外科および臨床実践ジャーナル

Holding back to move forward: Mobilization following posterior fossa neurosurgery

Gaspari Clara

The detrimental impact of immobility is known in the literature. There is a wide variation of specific activity recommendations and when the activity should begin. Increasingly, studies show the need for diagnosis-specific recommendations for protocols. The posterior cranial fossa houses parts of the brain that controls respiration, cardiac cycle, consciousness and balance. In the early post-operative (PO) period following posterior fossa neurosurgery, patients often have episodes of nausea, vomiting, headaches and general discomfort. Due to a significant loss of cerebrospinal fluid (CSF) during this surgery, there is a higher chance of developing these symptoms. Symptoms worsen with the upright posture. Traction and edema around cranial nerve VIII can lead to vestibular symptoms and poor tolerance of positional changes and upright position. The act of vomiting may increase intracranial pressure which could jeopardize hemostasis, cerebral perfusion and increase likelihood of CSF leak. Nausea and vomiting can lead to delayed discharge, thereby increasing medical cost. We believe it is beneficial for these patients to begin mobilization gradually. We have instituted a protocol that ensures a less aggressive mobilization approach immediately following posterior fossa surgery. To compare complications associated with surgical position, a retrospective study was conducted on 260 patients who underwent posterior fossa craniectomy. Data collected from the records included demographic profile, American Society of Anesthesiologists' physical status score, neurological status, cranial nerve involvement, associated medical illnesses, anaesthetic technique, patient position, haemodynamic changes, duration of surgery, venous air embolism (VAE), blood loss/transfusion, postoperative complications, duration of ICU stay, and postoperative neurological status. Statistical analysis was done using the Chi-square test and independent t-tests. The demographic profile and preoperative associated medical illnesses of patients were comparable between groups. The incidence of end-tidal carbon dioxide (EtCO2) detected VAE was more (p=0.00) in the sitting position than the horizontal positions (15.2% vs. 1.4%). Blood loss/transfusion and the duration of surgery were significantly higher in the horizontal position (p<0.05). Brainstem handling was the most common cause of prolonged postoperative mechanical ventilation and was seen more in the sitting position.