Presentation on theme: "The Management of Patients undergoing Neurosurgical Cranial Procedures"— Presentation transcript:
1 The Management of Patients undergoing Neurosurgical Cranial Procedures France EllysonKuwait, 2014
2 Overview Preoperative Phase Intraoperative phase Neuroanesthesia Neurosurgical ProceduresNursing Care
3 The Preoperative Phase Informed consent – MDPreoperative teaching – printed material is usefulIn planned surgeries, routine tests are completed as out-patientPt is kept NPO after midnightPt are asked to wash hair and skin with “Pre-op skin Prep detergent evening before and morning of ORLong hair is braidedAntiembolic stockings are wornNeurological assessment and VS are recordedNurse’s presence during the informed consent discussion is helpful in clarifying and reinforcing the information provided to the patient and family.
4 The Intraoperative Phase Monitoring equipment is attachedIV is startedFoley catheter is insertedEye ointment is applied and eyelids are taped closed; sterile eye pads applied (prevention corneal abrasions)DVT prophylaxis: Sequential compression boots are appliedPt is intubated (anaesthesia)Pt is positioned- sitting, lateral, proneVarious support devices are positioned and adjustedThe sitting position is often used for posterior fossa surgery as it affords optimal visualization of the operative fieldVarious supportive devices as: headrest, armrest, areas of potential pressure are padded to prevent decubitus ulcers and ischemic pressure injury to nerves. Positioning is complex and often may take 1 hour to complete
5 The Intraoperative Phase – Monitoring Phase EKGEsophageal/tympanic temperature probeArterial line for continuous BP monitoringCentral venous catheterPulse OxymeterRespiratory and end-tidal carbon dioxide monitors?? EEG, EMG, evoked potentials, TCD, ICP, etc
6 NeuroanesthesiaPt 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 ICPThiopenthal CBF ICPEtomidate CBF ICPPropofol CBF ICPKetamine CBF ICPMidazolam CBF ICPNitrous oxide CBFICPIsoflurane CBF ICP
7 NeuroanesthesiaGoal is to preserve CBF and avoid hypoxia and hypoxemiaCerebral protectionHypothermiaHypotensionHyperventilationHypothermia is useful to decrease both metabolic and functional activities of the brain by reducing metabolic rate for O2 consumption. The current therapeutic recommendation is brain temp 32-35° C.Hypotension is defined as lowering MAP mm HG in normotensive anaesthetized pt with the purpose of blood lossHyperventilation is used to reduce ICP
8 Neuroanesthesia Mannitol to reduce brain volume EVD or LD to remove CSFDecadron to reduce brain edemaDilantin to prevent seizuresAntibiotics as prophylaxisCardiac drugs to control BP
9 Venous Air Embolism Prevention Venous air embolus—potential intraoperative complication associated with the sitting operative positionNegative 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 sitePlacing 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
11 Craniotomy Surgical opening of the skull To provide access of intracranial contents – tumor, aneurysm, SDHInvolves creation of bone flapFree flap: Bone is completely removed and preserved for later replacementBone flap: Muscle is left attached to the skull to maintain vascular supply
12 Shape of Incision (determined by lesion size, site or both) 1. Straight2. Curved3. Coronal—ear to ear4. Pterional—slightly curved in front of the ear5. Question mark6. Horseshoe shaped
13 Advantages1. Provides direct visualization of brain tissue and tumor/lesion borders2. Enables total tumor/lesion removal, if possible3. Creates opportunity to obtain tumor/lesion tissue for pathology and definitive diagnosis4. Decompresses intracranial contents, reduces ICP5. Requires only local anesthesia and permits monitoring of conscious sedation for tumors involving the eloquent cortex6. Allows placement of local therapies (i.e., gliadel wafers, other chemotherapy, brachytherapy)7. Relieves symptoms8. Improves neurological status and quality of life
14 Disadvantages1. Involves inherent risks due to the invasive nature of the procedure2. May result in increased swelling due to trauma from surgery3. Usually requires intensive care unit (ICU) stay4. Results in higher total hospitalization costs compared with stereotactic surgery
15 Awake CraniotomyProcedure 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 fractureUsual access for posterior fossa; Small areas and increased risk of dural tear
17 CranioplastyRepair of the skull to reestablish the contour and integrity of the skullProcedure involves replacement of part of the cranium with a synthetic material
18 Cranioplasty Material chosen must: Show low infection rates Show low heat conductionBe non-magneticRadiolucentTissue acceptableDurableShapeableinexpensive
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 surgeonsAcrylic, ceramic, platinum, vitallium, ticoniumPerfection in cranioplasty is still not achieved, and ongoing researches on both biologic and nonbiologic substitutions continue with the help of recent technology. Stem cell experiments and development of morphogenic proteins are expected to take place in the short-term future.
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 tissueThe stereotaxic probe is passed to target areaUsed in precise localization and treatment of deep brain lesionsIn this context “stereo” means 3-dimensional and “tactic” means touchUsed in: Biopsy of deep lesions or lesions of brain stem, evacuation of ICH, ventricular shunt placement, placement of electrodes for epilepsy, ablative procedures for extrapyramidal diseases such as Parkinson, placement of deep brain stimulators (chronic pain)
23 Stereotactic Biopsy- Advantages 1. Provides access to deep-seated tumors and tumors in eloquent areas that are surgically inaccessible with significant neurologic risk2. Creates smaller incision3. Can be performed under local anesthesia and conscious sedation, which provides a safer option for patients who have a contraindication to general anesthesia4. Involves decreased operative time5. Requires shorter hospital stay6. Allows precise placement of burr hole7. Yields accurate diagnosis in ≥95% of cases8. 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 procedure2. Cannot address lesions causing mass effect, which must be addressed with craniotomy3. May cause bleeding from vascular tumors (metastatic melanoma), which can be catastrophic4. 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 CobaltStereotacsix is used to focus point of radiationCapable of destroying deep and inaccessible lesionsUsed for AVMs, deep BT (acoustic neuromas) and other lesions too risky for conventional surgery, failed OR or surgical inaccessible lesionsA few major concerns relating to the Gamma knife includes the lag time between treatment and result (AVM may take 1-3 years) to maximal shrinkage and the lag time for side effects to appear – hearing loss after Rx acoustic neuroma.
26 Postoperative Nursing Management Postanesthesia Care Unit (PACU) or straight to ICUTransfer should include:*overview of surgery (reason,anatomical approach, length)Hx of pre-existing neurological deficitsPre-existing medical problemsCurrent baseline of NVSReview of post-op ordersInfo to familyThis data base is a basis for planning care. The approach will depend on whether the patient has undergone supratentorial or infratentorial surgery.Most complications requiring surgery will occur in the first 6 hours following a craniotomy
27 Supratentorial Approach Above the tentorium and includes the cerebral hemispheresUsed to gain access to the frontal, parietal, temporal and occipital lobesThe Tentorium Cerebri is a double fold of the dura mater that forms a partition between the cerebral hemispheres and the brain stem and cerebellum
28 Infratentorial Approach Below the tentorium in the posterior fossa and includes brain stem (mid brain, pons and medulla) and cerebellum
29 Nursing Management Incision Supratentorial Infratentorial Supratentorial: The incision is made within the boundaries of the hairline, directly over the area to be exposed on the cerebral hemisphere. Sutures are usually removed 7-10 daysInfratentorial: The incision is made above the nape of the neck around the occipital area or posterolaterally in the occipitotemporal region. Sutures also removed 7-10 days.
30 Nursing Management Dressing Supratentorial Infratentorial Strip dressing or turban dressing is appliedMany physicians remove the dressing after 24 hours ? What is your practice? We are looking at harmonizing our practices at NeuroThe dressing is monitored for evidence of blood or CSFThe incision is monitored for redness, drainage or signs of wound infectionWith supratentorial approach pt may experience swelling at site of incision involving face and swelling of eye area on affected side of incision. It is usually accompanied by discoloration and ecchymosis and peaks about hours postop. May apply cold compress and/or ice packs, artificial tears and ungt. Will take 7-10 days to resolve.
31 Nursing Management Head Position in Bed Supratentorial / Infratentorial Always check MD orderUsual order id HOB 30°Maintain head in neutral positionSome physicians follow a protocol of gradual head elevation (shunts, SDH)If restrictions place a sign at HOBNote in Care Plan
32 Nursing Management Pain Management Supratentorial / 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 orderedMorphineTylenolCareful not to mask neurological signsMuch of the pain originates from surgical stretching or irritation of the nerves of the scalp. Pain can also result from traction on the dura or large blood vessels within the intracranial space.
33 Nursing Management Turning and Positioning Supratentorial / Infratentorial No restrictions unless patient does not have a bone flap – Place a sign above HOBPlace pt on his side to promote airway and facilitate drainage of secretionsAvoid extreme flexion of upper legs or flexion of neck
34 Nursing Management Ambulation Supratentorial Infratentorial Pt is allowed out of bed as soon as pt tolerates vertical positionPt undergoing infratentorial surgery may experience dizziness (cause by transient edema in area of cranial nerve ????)Pt is allowed out of bed as soon as toleratedCheck MD orderCranial nerve 8
35 Nursing Management Nutrition Supratentorial Infratentorial Date as per MD orderCheck order for “Fluid Restriction”Nausea tends to be more frequentMedicate with antiemetics - Propofol bolus and/or infusion, gravol, maxeran, zofran, stemetilKeep NPO if nausea present, keep IV fluidsCheck gag reflexEdema of Cranial nerves ? and ? may affect swallowing and gagCheck order for “Fluid Restriction”Cranial nerves 1X and XThe gag reflex is checked by touching the posterior wall of the pharynx. Pt may need “Swallowing Assessment” OT or Speech Rx
36 Nursing Management Fluid and Electrolyte Balance Supratentorial Infratentorial Most pt are kept euvolemic. Intake is balanced with outputMonitor strict I&OIf fluid restriction – adhere strictlySerum electrolyte and osmolarity are monitoredIf surgery in area of pituitary or hypothalamus, transient diabetes insipidus may develop. Urine output and SG are monitored Q 1-4 hoursMost pt are kept euvolemic. Intake is balanced with outputMonitor strict I&OIf fluid restriction – adhere strictlySerum electrolyte and osmolarity are monitored
37 Nursing Management Elimination Remove foley catheter asap unless surgery is in area of pituitary gland or hypothalamusIf difficulty to void – start bladder training programConstipation prevention – bowel regime asap
38 Nursing Management Special Focus of Neurological Assessment Supratentorial Monitor VS and NVS Q hourly or as orderedPotential 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 deficitsThe assessment is based on the understanding of specific neurological functions controlled by the supratentorial region and infratentorial region
39 Nursing Management Special Focus of Neurological Assessment Infratentorial Monitor VS and NVS Q hourly or as orderedPotential Cranial nerve dysfunction:Oculomotor, trochlear, abducens (CN lll, lV, Vl) extraocular movement deficitsFacial (CN Vll) lower lid deficit, absent corneal reflex, weakness or paralysis of facial musclesAcoustic (CN Vlll) decreased hearing, dizziness, nystagmusGlossopharyngeal and Vagus (CN lX and X) diminished or absent gag or swallowing reflex, orthostatic hypotensionPotential cerebellar dysfunction; ataxia, difficulty with fine motor movement and difficulty with coordination
40 Transfer from ICU to Acute Care Ward MD orders transferVerbal report given to nurse accepting pt to ensure smooth transitionAt MNH we are presently piloting a “Transfer form”
41 Basic Nursing Management Monitor routine VSS and NVSS at prescribed intervals and PRNGive basic hygiene care until pt is independent + skin care Q4 hoursUse TED stockings/ SCDCheck S/S thrombophlebitis – redness, warmth, swellingTurn pt Q2 hoursCarry out ROM exercise four times per dayProvide catheter care- remove asapProvide 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 edemaAdminister analgesics as orderedDo not combine nursing activities that are known to increase ICP in the pt at riskMonitor laboratory values
44 Cerebral hemorrhageSerious complication that can occur postoperativelyBleeding can occur in the subdural, epidural, intracerebral or intraventricular spaceUnlike external bleeding, bleeding within cranial vault is characterized by S/S of ICPDiagnosed clinically and confirmed on CTRx may require surgeryRequires early recognition and immediate intervention
45 Increased Intracranial Pressure Some increase in ICP is expected (peak hours post -op)Increase in ICP maybe life-threateningRx includes management of underlying cause, judicious use of osmotic diuretics and possibly EVD insertionUnderlying causes: cerebral edema, hemorrhage, meningitis and surgical trauma
46 PneumocephalusEntry of air into subdural, extradural, subarachnoid, intracerebral or intraventricular compartmentsComplication of posterior fossa craniotomy and transphenoidal hypophysectomyThe sitting position is a risk factorS/S include H/A drowsiness, decreased LOC and focal or lateral deficitsThe trapped air , when warmed with the body, expands. A small amount of air can be reabsorbed and is not usually problematic. However, if the air pocket is of sufficient volume, it acts as a space-occupying lesion, causing neurological deterioration.The time frame for pneumocephalus is either early, within 24 hours of the surgery or late, 1 week following surgery.Diagnosis is established by CT scan. Treatment includes surgical evacuation of the air. Repair of CSF leak or Burr hole to evacuate air.???? Bed rest, flat HOB with 100% 02 by rebreather mask. The goal is to replace nitrogen by oxygen and therefore decrease the time required for absorption. One study recommends 02 at 40% for 1 week.
47 Hydrocephalus Can develop as a result of edema or bleeding Usual treatment is EVD insertionIf not resolved, then a shunt may be warranted
48 SeizuresMay take the form of generalized convulsions or focal seizuresUsually occur within the first 7 days post opFocal seizures of the face, hand or twitching of various muscles are due to irritation of the motor cortex post surgery or cerebral edemaBecause seizures are common – use of prophylactic anticonvulsants, most common, phenytoin is routinely usedDrug 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 noseCSF leak will often seal spontaneouslyMay need serial lumbar punctures or lumbar drainIf these measures not successful may require surgical repairProphylactic antibiotics are usually orderedIf CSF is present in nasal passages – nasal suctionning or blowing of the nose is prohibitedThe fluid will test positive for glucose with a “Dextrostick”
50 MeningitisMicroorganisms that cause meningitis can be introduced by wound infection, contamination during surgery, contaminated wound dressingS/S include fever, H/A, nuchal rigidity, malaise & photophobiaPresence of a dural tear is a risk factor for meningitisMeningitis is treated with antibiotics and quiet environmentNurses should check for drainage on dressingNotify MDUse aseptic technique for dressing changesFollow your policyA wet dressing should be reinforced immediately. Because moisture provides organisms with a transport system, a wet dressing is an ideal medium on which organisms can grow. The gauze used in most dressings absorbs drainage by capillary attraction. The wicking action helps to remove drainage from the skin.
51 Wound InfectionMost frequent causative organisms for wound infections are the various staphylococcal organismsCan result from poor aseptic technique during surgery, dressing change or pt touching incisionRedness and drainage from wound are the usual early symptomsFoul odor and elevated white blood cell count raises suspicion
52 Other complications Gastric ulceration/hemorrhage Deep vein thrombosis Diabetes InsipidusCerebral salt wastingHyperglycemiaGastic ulceration: Some drugs used in neurological treatment are associated with increased incidence of gastric irritation ulcers. (decadron, dilantin, some antibiotics) A histamine H2-blocker should be administered to reduce gastric secretions and protect against hemorrhage. Monitor Ht and Hb and stoolsDVT: Neurosurgical pt are at increased risk due to the length, position and therapies during surgery (Hypothermia) Bed rest adds to the risk Use of TEDS/SCD encouragedDI: Supratentorial surgery, especially around pituitary fossa, can lead to temporary DI. DI is caused by a disturbance of the ADH. If this hormone is not secreted in in sufficient quantities the pt will secrete large amount of urine with a low specific gravity. Need to monitor strict I&O. ? Foley catheter. SG Q 1-4 hours Reading of or less is considered low If the condition does not correct itself DDAVP (Desmopressin) may be ordered. Carol will be covering these topics later.Cerebral salt wasting: Hyponatremia is common and may result from cerebral salt wasting. Treatment is saline solution to slowly correct low Na level.Hyperglycemia: Monitor Glu and Rx with insulin
54 Transphenoidal Hypophysectomy Used for pituitary adenomas, craniopharyngeomas and complete hypophysectomy for control of bone pain in metastatic cancerPalliative hypophysectomy for cancer necessitate total removal of pituitary. Cells left at surgical site will continue to secrete hormones and decrease the anticipated relief of pain.The mechanism is unclear.
55 Incision inside upper superior lip in front of hard palate Sphenoid sinus floor is dissectedSella Turnica is visiblePortion of Sella Turnica is removed, dura incisedWith assistance of microscope – the pituitary tumor is partially or totally removed or impinging tumor excisedGraft of muscle taken from anterior thigh or fat pad from abdomen is applied to surgical site as patch to prevent CSF leakageNasal vaseline packings are inserted to control bleeding and to replace the septal mucosaDry dressing is applied to donor site, thigh or abdomen
56 Transphenoidal Hypophysectomy POSTOPERATIVE COMPLICATION:Rhinorrhea (CSF leak)DISinusitisEpitaxisCentral DI is defined as the cessation of ADH by the pituitary gland. Can occur up to 2 weeks postoperatively.DI monitoring is a major nursing responsibility.S/S copious amounts pale urine (More than 250 ml for 2 consecutive hours) and a low SG (< 1.005) Serum osmolality needs monitoring.Total hypophysectomy – DI is expected and is permanent and replacement therapy is begun.In partial hypophysectomy – DI is not permanentImmediate postop period: DDAVP IV,SC, Pitressin IM, IV, SCAfter nasal packing is removed DDAVP intranasal can be used.
57 Hormonal ReplacementAdrenocorticotropic hormone (ACTH) 25mg IM in am and 12.5 mg IM at HS beginning immediately after surgeryCortisone acetate 100 mg per day IM begins 2 days before surgery to prevent adrenal insufficiency. Drug is continued at lower dose post-opAlways consult Endrocrinology
58 Patient TeachingMedication must be taken daily – failure may be life threateningDosage must be increased during periods of stress, illness, excessive exercise, fever, infectionGastric irritation can be minimized with antacid
59 Patient Teaching Check presence tarry stools Check BP (may elevate BP) Check hyperglycemiaCheck for behavioral changes (restless, depression, sleeplessness)Wear medical alert braceletAlways carry kit of hydrocortisone sodium succinate
60 S/S OVERMEDICATION UNDERMEDICATION CUSHINGOID SIGNS (moon face, fat pads, buffalo hump, acne, hirsutism, weight gainPsychic disturbancesPeptic ulcerH/A, vertigo, cataracts, increased ICP and intraocular pressureADDISON CRISISWeakness, dizziness, orthostatic hypotensionN/VSodium and water retentionDecreased BP
61 ReferencesBader, M.K., & Littlejohns, L.R. (Eds.). (2004). AANN core curriculum for neuroscience nursing (4th ed.). St-Louis, MO: Elsevier Health SciencesHichey, J.V. (2006) The Clinical Practice of Neurological and Neurosurgical Nursing. Lippincott.Dexter, Franklin MD, PHD; Reassner, Daniel K. MD, Theoretical Assessment of Normobaric Oxygen Therapy to treat Pneumocephalus: Recommendations for dse and duration of treatment, Journal of the American Society of Anesthesiologist, Inc, Vol 84(2), February 1996 ppAANN Reference Series for Clinical Practice