Pyrexia after Transcranial Surgery

Utility of Postoperative Fever Workup After Craniosynostosis Repair

BACKGROUND

Craniosynostosis is the premature fusion of ≥1 cranial sutures. Surgical management involves early cranial vault reconstruction. Postoperative management of these patients is often complicated by fever of unknown origin and results in additional laboratory studies, extended hospital intensive care unit stays, and increased cost to the patient.

METHODS

A retrospective analysis of 70 consecutive patients who underwent cranial vault reconstruction were included. Postoperative fever (Tmax), length of stay, transfusions, estimated blood loss, and white blood cell counts were obtained, as well as blood, urine, and other culture data.

RESULTS

Mean age at surgery was 1.1 years. Sixty (86%) patients had idiopathic postoperative fevers >38°C. Of those, 20% underwent fever workups, none of which returned a positive culture or concern for pneumonia. Length of stay was significantly increased in patients who had fever workups (6.1 days vs. 4.7, P < 0.001). There was no significant difference in age, estimated blood loss, T_max, white blood cell count, and day of postoperative fever between groups. The average estimated cost of a fever workup at our institution is $1288 (U.S. dollars).

CONCLUSIONS

Fever of unknown origin is a common finding after craniosynostosis repair. Workup for fever of unknown did not result in the identification of an infection and added significantly to the cost and patient's length of stay.

Intensive care unit course of infants and children after cranial vault reconstruction for craniosynostosis

BACKGROUND

Craniosynostosis (CSS) results from the premature closure of one or more cranial sutures, leading to deformed calvaria at birth. It is a common finding in children with an incidence of one in 2000 births. Surgery is required in order to release the synostotic constraint and promote normal calvaria growth. Cranial vault remodeling is the surgical approach to CSS repair at our institution and it involves excision of the frontal, parietal, and occipital bones. The purpose of this article is to describe the post-operative course of infants and children admitted to our PICU after undergoing cranial vault remodeling for primary CSS.

FINDINGS

Complete data was available for analyses in only 82 patients, 44 males (M) and 38 females (F); M: F ratio was 1:1.2. Patients (pts) age in months (mo) ranged from 2 mo to 132 mo, mean 18.2 ±-24.9 mo and weights (wt) ranged from 4.7 kg to 31.4 kg, mean 10.24 ± 5.5 Kg.. Duration of surgery (DOS) ranged from 70 minutes to 573 minutes mean 331.6 ± 89.0 minutes. No significant correlation exist between duration of surgery, suture category, patient's age or use of blood products (P > 0.05). IOP blood loss was higher in older pts (P < 0.05) and it correlates with body temperature in the PICU (P < .0001). Post-op use of FFP correlated with intra-operative PRBC transfusion (P < 0.0001). More PRBC was transfused within 12 hrs-24 hrs in PICU compared to other time periods (P < 0.05). LOS in PICU was < 3 days in 68% and > 3 days in 32%. Pts with fever had prolonged LOS (P < 0. 05); re-intubation rate was 2.4% and MVD were 1.83 days. Repeat operation for poor cosmetic results occurred in 9.7% of pts.

CONCLUSIONS

Post-op morbidities from increased use of blood products can be minimized if cranial vault remodeling is done at a younger age in patients with primary CSS. PICU length of stay is determined in part by post-op pyrexia and it can be reduced if extensive evaluations of post-op fever are avoided.

Temperature course after transcranial surgery for Apert syndrome: a possible indicator for postoperative complication

BACKGROUND

Pyrexia after surgical procedure is a commonly observed phenomenon. However, it is not easy to distinguish pyrexia related to a postoperative complication from the normal temperature increase after surgery. The aims of this study were to establish a normal template for postoperative temperature course after transcranial surgery in patients with Apert syndrome and to investigate the correlation between the pattern of temperature increase and etiological factors.

METHODS

Seventy-seven sequential case notes of patients with Apert syndrome were retrospectively reviewed to collect postoperative temperature courses. The mean change of temperature was plotted on a graph with trend line to compare the feature of the course in each possible factor. A separate group of those who underwent fronto-orbital advancement was independently evaluated.

RESULTS

The temperature course had a bimodal distribution during the first 48 hours. However, those who underwent longer surgery, fronto-facial advancement, or those accompanied by complication seemed to have the more obvious third temperature peak around 50 hours postoperatively. This finding was also true in the independent fronto-orbital advancement group. Temperature courses without postoperative complication seemed to have bimodal distribution of temperature course; on the other hand, those with postoperative complication seemed to have the obvious third temperature peak around postoperative 50 hours.

CONCLUSIONS

Together with our previous study, it was concluded that pyrexia after transcranial surgery had a bimodal distribution as a normal course within the first 48 hours postoperatively. Moreover, it was suggested that the third temperature peak around 50 hours postoperatively could be an indicator for a postoperative complication.

Pyrexia after transcranial surgery for Pfeiffer syndrome

BACKGROUND

Previously, we have reported the pattern of temperature increase after transcranial surgery for nonsyndromic craniosynostosis. It was found that pyrexia had a bimodal distribution during the first 48 hours after surgery.

AIM

The aims of this study were to evaluate pyrexia after transcranial surgery for syndromic craniosynostosis (Pfeiffer syndrome), to investigate whether the same pattern occurred, and to evaluate the correlation between pyrexia and possible factors, that is, sex, age, procedure, length of surgery, and incidence of postoperative cerebrospinal fluid (CSF) leakage.

METHOD

Twenty-one sequential case notes of Pfeiffer syndrome were retrospectively reviewed to collect 38 postoperative temperature courses. The mean change of temperature was plotted on a graph with a trend line to find the feature of the course.

RESULTS

Pyrexia after transcranial surgery for Pfeiffer syndrome had a bimodal distribution during the first 48 hours, similar to the pyrexia after transcranial surgery for nonsyndromic craniosynostosis. This pyrexia was higher and more prolonged in those undergoing a longer surgical procedure and frontofacial advancement and procedures accompanied with postoperative CSF leakage. Moreover, the temperature course was more complex in procedures accompanied with postoperative CSF leakage.

CONCLUSIONS

It was concluded that in Pfeiffer syndrome, which has more complicated pathologic status than nonsyndromic craniosynostosis, also had bimodal postoperative temperature course. Although the etiology of the bimodal pyrexia remains unclear, it seems that it is part of the normal postoperative course in these cases. However, prolonged raised temperature within the first 48 postoperative hours may suggest a complication.

Complications in the surgical treatment of craniosynostosis and craniofacial syndromes: apropos of 306 transcranial procedures

OBJECTIVE

To review the complications in the surgical treatment of craniosynostosis in 306 consecutive transcranial procedures between June 1999 and June 2007.

PATIENTS AND METHODS

Surgical series consist of 306 procedures done in 268 patients: 155 scaphocephalies, 50 trigonocephalies, 28 anterior plagiocephalies, one occipital plagiocephaly, 20 non-syndromic multisutural synostosis and 32 craniofacial syndromes (11 Crouzon, 12 Apert, seven Pfeiffer and two Saethre-Chotzen) Complications and time of hospitalisation were reckoned. Surgical procedures were classified in 12 different types according to the technique: Type I: frontal-orbital distraction (26 cases); Type II: endoscopic assisted osteotomies in sagittal synostosis (39 cases); Type III: sagittal suturectomy and expansive osteotomies (44 cases); Type IV: same as type III, but including frontal dismantling or frontal osteotomies in scaphocephalies (59 cases); Type V: complete cranial vault remodelling (holocranial dismantling) in scaphocephalies (13 cases); Type VI: frontal-orbital remodelling without frontal-orbital bandeau in trigonocephaly (50 cases); Type VII: frontal-orbital remodelling without frontal-orbital bandeau in plagiocephaly (14 cases); Type VIII: frontal-orbital remodelling with frontal-orbital bandeau in plagiocephaly (14 cases); Type IX: Occipital advancement in posterior plagiocephaly (one case); Type X: Standard bilateral front-orbital advancement with expansive osteotomies (28 cases); Type XI: holocranial dismantling (complete cranial vault remodelling) in multisutural craniosynostosis (12 cases); Type XII: occipital and suboccipital craniectomies in multiple suture craniosynostosis (six cases).

RESULTS

There was no mortality and all complications resolved without permanent deficit. Mean age at surgery was 6.75 months. Most frequent complication was non-filiated postoperative hyperthermia (13.17% of the cases) followed by infection (8.10%), subcutaneous haematoma (6.08%), dural tears (5.06%) and cerebrospinal fluid (CSF) leakage (2.7%). Number and type of complications was higher among the group of reoperated patients (12.8% of all): 62.5% of all the series infections, 93% of all dural tears and 75% of all CSF leaks. In relation to surgical procedures, endoscopic assisted osteotomies reported the lowest rate of complications, followed by standard frontal-orbital advancement in multiple synostosis, trigonocephalies and plagiocephalies. Highest number of complications was related to complete cranial vault remodelling (holocranial dismantling) in scaphocephalies and multiple synostoses and after the use of internal osteogenic distractors. Special consideration deserves two cases of iatrogenic basal encephaloceles after combined frontal-facial distraction. Finally, we establish considerations based on the complications related to every specific technique.

CONCLUSIONS

Percentage and severity of complications relates to the surgical procedure and is higher among patients going for re-operation. Mean time of hospitalization is also modified by these issues.