The Management of Patients
undergoing Neurosurgical
Cranial Procedures
France Ellyson
Kuwait, 2014
Overview
 Preoperative Phase
 Intraoperative phase
 Neuroanesthesia
 Neurosurgical Procedures
 Nursing Care
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
The Intraoperative Phase
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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 Intraoperative Phase –
Monitoring Phase
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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
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
Neuroanesthesia
 Goal is to preserve
CBF and avoid
hypoxia and
hypoxemia
 Cerebral protection
 Hypothermia
 Hypotension
 Hyperventilation
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
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:
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(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
Neurosurgical Procedures
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Craniotomy
Craniectomy
Cranioplasty
Burr hole
Stereotactic surgery
Laser
Gamma knife
Transphenoidal
Hypophysectomy
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
Shape of Incision
(determined by lesion size, site or both)
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1. Straight
2. Curved
3. Coronal—ear to ear
4. Pterional—slightly curved in front of the ear
5. Question mark
6. Horseshoe shaped
Advantages
 1. Provides direct visualization of brain tissue and tumor/lesio
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
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
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.
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
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
Cranioplasty
 Material chosen must:
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Show low infection rates
Show low heat conduction
Be non-magnetic
Radiolucent
Tissue acceptable
Durable
Shapeable
inexpensive
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
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
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
Stereotactic Surgery
 Stereotactic frame is
inserted
 Target site is located (XY-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
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
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
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
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
Supratentorial Approach
 Above the tentorium and includes the cerebral
hemispheres
 Used to gain access to the frontal, parietal,
temporal and occipital lobes
Infratentorial Approach
 Below the
tentorium in the
posterior fossa and
includes brain
stem (mid brain,
pons and medulla)
and cerebellum
Nursing Management
Incision
Supratentorial
Infratentorial
Nursing Management
Dressing
Supratentorial
Infratentorial
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
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
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
Nursing Management
Ambulation
Supratentorial
Infratentorial
 Pt is allowed out of bed  Pt is allowed out of bed
as soon as pt tolerates
as soon as tolerated
vertical position
 Check MD order
 Pt undergoing
infratentorial surgery
may experience
dizziness (cause by
transient edema in area
of cranial nerve ????)
Nursing Management
Nutrition
Supratentorial
Infratentorial
 Nausea tends to be more frequent
 Date as per MD
order
 Medicate with antiemetics Propofol bolus and/or infusion,
 Check order for
“Fluid Restriction” 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”
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
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
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
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
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”
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
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
Neurological Complications
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Cerebral hemorrhage
Increased Intracranial Pressure
Pneumocephalus
Hydrocephalus
Seizures
CSF leakage
Meningitis
Wound infection
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
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
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
Hydrocephalus
 Can develop as a result
of edema or bleeding
 Usual treatment is EVD
insertion
 If not resolved, then a
shunt may be warranted
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
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
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
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
Other complications
 Gastric
ulceration/hemorrhag
e
 Deep vein thrombosis
 Diabetes Insipidus
 Cerebral salt wasting
 Hyperglycemia
Transphenoidal Hypophysectomy
Transphenoidal Hypophysectomy
 Used for pituitary
adenomas,
craniopharyngeomas
and complete
hypophysectomy for
control of bone pain
in metastatic cancer
Transphenoidal Hypophysectomy
POSTOPERATIVE COMPLICATION:
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Rhinorrhea (CSF leak)
DI
Sinusitis
Epitaxis
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
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
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
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
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 pp442-447
 AANN Reference Series for Clinical Practice