What are the guidelines for performing a burr hole in pediatric patients?

From the Guidelines

Burr holes in pediatric patients should be performed by neurosurgeons or properly trained physicians in emergency situations, with specific anatomical considerations for the developing skull, and adherence to guidelines for sedation and airway management, as outlined in the most recent and highest quality studies, such as those published in 2019 1.

Key Considerations

• The procedure requires appropriate sedation or general anesthesia, with dosing adjusted for weight, and careful attention to the child's airway, as difficulty with mask ventilation can occur, and algorithms for management of difficult airway should be followed 1.
• The scalp should be prepared with chlorhexidine or povidone-iodine solution and draped in a sterile fashion, and local anesthesia using lidocaine 1% with epinephrine should be infiltrated at the incision site.
• For pediatric patients, burr holes are typically placed at Kocher's point, with adjustments based on the child's head size, and a smaller drill bit should be used compared to adults, with careful attention to the thinner skull.
• Post-procedure, close neurological monitoring is essential, with particular attention to signs of increased intracranial pressure, and children require careful fluid management, pain control, and prophylactic antibiotics.

Sedation and Airway Management

• Sedation of pediatric patients has serious associated risks, such as hypoventilation, apnea, airway obstruction, laryngospasm, and cardiopulmonary impairment, and guidelines for monitoring and management of pediatric patients during and after sedation should be followed 1.
• The concept of rescue is essential to safe sedation, and practitioners must have the skills to rescue the patient from a deeper level than that intended for the procedure, and be able to recognize the various levels of sedation and have the skills necessary to provide appropriate cardiopulmonary support if needed 1.

Anatomical Considerations

• The developing brain is more vulnerable to injury, so the procedure should be performed with extreme precision and only when absolutely necessary for conditions like acute epidural or subdural hematomas, hydrocephalus, or intracranial pressure monitoring.
• The dura should be opened cautiously to avoid injury to underlying brain tissue, and careful attention should be paid to the child's head size and anatomical landmarks when placing the burr hole.

From the Research

Guidelines for Performing a Burr Hole in Pediatric Patients

• The procedure for performing a burr hole in pediatric patients can be safely and successfully done by pediatric intensivists in a resource-limited setting, as shown in a 10-year experience at a single center 2.
• The technical difficulties and complications encountered during the procedure can be managed with a standard protocol, and the incidence of complications is relatively low, at 3.5% of patients 2.
• Intraparenchymal intracranial pressure monitoring can be established through a micro burr hole using a standard protocol, and the median duration of intracranial pressure monitoring is 96 hours 2.

Indications and Contraindications

• Burr hole surgery can be lifesaving for patients with acute subdural hematoma (ASDH) and can be performed in the emergency room 3.
• The procedure can be used to treat chronic subdural hematoma and subdural hygroma (CSDH/SDHy) in children under 2 years old, with a relatively low recurrence rate of 20% 4.
• However, the use of ventriculostomy catheters by pediatric intensivists in similar settings is not supported by the data 2.

Surgical Techniques and Considerations

• Multiple burr holes technique is an easy and diffuse indirect revascularization approach in the treatment of moyamoya syndrome, but its effectiveness in pediatric patients remains uncertain 5.
• Burr-hole craniotomy without continuous drainage can be a safe and effective treatment for CSDH/SDHy in children under 2 years old, with no complications related to the operation 4.
• The combined strategy of burr hole surgery and elective craniotomy under intracranial pressure monitoring can be a safe and effective treatment for severe acute subdural hematoma 3.

Training and Safety Considerations

• Extending the practice of bedside burr hole for intracranial pressure monitoring to the entire ICU team is safe and feasible, with comparable rates of complications to those of neurosurgical series 6.
• Anaesthetist-intensive care physicians can be trained to perform burr hole for ICP monitoring without help after 2-3 assisted procedures, with a high success rate and low complication rate 6.