Tumour craniotomy: standard operating procedure (SOP)

1. Admit patient under appropriate Consultant Neurosurgeon

The majority of cases will be extubated in theatre and will be admitted to a critical care setting (usually level 2) for 24 hours observation. Possible exceptions:

• Reduced coma scale +/- ventilation pre-op
• Extended cases (>12hours)
• Some posterior fossa operations if tight control of BP is needed
• High likelihood of bulbar dysfunction

Patients should be nursed in a 30-45° head up tilt.

2. Airway, breathing

The majority of post-op tumour craniotomy patients have been previously well and should not present any difficulties with the airway post-op. Some posterior fossa operations may have bulbar dysfunction (problems with swallowing) and could be at increased risk of aspiration. Very occasionally macroglossia (large tongue) can develop in patients who have been proned for prolonged periods.

3. Cardiovascular

Neurosurgery can be associated with substantial blood loss (> 1 blood volume), particularly in young children. Most of this blood loss is intra-operative.
All children will return with an arterial catheter in-situ, and most with a central venous catheter (CVC).
Some patients will return with a sub-galeal (scalp) drain in-situ and occasionally a pressure bandage. The drain may or not be under suction, at the Neurosurgeon’s discretion. Drain losses are usually minimal. If blood loss is excessive, the Neurosurgeon should be informed. If there is any suggestion of CSF leak (clear fluid) in the drain, through the bandages or other sites (e.g. nose), the Neurosurgeon should be informed immediately. 

• Post-op bleeding is unusual in craniotomy for tumour and usually presents with a reduction in conscious level (due to effects on ICP) before cardiovascular changes due to hypovolaemia. However, the patient should be monitored closely for signs of continuing blood loss: high drain losses, tachycardia, cool peripheries, poor U/O. A urinary catheter should be in-situ.

• Hb should be kept above 70 g/l. Patients will be transfused up during surgery. FBC and coagulation screen (including fibrinogen) should be repeated on return from theatre.
Tachycardia is common. ? secondary to pain, blood loss, pyrexia, too tight bandage, blocked urinary catheter, EVD not opened/set at appropriate height. 
Some patients remain tachycardic for > 24 hours.
Hypertension is less common and may indicate a complication such as a post- operative intra-cerebral haematoma.

4. Neurology

Neurological examination documented and neuro observations commenced.
An uncommon but important complication of surgery is post-operative haematoma (either intracerebral or extradural/subdural). Any deterioration in the coma scale should be taken seriously. A CT scan should be performed and the Consultant Neurosurgeon informed.

Basic Neuro obs (these may be extended if there are ongoing concerns):

• Every 30 mins for the first 4 hours
• Every hour for the next 4 hours
• Then 2 hourly

It is particularly important to assess and document pupil reaction and monitor for any pupil asymmetry. Some patients may already have a documented pupil asymmetry from pre-op, or from theatre.

The patient may have an external ventricular drain (EVD) sited as part of the operation. The height this is to be set at should be confirmed with the Neurosurgeon at handover. Care should be taken to maintain the EVD at this height if the bed height changes. See EVD guideline.

A high urine output may be a sign of Diabetes Insipidus. The urine should be dipsticked for specific gravity. Plasma Na+ should be re-checked (U+E’s) and paired samples of plasma and urine osmolality taken. See Diabetes Insipidus guideline.

5. Pain management

Craniotomy patients usually require IV morphine for at least the first 24 hours. This will be by infusion (usually at 10 to 20 μg/kg/h) or NCA/PCA depending on the age of the child. Regular I.V. paracetamol is prescribed. NSAIDs can be added, usually on the 2nd post-op day. NSAIDs can sometimes be added sooner but this should only be done after discussion with the Neurosurgeon.

6. Fluids

Plasmalyte-148 is standard IV fluid (+/- dextrose), usually restricted to about 70% calculated maintenance rate.
Patients are encouraged to eat and drink as usual as soon as they feel able to. The exception to this is if bulbar function may be disturbed. This will be passed on at the handover if thought to be likely. If the patient has D.I., then free access to oral fluids (jug of water or juice at bedside) is usually advised. 

7. Antibiotics

Most patients do not require further antibiotics, but sometimes 2 post-op doses are prescribed at the Neurosurgeon’s discretion. Standard treatment is Cefuroxime 50 mg/kg (Teicoplanin 10 mg/kg if allergic).

8. Steroids

Most tumour patients will be on steroids (usually dexamethasone). This should continue at the dose prescribed pre-operatively. If the child is unable to take oral medication then they should receive it IV.

9. Bloods

FBC, U&E, coagulation screen (including fibrinogen) and ABG are performed on admission.

10. Vomiting

Regular IV ondansetron should be prescribed. If severe, cyclizine should be added in. Dexamethasone should not be used solely as an anti-emetic unless this has been discussed with the Neurosurgeon.

11. Thromboprophylaxis

Prescribe mechanical devices (e.g. ‘FloTrons’ & TEDS) in all post-pubertal patients. Anticoagulation (with LMWH or UFH) is not appropriate immediately after neuraxial surgery.

1. Morning bloods: FBC, U&E, coagulation screen and ABG.

2. TPR and Neuro-obs (4 hourly for 48 hours)

3. Remove arterial catheter and urinary catheter if stable. Remove CVC if adequate peripheral access available, and repeated blood sampling (e.g. patients with DI) is not anticipated.

4. Following Neurosurgical review – discharge to ward.
The decision about removing drains will be taken by the Neurosurgeon.

5. Morphine PCA/NCA can usually be discontinued. Regular paracetamol should be prescribed, with NSAID from the 2nd post-operative day. Oramorph prn.

6. Mobilise

7. Patient will be discharged to ward 3A – to be discussed with the Neurosurgical Team and ward doctor.

8. Ensure post-op management nursing plan paperwork sent with discharge.