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Cranioplasty
Clinical Procedure
 
Aliases:
Vault surgery

Topic aliases are alternate phrasings for a particular topic.


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Cranioplasty is a surgical repair of a defect or deformity of the skull.
It may be performed for congenital conditions such as craniosynostosis.

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Craniosynostosis

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2 large bore intravenous cannulae (2 x 20g usually adequate)

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Central line. 4 fr double lumen CVC, or 5 fr if intravenous cannulae not large enough

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left IJV-line coming out a little sideways seems to kink the least; in to the hilt usually sits at the innom/SVC junction #PH
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Leave CVC in postoperatively. If antifibrinolytics have been used, run fluid through the distal lumen to discourage clots.

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Careful attention needs to be paid to haemodynamics to pick up signs of hypovolaemia and air embolus. Stay alert, minimise distractions

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Patient will require an indwelling urinary catheter

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An oral RAE is usually requested by the surgeons for fronto orbital-surgery.
Reinforced ETT out either nose or left side of mouth if total vault-surgery.

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If heart rate high and blood pressure high: give 1 mcg/kg fentanyl

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Run volatile anaesthetic at 0.8 MAC

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Close attention should be paid to post-operative fluid management Example form from RCH refl.in/25

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#protocol
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If heart rate is high and blood pressure low, give crystalloid or 4% albumin (or even better, run at a CVP just high enough to prevent falls in bp)

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In anaesthetic bay give 20ml/kg bolus CSL/Hartmans solution as catchup fluid for fasting.

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Book cell saver for total vault surgery

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Fronto-orbital surgery blood loss usually about 1 blood volume

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If total vault surgery is being undertaken, thaw a bag of FFP even though it may not be used.

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In total vault surgery, expected blood loss is 1 to 2 blood volumes

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Measured blood loss is unreliable for estimating blood requirements. Use blood pressure and calculated ABL to guide fluid/blood administration.

Calculate estimated blood-volume (EBV):
Prem neonate 90ml/kg;
Term neonate 80ml/kg;
<1 year old 75ml/kg;
1-3yrs old 70ml/kg;
>3 yrs old 65ml/kg

Calculated allowable blood-loss (ABL) to determine at what point you will commence replacing volume with blood rather than crystalloid/colloid. ABL = estimated blood volume x (preop Hb - acceptable Hb)/(preop Hb)

Administer 4% albumin in response to hypotension up to calculated allowable blood loss. Then check Hb & commence blood transfusion, aiming to maintain a Hb >70g/L

Check full blood count and coagulation profile after 2/3 estimated blood volume loss.

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Visit blood bank: check blood has arrived (<5 day old, leukocyte depleted)

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Keep patient warm, measure core temp with rectal thermometer

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CXR to check central line in recovery

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Chapter in Gregory's Pediatric Anaesthesia available on google books.
books.google.com.au/books...

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