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
Nurse’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 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
The sitting position is often used for posterior fossa surgery as it affords optimal visualization of the operative field
Various 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
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
Hypothermia 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 loss
Hyperventilation is used to reduce ICP

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
Transphenoidal Hypophysectomy

11. Craniotomy Surgical opening of the skull
To provide access of intracranial contents – tumor, aneurysm, SDH
Involves creation of bone flap
Free flap: Bone is 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
Perfection 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 tissue
The stereotaxic probe is passed to target area
Used in precise localization and treatment of deep brain lesions
In this context “stereo” means 3-dimensional and “tactic” means touch
Used 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 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
A 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 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
This 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 hemispheres
Used to gain access to the frontal, parietal, temporal and occipital lobes
The 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 days
Infratentorial: 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 applied
Many physicians remove the dressing after 24 hours ? What is your practice? We are looking at harmonizing our practices at Neuro
The dressing is monitored for evidence of blood or CSF
The incision is monitored for redness, drainage or signs of wound infection
With 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 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 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 ordered
Morphine
Tylenol
Careful not to mask neurological signs
Much 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 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 Management Ambulation Supratentorial Infratentorial
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 ????)
Pt is allowed out of bed as soon as tolerated
Check MD order
Cranial nerve 8

35. Nursing Management Nutrition Supratentorial Infratentorial
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”
Cranial nerves 1X and X
The 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 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 Management Elimination
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 Management Special Focus of Neurological Assessment Supratentorial
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
The 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 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
Requires early recognition and immediate intervention

45. Increased Intracranial Pressure
Some increase in ICP is expected (peak hours post -op)
Increase in ICP maybe life-threatening
Rx includes management of underlying cause, judicious use of osmotic diuretics and possibly EVD insertion
Underlying causes: cerebral edema, hemorrhage, meningitis and surgical trauma

46. Pneumocephalus
Entry of air into subdural, extradural, subarachnoid, intracerebral or intraventricular compartments
Complication of posterior fossa craniotomy and transphenoidal hypophysectomy
The sitting position is a risk factor
S/S include H/A drowsiness, decreased LOC and focal or lateral deficits
The 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 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
The fluid will test positive for glucose with a “Dextrostick”

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
A 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 Infection
Most frequent causative organisms for wound infections are the various staphylococcal organisms
Can result from poor aseptic technique during surgery, dressing change or pt touching incision
Redness and drainage from wound are the usual early symptoms
Foul odor and elevated white blood cell count raises suspicion

52. Other complications Gastric ulceration/hemorrhage Deep vein thrombosis
Diabetes Insipidus
Cerebral salt wasting
Hyperglycemia
Gastic 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 stools
DVT: 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 encouraged
DI: 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

53. Transphenoidal Hypophysectomy

54. Transphenoidal Hypophysectomy
Used for pituitary adenomas, craniopharyngeomas and complete hypophysectomy for control of bone pain in metastatic cancer
Palliative 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 dissected
Sella Turnica is visible
Portion of Sella Turnica is removed, dura incised
With assistance of microscope – the pituitary tumor is partially or totally removed or impinging tumor excised
Graft of muscle taken from anterior thigh or fat pad from abdomen is applied to surgical site as patch to prevent CSF leakage
Nasal vaseline packings are inserted to control bleeding and to replace the septal mucosa
Dry dressing is applied to donor site, thigh or abdomen

56. Transphenoidal Hypophysectomy
POSTOPERATIVE COMPLICATION:
Rhinorrhea (CSF leak) DI
Sinusitis
Epitaxis
Central 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 permanent
Immediate postop period: DDAVP IV,SC, Pitressin IM, IV, SC
After nasal packing is removed DDAVP intranasal can be used.

57. Hormonal Replacement
Adrenocorticotropic hormone (ACTH) 25mg IM in am and 12.5 mg IM at HS beginning immediately after surgery
Cortisone acetate 100 mg per day IM begins 2 days before surgery to prevent adrenal insufficiency. Drug is continued at lower dose post-op
Always consult Endrocrinology

58. Patient Teaching
Medication must be taken daily – failure may be life threatening
Dosage must be increased during periods of stress, illness, excessive exercise, fever, infection
Gastric irritation can be minimized with antacid

59. Patient Teaching Check presence tarry stools Check BP (may elevate BP)
Check hyperglycemia
Check for behavioral changes (restless, depression, sleeplessness)
Wear medical alert bracelet
Always carry kit of hydrocortisone sodium succinate

60. S/S OVERMEDICATION UNDERMEDICATION
CUSHINGOID SIGNS (moon face, fat pads, buffalo hump, acne, hirsutism, weight gain
Psychic disturbances
Peptic ulcer
H/A, vertigo, cataracts, increased ICP and intraocular pressure
ADDISON CRISIS
Weakness, dizziness, orthostatic hypotension
N/V
Sodium and water retention
Decreased BP

61. References
Bader, M.K., & Littlejohns, L.R. (Eds.). (2004). AANN core curriculum for neuroscience nursing (4th ed.). St-Louis, MO: Elsevier Health Sciences
Hichey, 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 pp
AANN Reference Series for Clinical Practice