Wednesday 25 march
Preoperative Diagnosis: Cerebral edema, status post evacuation of epidural hematoma.
Postoperative Diagnosis: Cerebral edema, status post evacuation of epidural hematoma.
Procedure Performed: Placement of left frontal ventricular catheter, ventriculostomy through twister.
Anesthesia: Phenobarbital coma, plus local 1% lidocaine with epinephrine.
Indications: The patient is a 13-year-old who, following a bicycling accident, was found to have skull fracture and right epidural hematoma. He was en route to the hospital when the epidural
hematoma blossomed. He went into a coma, was intubated, was taken directly from the ambulance to CAT scan, where it was confirmed there was a huge clot. He was taken down to the operating room
immediately, which was prepared for him. The hematoma was evacuated promptly. He had a problem with increased pressure and coagulopathy. He had a hematoma along the catheter track on the right side
parenchymal catheter. Once the coagulopathy was controlled, the catheter was removed. The patient was taken off phenobarbital to see how he was generally doing, in hope that his white count and CAT
scan were looking good. Once phenobarbital was sufficiently weaned, he developed cerebral edema. He was being followed with CT scans twice daily. The CT scans showed increased edema. I discussed
the problem with the family, the concerns about placing another catheter, of infection, bleeding, paralysis, and seizures. The family understood and requested the following be performed.
Details of Procedure: The patient was in the pediatric intensive care unit. Hair was shaved and now, on the left side, skin was shaved and prepped with alcohol and then Betadine, and the paint was
allowed to dry. After careful draping, the parasagittal incision was made approximately 3 cm left of center, about 9 to 10 cm back from the mid pupillary line from the glabella, and this was taken
down to the bone. Heiss retractor was placed, and the twister was used to make the twist hole.
The dura was incised and bone was removed with forceps. Then the 35-cm ventricular catheter was advanced into the lateral ventricle without difficulty. CSF came out under what appeared to be
elevated pressure; it was clear. This was then tunneled laterally and then the slack was taken out of the system. The hub was then placed and secured with 3-0 Prolene and connected to a Becker
drainage system, which was primed, and the intracranial pressures were running 39 to 43.
The wound was closed with running 3-0 Prolene in a single layer and then the ventricular cavity was secured at the exit point with 3-0 Prolene. Sterile dressing was applied. We were able to drain
CSF from the cavity, but after a few drops came out, it would slow down. As a result, we went back to the monitor and plan to continue this pattern to keep the catheter open. There were no
By VINOD NAIR