Awake surgery in pediatric patient

Awake surgery in pediatric patient

Awake brain surgery (ABS) in children remains a subject of controversial debate for the potential psychological limitations that are related to this type of procedure. However, the tolerance and benefits of ABS in adults advocate for increased application of ABS in children.

Literature review

literature review was performed using the MEDLINE(PubMed) electronic database applying the following MeSHterms to the keyword search within titles and abstracts: “awake brain surgery children,” “awake brain surgery pediatric,” “awake craniotomy children,” “awake craniotomy pediatric,” and “awake surgery children.” Of the initial 753 results obtained from these keyword searches, a full text screening of 51 publications was performed, ultimately resulting in 18 eligible articles for this review.

A total of 18 full-text articles reporting the results of 50 patients were included in the analysis. Sixteen of the 18 studies were retrospective studies, comprising 7 case series, 9 case reports, and 2 reviews. Eleven studies were conducted from anesthesiological (25 patients) and 7 from neurosurgical (25 patients) departments. Most of the patients underwent ABS for supratentorial lesions (26 patients), followed by epilepsy surgery (16 patients) and deep brain stimulation (DBS) (8 patients). The median age was 15 years (range 8-17 years). Persistent deficits occurred in 6 patients, (12%), corresponding to minor motor palsies (4%) and neuropsychological concerns (8%). An awake procedure was aborted in 2 patients (4%) due to cooperation failure and anxiety, respectively.

Despite well-documented beneficial aspects, ABS remains mainly limited to adults. This review confirms a reliable tolerability of ABS in selected children; however, recommendations and guidelines for its standardized implementation in this patient group are pending. Recommendations and guidelines may address diagnostic workup and intra-operative handling besides criteria of eligibility, psychological preparation, and coordinated neuropsychological testing in order to routinely offer ABS to children 1).

Case series

Huguet et al., reported the psychological assessment, evaluation algorithm, and outcome of pediatric patients, who underwent ABS for surgical treatment of lesions in eloquent areas. Psychological selection criteria and the specifications of psychological support are described. A retrospective review and analysis of psychological assessment and psychological outcome of pediatric patients, who underwent ABS between 2005 and 2018 at the Department of pediatric neurosurgery, of Hôpital Femme Mère Enfant, was performed. Long-term psychological outcomes are reported. ABS was proposed to 18 children aged between 9 and 17 years and their families. After psychological evaluation of the individual patient and their familial surrounding, five boys and 12 girls (n = 17) were accounted eligible for ABS. They underwent asleep-awake-asleep brain surgery with intraoperative testing. In 16 cases, ABS could be performed as planned. Psychological alterations were postoperatively observed in 3 patients, symptoms of a post-traumatic stress disorder in 1 patient. The precise preoperative evaluation of the risk-benefit ratio in children plays a crucial role in anticipating a good psychological outcome. Professional psychological preparation and support of the child and his or her family are the key elements for successful completion of ABS 2).


Balogun et al., from The Hospital for Sick Children, reported the experience of awake craniotomy and cortical stimulation for epilepsy and supratentorial tumors located in and around eloquent areas in a pediatric population (n=10, five females). The presenting symptom was mainly seizures and all children had normal neurological examinations. Neuroimaging showed lesions in the left opercular (n=4) and precentral or peri-sylvian regions (n=6). Three right-sided and seven left-sided awake craniotomies were performed. Two patients had a history of prior craniotomy. All patients had intra-operative mapping for either speech or motor or both using cortical stimulation. The surgical goal for tumor patients was gross total resection, while for all epilepsy procedures, focal cortical resections were completed without any difficulty. None of the patients had permanent post-operative neurologic deficits. The patient with an epileptic focus over the speech area in the left frontal lobe had a mild word finding difficulty post-operatively but this improved progressively. Follow-up ranged from 6 to 27 months. Pediatric awake craniotomy with intra-operative mapping is a precise, safe and reliable method allowing for resection of lesions in eloquent areas. Further validations on larger number of patients will be needed to verify the utility of this technique in the pediatric population 3).


Ard et al., presented the experience with the use of dexmedetomidine, an alpha2 agonist, in two children undergoing awake craniotomy. General anesthesia with the laryngeal mask airway was used for parts of the procedure not requiring patient cooperation to reduce the duration of wakefulness and abolish the discomfort of surgical stimulation. Dexmedetomidine was used as a primary anesthetic for brain mapping of the cortical speech area. The asleep-awake-sleep technique provided adequate sedation and analgesia throughout the surgery and allowed the patient to complete the necessary neuropsychological tests. This is the first description of the use of dexmedetomidine in pediatric neurosurgery 4).

References

1)

Lohkamp LN, Mottolese C, Szathmari A, Huguet L, Beuriat PA, Christofori I, Desmurget M, Di Rocco F. Awake brain surgery in children-review of the literature and state-of-the-art. Childs Nerv Syst. 2019 Aug 3. doi: 10.1007/s00381-019-04279-w. [Epub ahead of print] Review. PubMed PMID: 31377911.
2)

Huguet L, Lohkamp LN, Beuriat PA, Desmurget M, Bapteste L, Szathmari A, Mottolese C, Di Rocco F. Psychological aspects of awake brain surgery in children-interests and risks. Childs Nerv Syst. 2019 Jul 27. doi: 10.1007/s00381-019-04308-8. [Epub ahead of print] PubMed PMID: 31352575.
3)

Balogun JA, Khan OH, Taylor M, Dirks P, Der T, Carter Snead Iii O, Weiss S, Ochi A, Drake J, Rutka JT. Pediatric awake craniotomy and intra-operative stimulation mapping. J Clin Neurosci. 2014 Nov;21(11):1891-4. doi: 10.1016/j.jocn.2014.07.013. Epub 2014 Oct 1. PubMed PMID: 25282393.
4)

Ard J, Doyle W, Bekker A. Awake craniotomy with dexmedetomidine in pediatric patients. J Neurosurg Anesthesiol. 2003 Jul;15(3):263-6. PubMed PMID: 12826975.

Nursing Care of the Pediatric Neurosurgery Patient

Nursing Care of the Pediatric Neurosurgery Patient

Nursing Care of the Pediatric Neurosurgery Patient

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This updated third edition is a detailed reference for nurses and other health care providers who care for children with neurosurgical conditions. The explanations of pathophysiology, anatomy, neurodiagnostic imaging, and treatment options for each neurosurgical diagnosis will help to clarify the rationale behind the nursing care. Descriptions of presenting symptoms, history and findings on neurological examination will help nurses understand the neurological disorder and identify problems. New chapters have been added on skull and scalp anomalies, pediatric concussion, abuse head trauma and on neuroimaging. Each chapter includes case studies, impact on families, patient and family education, and practice pearls. Staff and student nurses working in clinics, critical care units, pediatric units, operating rooms, post-anesthesia care units, emergency departments, and radiology departments will benefit from the information presented. Although this book is written for nurses, child life therapists, physical and occupational therapists, medical students and neurosurgery residents will also find it helpful. Parents of children with neurosurgical disorders will also find it a useful resource in understanding their child’s condition.


Product Details

  • Published on: 2017-04-28
  • Original language: English
  • Number of items: 1
  • Dimensions: 10.25″ h x 7.25″ w x 1.50″ l,
  • Binding: Hardcover
  • 613 pages

Editorial Reviews

Review
From the reviews:
“…The attributes of this text result in a much wider appeal than to just pediatric neurosurgical nurses. This book will prove useful to anyone remotely interested in pediatric neurosurgery. I have no hesitation in recommending a copy be in every neurosurgical residency library. Hospitals will find this a useful textbook reference to place on the pediatrics floors for nurses and pediatric house staff to be able to quickly and concisely review any of the various neurosurgical subjects along with appropriate surgical interventions. Libraries will find this book is a must addition if they have patrons interested in neurosurgery. My only caveat is that I suspect this book will have a high disappearance (ie, “borrowing”) rate due to its value as a great educational tool.” (J.T. Goodrich, JAMA, November 2007)
“This book provides a one-of-a-kind clinical resource for nursing staff who work with this challenging population of patients. In addition to the easy-to-read text, this book includes 119 figures and 61 tables of valuable information to enhance nursing practice. … is written for nurses who are for pediatric neurosurgery patients but is also a tremendous reference for students and others in the healthcare profession. … This book will be a tremendous resource for me, and for the patients and staff with whom I work.” (Julie A Warren, Doody’s Review Service, August, 2007)
“The architecture of the book, subdivided in 12 multi-authored chapters, is quite solid, each contribution offering the basic knowledge necessary to understand the pathophysiology of a given disease, the essential of the surgical management, and the nurses’ considerations. Each chapter is nicely illustrated and enriched by numerous tables aimed at illustrating specific points, as well as providing further sources of information when needed … . Although this book is written by nurses, also medical students and neurosurgeons in training will find its reading quite useful.” (Concezio Di Rocco, Child’s Nervous System, Vol. 23, 2007)
From the Back Cover
This updated third edition is a detailed reference for nurses and other health care providers who care for children with neurosurgical conditions. The explanations of pathophysiology, anatomy, neurodiagnostic imaging, and treatment options for each neurosurgical diagnosis will help to clarify the rationale behind the nursing care. Descriptions of presenting symptoms, history and findings on neurological examination will help nurses understand the neurological disorder and identify problems. New chapters have been added on skull and scalp anomalies, pediatric concussion, abuse head trauma and on neuroimaging. Each chapter includes case studies, impact on families, patient and family education, and practice pearls. Staff and student nurses working in clinics, critical care units, pediatric units, operating rooms, post-anesthesia care units, emergency departments, and radiology departments will benefit from the information presented. Although this book is written for nurses, child life therapists, physical and occupational therapists, medical students and neurosurgery residents will also find it helpful. Parents of children with neurosurgical disorders will also find it a useful resource in understanding their child’s condition.
About the Author

Cathy C. Cartwright, MSN, RN-BC, PCNS, FAAN is a Pediatric Clinical Nurse Specialist and Director of Advanced Professional Practice at Children’s Mercy Hospital, Kansas City, Missouri. Prior to this position, she worked at the Children’s Hospital, University Hospitals and Clinics, Columbia, Missouri in a variety of positions, including Pediatric Clinical Nurse Specialist in Neurosurgery, Manager of Pediatric Services, Pediatric Outreach Coordinator, and Manager of the Pediatric Intensive Care Unit. She has received many awards, including the 2015 Magnet Nurse of the Year for Exemplary Professional Practice, an Excellence in Advanced Practice Award from the American Association of Neuroscience Nurses, March of Dimes Future of Nursing Award (Pediatric) and a Circle of Excellence Award (Management). She was President of the American Association of Neuroscience Nurses in 2009-10, having previously served on its Board of Directors. She has an extensive publication record and has given numerous national and international presentations.
Donna C. Wallace is currently a Pediatric Nurse Practitioner in the Neurosurgery Division of Banner Children Specialists, at Cardon Children’s Medical Center in Mesa, Arizona. Prior to that, she was a Nurse Practitioner for 16 years at the Barrow Neurological Institute in Phoenix, Arizona. Ms. Wallace has been a manager, and has also held several teaching positions. She has received several awards including the Mary Decker Mentorship Award, and the Excellence in Advanced Practice Award, from the American Association of Neuroscience Nursing (AANN). Additionally, she has served on the AANN Board of Directors.  Her passion for writing has resulted in numerous articles and lectures.

Book: Neurotrauma Management for the Severely Injured Polytrauma Patient

Neurotrauma Management for the Severely Injured Polytrauma Patient

Neurotrauma Management for the Severely Injured Polytrauma Patient
List Price : $129.00
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This text addresses many of the questions which occur when medical professionals of various disciplines interact and have different plans and interventions, each with its own valid scientific and/or experience-based rationale:  Questions involving tourniquet placement, ideal fluids and volumes for resuscitation, VTE prophylaxis and many other management considerations. Straightforward decisions in the patient with a single diagnosis often conflict when applied to the neurologically injured polytrauma patients.

 Neurotrauma Management for the Severely Injured Polytrauma Patient answers as many of these questions as possible based on the current literature, vast experience with severe neurotrauma in the current conflicts in Afghanistan and Iraq, and the experience of trauma experts across the globe as well as proposes areas for future study where answers are currently less clear.

Product Details

  • Published on: 2017-01-13
  • Original language: English
  • Number of items: 1
  • Dimensions: 10.00″ h x .0″ w x 7.00″ l, .0 pounds
  • Binding: Hardcover
  • 340 pages

James M. Ecklund, M.D., F.A.C.S. serves as Chairman of the Inova Neuroscience Institute. Prior to joining Inova Medical Group, he served as Professor and Chairman of the Neurosurgery Program of the National Capital Consortium, which includes Walter Reed Army Medical Center, National Naval Medical Center and the Uniformed Services University. He is a retired colonel in the U.S Army and was deployed as a Neurosurgeon to both Afghanistan and Iraq. His program received the vast majority of American neurotrauma casualties.

Dr. Ecklund’s primary clinical and research interests include complex spine, cerebrovascular disease and neurotrauma with an emphasis on blast and penetrating injury. He directs a neurotrauma laboratory at the Uniformed Services University, has over 100 publications and abstracts, and has lectured throughout the world. He also has served on multiple oversight and advisory boards for the Veterans Administration, Department of Defense, National Institutes of Health, NATO, Neurotrauma Foundation, and Brain Trauma Foundation.

Leon E. Moores, MD, MS, FACS is the CEO of Pediatric Specialists of Virginia and the Associate Chair for Pediatric Programs at the Inova Neuroscience Institute. He retired as a Colonel from the US Army where he led as an Infantry Platoon Leader, Chief of Neurosurgery at Walter Reed, Chairman of the Department of Surgery at Walter Reed, Deputy Commander of the National Naval Medical Center, and Commander of the Fort Meade Medical System. Dr Moores also served two tours of duty in Afghanistan and Iraq.
Dr Moores’ clinical and research interests center on brain and spinal tumors in children, CNS infections in combat soldiers, and complex craniofacial reconstruction in severe head and facial trauma. He is a Professor of Surgery and Pediatrics at the Uniformed Services University, and a Professor of Neurosurgery at Virginia Commonwealth University.
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