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This SOP covers the initial management of children that have recently undergone craniofacial surgery.
Post-operative craniofacial surgery patients.
Paediatric critical care staff.
The majority of craniofacial cases will be extubated in recovery and will be admitted to a critical care setting (usually HDU) for 24 hours observation.
Some craniofacial patients may have a difficult airway either secondary to an underlying syndrome and/or secondary to hardware placed at surgery.
a) Identify any potential risk factors with anaesthetics at handover.
b) If headgear is in place: make a contingency plan with anaesthesia and surgeons for the rare occasion when an emergency re- intubation is required. Ensure appropriate equipment is at the bedside in order to facilitate this.
Craniofacial surgery can be associated with substantial blood loss particularly in young children.
All children will return with an arterial line in-situ.
The majority of patients will return with a sub-galeal (scalp) drain in-situ (see image) and pressure bandage. If bleeding from pressure dressing contact Cons. Surgeon.
The drain must never be re-vacced. Occasionally the drain will not be vacced at surgeon discretion. If bandage falls off - replace
Monitor closely for signs of continuing blood loss: High drain losses, tachycardia, cool peripheries, poor U/O. A urinary catheter should be in-situ.
Tachycardia –Common. Consider if secondary to pain, blood loss, pyrexia, too tight bandage, blocked catheter etc. Some patients remain tachycardic for 24 hours
Patients should be nursed at 45o.
Neurological examination documented and neurobservations commenced.
An uncommon but important complication of surgery is clot formation (scalp /extra-dural/subdural). Therefore need to be vigilant with neuro-obs. Important changes are rarely subtle.
It is particularly important to assess and document pupil reaction. Craniofacial cases inevitably develop marked diffuse bruising and swelling of eyes in the first 24 hours which subsequently makes pupil assessment impossible.
Any changes in neurology should be taken seriously. The Consultant neurosurgeon should be informed and CT scan arranged.
Monitor for any evidence of CSF leak (nose). Contact Cons. Surgeon.
Patients usually arrive with a standard morphine NCA/PCA for first 24 hours.
Regular paracetamol is prescribed. Ibuprofen can be added in addition.
0.9% saline is standard IV fluid (+/- dextrose) – 70% restricted
Patients are encouraged to eat and drink as usual as soon as they feel able to.
Flucloxacillin 25mg/kg is prescribed for a further 2 doses post-op.
(Teicoplanin 10mg/kg if allergic)
At surgical discretion- see operation note.
FBC, U&E, coagulation screen and gas is performed on admission.
PRN ondansetron prescribed. However remember vomiting can be associated with raised ICP.
It is not unusual to develop a pyrexia in the first 24 hours. First step should be to remove tight head bandage. Re-bandage with light dressing, then consider other causes.
Last reviewed: 03 November 2015
Next review: 12 August 2018
Author(s): Anne McGettrick
Approved By: Clinical Effectiveness
Reviewer Name(s): Paediatric Clinical Effectiveness & Risk Committee