from theatre
• ½ hourly for 2 hours
• Hourly for the next four hours
• Then reduce to 2-4 hourly if condition stable

PEWS Policy for MEDICAL REVIEW should be activated at any time if indicated by PEWS score or concern about airway compromise.

Analgesia

Regular IV Paracetamol and Ibuprofen when tolerating milk/diet with PRN Oramorph will be prescribed according to the RHC Acute Pain Protocol. After the first 12-24hrs post op transition to oral paracetamol can be implemented.

Some infants (especially those having sagittal strip craniectomy) may benefit from a bolus only NCA for the 1^st post-operative night, this will be decided based on surgical/anaesthetist assessment.

Antibiotics

A dose of antibiotics will be given at induction of anaesthesia. There is no routine requirement for post-operative antibiotics.

Fluids and Diet Intake

IV access must be maintained for at least 24 hrs

IV maintenance fluids (usually 70% maintenance plasmalyte in 5% dextrose) should be continued from theatre.

Encourage oral fluids and soft diet if weaned, and reduce IV fluids appropriately.

Medical Staff Review and Role of Hospital at Night (HaN)

1. Clinical concerns should be discussed with Neurosurgical Registrar DECT 82164 or via switchboard or PICU (84727) +/- Anaesthesia (84342) immediately if significant airway concern or reduced level of consciousness.
   
   
2. ESC patients will categorised as ‘Amber’ to highlight presence of SOP
   1. For arrival to ward <1645 Mon-Fri
      GPST/ANP add to specialties watcher list and attend 1645 handover
      For OOH ward arrival
      OOH FY2 dect 84869 to be informed, no requirement to review but to allow addition to handover as Amber patient group

Nursing staff will follow usual procedure for OOH review, apply by utilising HaN request on Trak for non immediate concerns (IV access or clinical review) if immediate concerns contact via telephone on dect numbers below.

Hospital at Night Coordinator 85770
HaN Lead Medic 85735 (2100-0900)

3. Craniofacial patients to be flagged up to PICU as Amber patients TBA (to be aware) with a clear plan for escalation in the event of clinical deterioration
   
   

The HaN team do not possess airway skills. They will respond to routine tasks such as requests for re-siting of cannulae, and will of course attend in acute deterioration or emergency situation but they will not be the “decision makers” for the cases overnight.

Guidance for nursing staff in the event of clinical concern regarding craniofacial patients on Ward 3A

Examples of who to contact in the following situations:

1. Reduced level-of-consciousness or suggestion of intracranial bleeding (as indicated by high PEWS score)
   • On-call Neurosurgical Registrar via switchboard (or ext 82164)
   • Request medical review from HaN team DECT 85770 (OOH 85735)
   • Anaesthetic Registrar DECT 84342

2. Signs of airway compromise:
   • Anaesthetic Registrar: DECT 84342
   • PICU Registrar: DECT 84725
   • Inform Neurosurgical Registrar: DECT 82164

Patient will be reviewed by the craniofacial team. Child will be encouraged to eat and drink as able and nursed upright to assist with swelling. Transition any IV pain relief to oral and continue with regular analgesia.

Dressings/head bandage will be removed (if in-situ) to visualise wound, Steri-strips if utilised can remain in-situ for 5-7 days. Wound care advice will be provided by CNS.

Patients can be discharged following craniofacial/neurosurgical review.

Wound review will be completed at 2 weeks post-op by CNS

Initial follow up at craniofacial clinic will be 6 weeks post-op.

Prior to discharge family will be provided with appointment for orthotic department, Clinic 12 RCH.

Treatment will be provided by members of the orthotic department who have completed Orthomerica training and have working knowledge of moulding helmets.

Baseline non-invasive helmet scan pre surgery will be completed for comparison

Post-op helmet scan will be completed 2-4 days post-operatively where the first helmet will be manufactured by Orthomerica

On receipt of helmet in the orthotic department family will be appointed to attend for first helmet fitting. It is the clinical aim to commence orthosis 10-14days post operatively.

Each child will require 2-3 helmets that must be worn for 23hours/day for between 6-18months.

Frequent review and alterations will be provided by orthotic department, timeframes will be guided by clinical need including utilising telephone and virtual options where appropriate.

Baseline anthropometric measurements will be obtained along with updated measurements for comparison at each review.

If suitable for the patient a scan and clinical photography will be taken at Pre-Op, every new helmet fitting and End of treatment. Then at each routine MDT review as per ongoing follow-op pathway.

More scans may be taken as required for orthotic needs and further assessment of progress.

Decision to stop helmet therapy will be made by clinical orthotist for single craniosynostoisis patients. With the following guide.

Sagittal 16mths of age (minimum)

Metopic 14-15mths of age

Unicoronal 16-18mths of age

Multisuture children or children falling outwith these parameters decision to stop orthosis will be combined orthotist and surgical

Data collected will include;

• Age at procedure
• Diagnosis
• Length of stay
• Transfusion requirement
• Pre and post op Hb (if available)
• Day post-op helmet therapy commenced
• Total duration helmet therapy
• Complications (both surgical/orthotic)
• Revision surgery requirements

Ongoing follow up as per usual course in craniofacial service will be provided to allow assessment of long term outcomes. This will be provided at 6 weeks, 6 months, 18mnths of age, followed by age 3, age 5, age 7 age 10 and age 15.