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Show all. From the reviews: " Goodrich, JAMA, November "This book provides a one-of-a-kind clinical resource for nursing staff who work with this challenging population of patients. Craniosynostosis Pages Cartwright, Cathy C. Show next xx. Read this book on SpringerLink. Recommended for you. Cartwright Donna C.
PAGE 1. The main complication of operative management in patients with craniostenosis is coping with the inevitable and often significant blood losses occurring during these procedures. This becomes even more important if the fact that the majority of these surgeries are performed on infants is taken into account. Koh 22 , in a non-systematic review on craniostenosis surgical management, identified studies estimating surgery blood loss. Meyer and et al. Kearney et al. Brain tumors in children are great surgical challenges, mainly because they are located in areas difficult to reach in the central nervous system, have large dimensions, and are at risk for sequelae from injury of important brain structures, despite the benign histological character of many of these lesions.
On the other hand, the survival of children with brain tumors has significantly increased in the last years, with most of the patients reaching an adult age Thus, patients with neurological sequelae resulting from the tumor or the surgical procedure itself have higher morbidity over longer periods of time, including cognitive and psychological conditions, epilepsy, strokes, endocrine deficiencies such as diabetes insipidus and panhypopituitarism or tumor relapses. The most frequent nonmetastatic primary tumors in the central nervous system are listed in Table 1 Brain tumor incidence has increased in recent decades, probably due to improvement in imaging diagnosis methods.
The estimated incidence is between 2. In Brazil, few available data elucidate tumor incidence in children.
Nursing Care of the Pediatric Neurosurgery Patient
Argollo et al. Diagnosing brain tumors in a pediatric population is challenging, with several visits to a pediatrician or to emergency rooms being required before the correct diagnosis is made. This is partly due to the low symptom specificity early in the disease course. However, advances in surgical techniques and adjuvant therapies have increased the survival in affected children, as described above.
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Historically, their histological characteristics make these tumors optimal for developing new surgical techniques. Morbidity resulting from radical tumor resection aiming to reduce relapse chances is explained by the close anatomical relationship of craniopharyngiomas with the neurohypophysis and particularly the hypothalamus. The hypothalamic-pituitary dysfunction characterized by panhypopituitarism, obesity, hyperphagia, obsessive search for food, and neuropsychological disorders dramatically affects the children's and family's quality of life Perianesthetic complications in children with brain tumors may also arise from the prone position, as the preferential location of the tumor is the posterior cranial fossa, as described above The pins used in the surgery may cause skull fractures, dural fistulae, and intracranial hematomas.
Gray matter and cranial nerve injuries may also occur, as well as respiratory center injuries, possibly causing postoperative apnea. In Brazil, an epidemiological study conducted by Monteiro et al.
Postoperative meningitis is an important cause for morbidity and mortality after craniotomies. The most frequent infections in these procedures are surgical wound infections, followed by meningitis. Postoperative meningitis causes higher mortality and larger number of neurological sequelae compared with extradural infections. Most authors cannot accurately define the antibiotic prophylaxis efficacy for meningitis, especially because when meningitis occurs in spite of antibiotic therapy, it is usually caused by difficult to treat, resistant organisms.
Postoperative neurosurgical infections have high morbidity rates and they are among the most severe and threatening infections One of the seminal studies on local and systemic antibiotics in preventing infections used an intraoperative regimen of antibiotic prophylaxis consisting of intramuscular gentamicin or tobramycin, intravenous vancomycin, and streptomycin irrigation solution, with no postoperative antibiotics.
Total protection against postoperative infections was achieved in a series of 1, surgical procedures In , Barker et al. To date, only general recommendations for clean neurosurgeries and ventriculoperitoneal shunting were reported, and no consensus was reached regarding the optimal antibiotic class or the optimal administration period. In this analysis, six controlled studies were reviewed, with a total of 1, patients.
Antibiotic use reduced postoperative infection rates in five out of six studies. The combined odds ratio for meningitis occurrence after using antibiotics was 0. Subgroup analysis did not detect differences in antibiotic efficacy whether gram-negative cover was used or not, or for single-blind or double-blind studies. Most cases presenting with postoperative fever have no etiological or topographical diagnosis of infection and they are cause for warning and exhaustive clinical and laboratory investigation for better understanding of the subject Considering postoperative seizure prophylaxis, phenytoin is still the most used drug; however, a high incidence of side effects is found, such as cytochrome P enzyme induction particularly damaging to patients requiring neoadjuvant chemotherapy with hepatic metabolism drugs.
Similarly, carbamazepine and phenobarbital also significantly induce the enzyme system, whereas valproate may result in coagulation and platelet function disorders.
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Recent studies on oral or intravenous levetiracetam have been promising, with a high efficacy in preventing seizures and a low incidence of side effects compared to other antiepileptic drugs 39 ; however, its cost and low availability in Brazil impair the drug use in the current neurosurgical setting. The current consensus establishes that, if a neurosurgical patient has seizures before the procedure, antiepileptic drug therapy is required.
However, drug selection and determination of its administration period, as well as prophylaxis selection in patients without seizures are more complex issues that lack definitive recommendation Seizures may cause severe consequences to the patient not only from neurological sequelae, but also from increased brain oxygen consumption, increased ICP, brain hypoxia, acidosis, and traumatic injuries from falls.
On the other hand, postoperative seizures are rare but drug side effects are common and include cognitive dysfunction, bone marrow suppression, liver failure, and reduced action of chemotherapeutic drugs. The concept of "mandatory" antiepileptic drugs in craniotomies comes from studies conducted almost 20 years ago. In a meta-analysis selecting four randomized and controlled studies on phenytoin use 41 , a trend towards reduced seizures in three out of four trials was observed.
Overall, the odds ratio for seizure occurrence was 0. These data are in contrast with the American Academy of Neurology recommendation, which did not indicate the routine use of such prophylaxis one year before Recent meta-analysis reported by the Cochrane group concluded there was no difference between control and intervention groups in preventing a first seizure in patients with brain tumors The same analysis showed patients on antiepileptic drugs were six times more likely to have adverse effects, and these data further reduced that therapy indication.
Hyponatremia incidence depends on the patient population in the study. Hyponatremia is the most common electrolyte disturbance in patients undergoing neurosurgery. Severe hyponatremia may result in brain swelling and the symptoms reflect its effects on the central nervous system; in addition, the symptom magnitude is related to hyponatremia severity and the fall rate of plasma sodium levels.
Initial symptoms may include headache, nausea, and vomiting; as hyponatremia worsen, mental confusion, seizures, stupor, and coma may develop. Studies show that in adult neurosurgical patients with hyponatremia, mortality is significantly higher and directly related to the electrolyte disturbance severity In neurosurgical patients, hyponatremia is often attributed to one of the following conditions: the syndrome of inappropriate antidiuretic hormone secretion SIADH or the salt-losing brain syndrome The former causes hyponatremia resulting from excessive water retention, whereas the latter is characterized by hyponatremia, polyuria, and dehydration.
Both are described in several neurosurgical settings. Hypothalamic-pituitary axis tumors may course with both complications, whereas tumors out of that axis most commonly course with SIADH. The differential diagnosis between the two clinical conditions described above is fundamental, since treatment strategies are completely different in both syndromes.
Nursing Care of the Pediatric Neurosurgery Patient
In the salt-losing syndrome, volume replacement with an isotonic solution and increased sodium supply are mandatory, given the severe dehydration risk. Clinical and laboratory criteria for differential diagnosis can be found in Table 2. The resection of suprasellar tumors extending to the pituitary stalk can cause loss of pituitary function and consequent impairment in antidiuretic hormone secretion. Craniopharyngiomas are tumors whose main postoperative complication is diabetes insipidus. The absence of ADH secretion promotes hypernatremia due to intravascular solvent loss, polyuria, and dehydration.
Intranasal desmopressin, an ADH synthetic analogue, should be replaced within the first postoperative hours to avoid the described metabolic complications. This medication can also be intravenously or orally used, but the intranasal route is preferred, as it makes dose titration easier, as well as the management of complications resulting from overdose, such as oliguria and dilutional hyponatremia. Postoperative hyperglycemia is common due to surgical stress and release of insulin counter-regulatory hormones, such as catecholamines, glucagon, and cortisol.
Several studies recognize the importance of hyperglycemia in pediatric intensive therapy, increasing the patients' morbidity and mortality during hospitalization. In a neurosurgical setting, hyperglycemia is poorly studied. In a retrospective cohort study, Mekitarian Filho et al. As described above, the finding of fever, mainly within the first 48 hours of the surgical procedure, is very common and has been the subject of extended and costly investigations. Surgical handling of any area of the central nervous system may cause perilesional edema in several grades, impacting the postoperative clinical symptomatology.
Postoperative systemic corticosteroid use is usual in pediatric neurosurgery aiming to reduce complications; however, there is no evidence warranting a benefit from the use of these drugs. Corticosteroid adverse effects, such as hyperglycemia, infection, and slow wound healing are well known, but the role of costicosteroid use on complications is unclear.
In certain surgeries, such as meningioma resection and spine surgical manipulation, deficits may be more common. Hamilton et al.
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In supratentorial tumors, such as gliomas and meningiomas, the findings show a new deficit development in 6. Recognizing the complications in pediatric neurosurgery is fundamental for appropriate patient management during the early postoperative period. The three most common procedures in children are craniostenosis correction, hydrocephalus and ventriculoperitoneal shunting and brain tumor resection, each of them with their most common complications. Bleeding, infection, and sodium disturbances are the more frequently reported complications. Elective neurosurgeries are potentially contaminated procedures in which cephalosporins, especially second-generation cephalosporins, should be used as prophylaxis for 48 to 72 hours.
Antiepileptic drugs are mandatory in early postoperative prescriptions if the patient has had seizures before the procedure. An Pediatr Barc. Piatt JH. Recognizing neurosurgical conditions in the pediatricians office.