The Management of Patients undergoing Neurosurgical Cranial Procedures

1. The Management of Patients undergoing Neurosurgical Cranial Procedures France Ellyson Kuwait, 2014

2. Overview Preoperative Phase Intraoperative phase Neuroanesthesia Neurosurgical Procedures Nursing Care

3. The Preoperative Phase • Informed consent – MD • Preoperative teaching – printed material is useful • In planned surgeries, routine tests are completed as out-patient • Pt is kept NPO after midnight • Pt are asked to wash hair and skin with “Pre-op skin Prep detergent evening before and morning of OR • Long hair is braided • Antiembolic stockings are worn • Neurological assessment and VS are recorded

4. The Intraoperative Phase • Monitoring equipment is attached • IV is started • Foley catheter is inserted • Eye ointment is applied and eyelids are taped closed; sterile eye pads applied (prevention corneal abrasions) • DVT prophylaxis: Sequential compression boots are applied • Pt is intubated (anaesthesia) • Pt is positioned- sitting, lateral, prone • Various support devices are positioned and adjusted

5. The Intraoperative Phase – Monitoring Phase EKG Esophageal/tympanic temperature probe Arterial line for continuous BP monitoring Central venous catheter Pulse Oxymeter Respiratory and end-tidal carbon dioxide monitors ?? EEG, EMG, evoked potentials, TCD, ICP, etc

6. Neuroanesthesia • Pt is graded on a 5-point scale (Class 1 healthy – Class 5 moribund pts) • Combination of inhalants and IV drugs are chosen considering their effects on CBF and ICP • ThiopenthalCBF ICP • EtomidateCBF ICP • PropofolCBF ICP • Ketamine CBF ICP • Midazolam CBF ICP • Nitrous oxide CBFICP • IsofluraneCBF ICP

7. Neuroanesthesia • Goal is to preserve CBF and avoid hypoxia and hypoxemia • Cerebral protection • Hypothermia • Hypotension • Hyperventilation

8. Neuroanesthesia • Mannitol to reduce brain volume • EVD or LD to remove CSF • Decadron to reduce brain edema • Dilantin to prevent seizures • Antibiotics as prophylaxis • Cardiac drugs to control BP

9. Venous Air Embolism Prevention • Venous air embolus—potential intraoperative complication associated with the sitting operative position • Negative pressure is produced in the dural venous sinuses and veins draining the brain. • Air is quickly carried to the right side of the heart. • Signs and symptoms include the following: • (1) hypotension • (2) circulatory shock • (3) respiratory distress • (4) tachycardia • (5) cyanosis. • Treatment possibilities include the following: • (1) Identifying possible site of air introduction and occlude that site • Placing the patient in the left lateral decubitus position, terminating the surgery, and observing patient for transient neurological deficits, if the entry site cannot be located

10. Neurosurgical Procedures • Craniotomy • Craniectomy • Cranioplasty • Burr hole • Stereotactic surgery • Laser • Gamma knife • TransphenoidalHypophysectomy

11. Craniotomy • Surgical opening of the skull • To provide access of intracranial contents – tumor, aneurysm, SDH • Involves creation of bone flap • Free flap: Boneis completely removed and preserved for later replacement • Bone flap: Muscle is left attached to the skull to maintain vascular supply

12. Shape of Incision (determined by lesion size, site or both) 1. Straight 2. Curved 3. Coronal—ear to ear 4. Pterional—slightly curved in front of the ear 5. Question mark 6. Horseshoe shaped

13. Advantages 1. Provides direct visualization of brain tissue and tumor/lesion borders 2. Enables total tumor/lesion removal, if possible 3. Creates opportunity to obtain tumor/lesion tissue for pathology and definitive diagnosis 4. Decompresses intracranial contents, reduces ICP 5. Requires only local anesthesia and permits monitoring of conscious sedation for tumors involving the eloquent cortex 6. Allows placement of local therapies (i.e., gliadel wafers, other chemotherapy, brachytherapy) 7. Relieves symptoms 8. Improves neurological status and quality of life

14. Disadvantages 1. Involves inherent risks due to the invasive nature of the procedure 2. May result in increased swelling due to trauma from surgery 3. Usually requires intensive care unit (ICU) stay 4. Results in higher total hospitalization costs compared with stereotactic surgery

15. Awake Craniotomy • Procedure is useful when the tumor involves the motor strip, sensory areas, and speech). • Medical team can interact with the patient during surgery and monitor for complications.

16. Craniectomy • Excision of a portion of skull without replacement • Procedure may be done to achieve decompression after cerebral debulking or removal of bone fragments post skull fracture • Usual access for posterior fossa; Small areas and increased risk of dural tear

17. Cranioplasty • Repair of the skull to reestablish the contour and integrity of the skull • Procedure involves replacement of part of the cranium with a synthetic material

18. Cranioplasty • Material chosen must: • Show low infection rates • Show low heat conduction • Be non-magnetic • Radiolucent • Tissue acceptable • Durable • Shapeable • inexpensive

19. Cranioplasty • Autographs: • Bone is kept sterile and frozen -70° C • Bone can be kept in fatty tissue of abdomen -Requires 2nd surgery -Scar tissue in abdomen -Preferred method with some surgeons • Acrylic, ceramic, platinum, vitallium, ticonium

20. Burr Hole • Creation of a hole in the cranium using a special drill • Used for evacuation of extra-cerebral clots or in preparation of craniotomy

21. Burr Holes for craniotomy • A series of Burr Holes are made in a craniotomy – the bone between the holes are cut with a special saw – allowing for the bone flap removal

22. Stereotactic Surgery • Stereotactic frame is inserted • Target site is located (X-Y-Z) • Point of intersection of all 3 coordinates identify the target tissue • The stereotaxic probe is passed to target area • Used in precise localization and treatment of deep brain lesions

23. Stereotactic Biopsy- Advantages 1. Provides access to deep-seated tumors and tumors in eloquent areas that are surgically inaccessible with significant neurologic risk 2. Creates smaller incision 3. Can be performed under local anesthesia and conscious sedation, which provides a safer option for patients who have a contraindication to general anesthesia 4. Involves decreased operative time 5. Requires shorter hospital stay 6. Allows precise placement of burr hole 7. Yields accurate diagnosis in ≥95% of cases 8. Serves as a more cost-effective option compared with open craniotomy

24. Stereotactic Biopsy- Disadvantages 1. Does not provide the direct visualization of an open procedure 2. Cannot address lesions causing mass effect, which must be addressed with craniotomy 3. May cause bleeding from vascular tumors (metastatic melanoma), which can be catastrophic 4. Only provides tumor pathology of small samples, which may not be representative of large tumor

25. Radiosurgery: Gamma Knife • Consists of heavily shielded helmet containing radioactive Cobalt • Stereotacsix is used to focus point of radiation • Capable of destroying deep and inaccessible lesions • Used for AVMs, deep BT (acoustic neuromas) and other lesions too risky for conventional surgery, failed OR or surgical inaccessible lesions

26. Postoperative Nursing Management • Postanesthesia Care Unit (PACU) or straight to ICU • Transfer should include: *overview of surgery (reason, anatomical approach, length) • Hx of pre-existing neurological deficits • Pre-existing medical problems • Current baseline of NVS • Review of post-op orders • Info to family

27. Supratentorial Approach • Above the tentorium and includes the cerebral hemispheres • Used to gain access to the frontal, parietal, temporal and occipital lobes

28. Infratentorial Approach • Below the tentorium in the posterior fossa and includes brain stem (mid brain, pons and medulla) and cerebellum

29. Nursing ManagementIncisionSupratentorialInfratentorial

30. NursingManagementDressingSupratentorialInfratentorial

31. Nursing ManagementHead Position in BedSupratentorial / Infratentorial • Always check MD order • Usual order id HOB 30° • Maintain head in neutral position • Some physicians follow a protocol of gradual head elevation (shunts, SDH) • If restrictions place a sign at HOB • Note in Care Plan

32. Nursing ManagementPain ManagementSupratentorial / Infratentorial Postoperative H/A is expected in the first few days, and it may be moderate to severe. Can be intensified by tight dressing (Check for snugness) Medicate with analgesics as ordered Morphine Tylenol Careful not to mask neurological signs

33. Nursing ManagementTurning and PositioningSupratentorial / Infratentorial • No restrictions unless patient does not have a bone flap – Place a sign above HOB • Place pt on his side to promote airway and facilitate drainage of secretions • Avoid extreme flexion of upper legs or flexion of neck

34. Nursing ManagementAmbulationSupratentorialInfratentorial • Pt is allowed out of bed as soon as tolerated • Check MD order • Pt is allowed out of bed as soon as pt tolerates vertical position • Pt undergoing infratentorial surgery may experience dizziness (cause by transient edema in area of cranial nerve ????)

35. Nursing ManagementNutritionSupratentorialInfratentorial • Date as per MD order • Check order for “Fluid Restriction” • Nausea tends to be more frequent • Medicate with antiemetics - Propofol bolus and/or infusion, gravol, maxeran, zofran, stemetil • Keep NPO if nausea present, keep IV fluids • Check gag reflex • Edema of Cranial nerves ? and ? may affect swallowing and gag • Check order for “Fluid Restriction”

36. Nursing ManagementFluid and Electrolyte BalanceSupratentorialInfratentorial • Most pt are kept euvolemic. Intake is balanced with output • Monitor strict I&O • If fluid restriction – adhere strictly • Serum electrolyte and osmolarity are monitored • If surgery in area of pituitary or hypothalamus, transient diabetes insipidus may develop. Urine output and SG are monitored Q 1-4 hours • Most pt are kept euvolemic. Intake is balanced with output • Monitor strict I&O • If fluid restriction – adhere strictly • Serum electrolyte and osmolarity are monitored

37. Nursing ManagementElimination • Remove foley catheter asap unless surgery is in area of pituitary gland or hypothalamus • If difficulty to void – start bladder training program • Constipation prevention – bowel regime asap

38. Nursing ManagementSpecial Focus of Neurological AssessmentSupratentorial Monitor VS and NVS Q hourly or as ordered Potential Cranial nerve dysfunction: -Optic nerve (CN II); visual deficits, homonymous hemianopia -Oculomotor nerve (CN lll); ptosis -Oculomotor, trochlear, abducens (CN lll, lV, Vl) extraocular movement deficits

39. Nursing ManagementSpecial Focus of Neurological AssessmentInfratentorial • Monitor VS and NVS Q hourly or as ordered • Potential Cranial nerve dysfunction: • Oculomotor, trochlear, abducens (CN lll, lV, Vl) extraocular movement deficits • Facial (CN Vll) lower lid deficit, absent corneal reflex, weakness or paralysis of facial muscles • Acoustic (CN Vlll) decreased hearing, dizziness, nystagmus • Glossopharyngeal and Vagus (CN lX and X) diminished or absent gag or swallowing reflex, orthostatic hypotension • Potential cerebellar dysfunction; ataxia, difficulty with fine motor movement and difficulty with coordination

40. Transfer from ICU to Acute Care Ward • MD orders transfer • Verbal report given to nurse accepting pt to ensure smooth transition • At MNH we are presently piloting a “Transfer form”

41. Basic Nursing Management Monitor routine VSS and NVSS at prescribed intervals and PRN Give basic hygiene care until pt is independent + skin care Q4 hours Use TED stockings/ SCD Check S/S thrombophlebitis – redness, warmth, swelling Turn pt Q2 hours Carry out ROM exercise four times per day Provide catheter care- remove asap Provide eye care – warm or cold compresses, lubricate with artificial tears, apply ungt, protect eye from injury using eye shield

42. Basic Nursing Management Evaluate if pt is restless for underlying causes – pain, cerebral edema Administer analgesics as ordered Do not combine nursing activities that are known to increase ICP in the pt at risk Monitor laboratory values

43. Neurological Complications Cerebral hemorrhage Increased Intracranial Pressure Pneumocephalus Hydrocephalus Seizures CSF leakage Meningitis Wound infection

44. Cerebral hemorrhage • Serious complication that can occur postoperatively • Bleeding can occur in the subdural, epidural, intracerebral or intraventricular space • Unlike external bleeding, bleeding within cranial vault is characterized by S/S of ICP • Diagnosed clinically and confirmed on CT • Rx may require surgery

45. Increased Intracranial Pressure • Some increase in ICP is expected (peak 24-72 hours post -op) • Increase in ICP maybe life-threatening • Rx includes management of underlying cause, judicious use of osmotic diuretics and possibly EVD insertion

46. Pneumocephalus • Entry of air into subdural, extradural, subarachnoid, intracerebral or intraventricular compartments • Complication of posterior fossa craniotomy and transphenoidalhypophysectomy • The sitting position is a risk factor • S/S include H/A drowsiness, decreased LOC and focal or lateral deficits

47. Hydrocephalus • Can develop as a result of edema or bleeding • Usual treatment is EVD insertion • If not resolved, then a shunt may be warranted

48. Seizures May take the form of generalized convulsions or focal seizures Usually occur within the first 7 days post op Focal seizures of the face, hand or twitching of various muscles are due to irritation of the motor cortex post surgery or cerebral edema Because seizures are common – use of prophylactic anticonvulsants, most common, phenytoin is routinely used Drug levels must be monitored

49. CSF Leakage Caused by opening in the dura to the subarachnoid space Usually from incision but may be noted from ears and nose CSF leak will often seal spontaneously May need serial lumbar punctures or lumbar drain If these measures not successful may require surgical repair Prophylactic antibiotics are usually ordered If CSF is present in nasal passages – nasal suctionning or blowing of the nose is prohibited

50. Meningitis Microorganisms that cause meningitis can be introduced by wound infection, contamination during surgery, contaminated wound dressing S/S include fever, H/A, nuchal rigidity, malaise & photophobia Presence of a dural tear is a risk factor for meningitis Meningitis is treated with antibiotics and quiet environment Nurses should check for drainage on dressing Notify MD Use aseptic technique for dressing changes Follow your policy