What is the management for vomiting after burr holes?

Management of Vomiting After Burr Holes

Implement a multimodal antiemetic regimen targeting different chemoreceptor pathways, prioritizing 5-HT3 receptor antagonists (ondansetron) combined with dexamethasone, while maintaining euvolemia and avoiding medications that impair neurological examination. 1

Immediate Assessment and Red Flags

Vomiting after burr holes requires urgent evaluation to distinguish between benign postoperative nausea and serious complications:

• Assess for concerning features requiring immediate intervention: new-onset severe headache with change in character/location, altered consciousness, focal neurological deficits, fever, or signs of increased intracranial pressure 1
• Evaluate for mechanical complications: intracranial migration of bone dust (which can cause acute hydrocephalus), subdural hematoma expansion, or CSF leak—all of which may present with vomiting 2
• Monitor neurological status closely: any confusion or sedation from antiemetics can mask deterioration, making frequent reassessment critical 1

Pharmacological Management

Primary antiemetic strategy:

• First-line combination therapy: 5-HT3 receptor antagonists (ondansetron) plus dexamethasone—this combination is most frequently used and recommended for postoperative nausea and vomiting after craniotomy 1
• Multimodal approach targeting different receptors: add propofol (if still intubated) or consider additional agents if initial therapy fails 1
• Reduce opioid analgesics: narcotics worsen nausea and should be minimized; consider alternative analgesics like NSAIDs or acetaminophen if not contraindicated 1

Medications to avoid:

• Anticholinergics (scopolamine) and phenothiazines (promethazine) at higher doses: these cause confusion and sedation that impair neurological examination—critical to avoid in neurosurgical patients 1
• Volatile anesthetic agents: if the patient requires re-operation, propofol-based anesthesia is preferred over volatile agents as it reduces postoperative nausea and vomiting incidence 1

Supportive Management

• Maintain euvolemia: adequate hydration is essential and generally advocated as part of antiemetic strategy; avoid hypovolemia which can worsen symptoms 1
• Optimize analgesia without opioids: use long-acting NSAIDs prophylactically if not contraindicated, as adequate pain control reduces nausea 1
• Monitor and correct electrolyte abnormalities: check basic metabolic panel, as imbalances can contribute to persistent vomiting 3

When to Escalate Care

Obtain urgent neuroimaging (CT head) if:

• Vomiting is associated with worsening headache, altered mental status, or new focal deficits 1
• Persistent vomiting despite appropriate antiemetic therapy 1
• Any concern for intracranial complication such as hematoma expansion, hydrocephalus, or bone dust migration 2

Neurosurgical consultation required for:

• Evidence of subdural hematoma with mass effect (may require re-drainage) 1
• Acute hydrocephalus from any cause 2
• Signs of increased intracranial pressure refractory to medical management 1

Common Pitfalls

• Failing to distinguish postoperative nausea from signs of intracranial complication: always maintain high index of suspicion for mechanical problems after burr holes 2
• Over-sedating with antiemetics: this masks neurological deterioration—use agents that minimize sedation and confusion 1
• Inadequate pain control leading to persistent nausea: address pain with non-opioid analgesics preferentially 1
• Performing lumbar puncture in patients with burr holes closed with bone dust: this can create negative pressure gradient causing migration of bone dust into ventricles and acute hydrocephalus 2

Postoperative Instructions

• Advise patients to seek urgent medical attention for: persistent vomiting, fever, severe headache with change in character, or any neurological symptoms 1
• Position considerations: patients should lie flat as much as possible for 1-3 days after procedure if CSF leak is suspected 1
• Activity restrictions: minimize bending, straining, and Valsalva maneuvers for 4-6 weeks to prevent complications 1