Tethered Cord Evaluation and Perioperative Management — Complex Tethered Cord Post-operative — Clinical Pathway: Inpatient and Primary Care

Tethered Cord Evaluation and Perioperative Management Clinical Pathway — Inpatient and Primary Care

Complex Tethered Cord Post-operative

ICU Level of Care (PICU): POD #0 until cleared by Neurosurgical and ICU teams for transfer.

Neuroscience Unit (9S) level of care: Typically, POD #2 when child cleared by Neurosurgical and ICU teams, regardless of floor bed availability.

  • Goals for PICU level of care:
    • Maintain calm child; avoid spinal pressure elevations
    • Wound care PRN
    • Pain management
    • Avoid constipation

ICU Level of Care

Care Management POD #0-1 (ICU Level of Care)
Pain Management
  • Scheduled:
    • Acetaminophen IV or PO x 24 hrs
    • Diazepam IV or PO x 48-72 hrs
    • Ketorolac (avoid in renal disease) IV x 8 doses
    • Dexamethasone per surgeon’s discretion
  • May require dexmedetomidine infusion to maintain calm/flat
  • PRN:
    • Diazepam for spasms
    • Oxycodone for severe pain
Post-op Antibiotic Recommendations
Cefazolin, IV
  • Postnatal Age ≤ 7 days
    • 20 mg/kg/dose every 12 hrs
  • Postnatal Age > 7 days
    • ≤ 2000 g
      • 20 mg/kg/dose every 12 hrs
    • > 2000 g
      • 20 mg/kg/dose every 8 hrs
  • Infants and Children
    • 30 mg/kg/dose every 8 hrs
Post-op UTI Prophylaxis Recommendations Sulfamethoxazole-trimethoprim prophylaxis starts when post-op cefazolin completes and continues until follow-up appointment
Neuro Assessments and Vital Signs
  • Neuro checks and VS q1 hr for first 24 hrs
  • Can decrease frequency based on clinical status
Activity/Physical Therapy Recommendations
  • Flat and calm for 48 hrs
  • Calm most important, allow family to hold smaller children if needed
  • No upright positioning
  • No physical therapy order required
Nutrition
  • Clears and advance as tolerated
  • IV + PO
  • I&O
  • Bowel regimen
Tubes/Drains
  • Monitor JP drainage q4 hrs
  • If JP appears blocked or has no output in 4 hrs, call APP to assess. APP may place order for nurse to strip drain after assessing.
  • Notify Neurosurgery if:
    • Bulb is filling faster than ordered empty time
    • Bulb not holding suction
    • Leakage noted at drain site
    • Child has signs of over drainage (positional headache)
  • Drain falls out: apply pressure dressing gauze and call Neurosurgery
Dressing
  • Maintain incisional dressing until POD #3: Mepilex AG removed by Neurosurgery or Neuroscience APP
  • On POD #3 when dressing removed or if dressing becomes soiled, may remove and begin incision care of: J&J washes BID, then cover with gauze and split Mepilex border
  • Post-operative Neurosurgical Incision Care and Dressings Procedure
Consults, Laboratory
and Imaging
  • Urology Consult POD #0, seen within 24-48 hrs
  • For first 48 hrs based on urology recommendations:
    • Bladder scans
    • Post-void residuals (PVRs)
    • Renal bladder ultrasound (RBUS)
Disposition Planning Transfer to the Neurology service on the Neuroscience Unit (9S) POD #1-2
Discharge Criteria
  • Minimal/no drainage from JP
  • Tolerating PO’s
  • Pain management controlled
  • Family education
Post-discharge Follow-up
  • Neurosurgery RN calls within 72 hrs after discharge, schedule follow-up during call
  • Follow-Up 4-6 wks post-op in Neurosurgery Clinic