Perioperative care of neurosurgical pt

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mbrieger
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109945
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Perioperative care of neurosurgical pt
Updated:
2011-10-21 13:03:17
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Perioperative care neurosurgical pt
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Perioperative care of neurosurgical pt
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  1. Neurologic Preoperative Risks
    • Increased ICP
    • Coma
    • Seizuers
    • Contaminated or open wound
  2. Management of increased ICP
    • CSF drainage
    • Steroids
    • Controlled anesthesia induction
    • Hyperventilation
    • Narcotics
    • Manitol
  3. Management of Coma
    • Early intubation, assessment and systemic stabilization
    • ICP management
    • Treatment of urinary retention: bladder catheter
  4. Management of Seizures
    • Parenteral medication with loading dose
    • Treatment of status epileptics.
  5. managment of contaminated or open wound
    abx to cover skin contamination and prompt debridement and secondary closure
  6. Systemic preoperative risks by system: Cardiovascular
    Control HTN, hypotension, arrhthmias
  7. Systemic preoperative risks by system: Respiratory
    • Assess complicating lesions and need for bronchodilation with
    • PFTs
    • CHX
  8. Systemic preoperative risks by system: Endocrine
    • Diabetes managment
    • Pituitary assessment
    • Steroid coverage for stress managment
  9. Systemic preoperative risks by system: Hematologic
    • Coagulation disorders and platelets
    • Anemia evaluation
  10. Systemic preoperative risks by system: Gastrointestinal
    • Risk of spiration
    • General nutrition for healing
  11. Systemic preoperative risks by system: Genitourinary
    Managment of urinary infx and drainage
  12. Systemic preoperative risks by system: Renal
    Need dialysis in pt with renal compromise
  13. Systemic preoperative risks by system: Fluids and electrolytes
    • Metablic balance
    • Control of electrolytes
  14. Systemic preoperative risks by system: Infection
    • Indentification of source
    • Treatment of antibiotics
  15. Preoperative preparation and informed consent
    • Nature of the condition
    • Proposed treatment and associated possible complications
    • Alternative forms of treatment
    • Customary and usual treatment schemes
    • Expected benefit of proposed treatment is not guaranteed
    • Clinical history, exam, diagnostic tests
    • Possible benefit when balanced against know and/or unexpected risks
    • Benefits and risks compared to natural history and proposed treatment, including nonoperative managment
    • Recommended standard of care
  16. Rationale and duration of perioperative antibiotics
    • First dose prior to anesthesia
    • Continue throughout surgery until skin closed, unless infx or wound contamination
  17. Rationale and duration of perioperative steroids
    • useful for spnial cord injury
    • brain tumor edema
    • increased ICP
    • dexamethasone 10 to 20 mg loading, 4 to 6 mg Q6H
  18. Rationale and duration of Hypertonic solutions perioperatively
    • Mannitol 1g/kg for increased ICP to help retraction;
    • 3% saline for persistent hyponatremia
  19. Rationale and duration of antihypertensives perioperatively
    To prevent immediate postoperative bleeding and for managment of subarachnoid hemorrhage
  20. Rationale and duration of anticonvulsants perioperatively
    full preoperative load when risk of seizures exceeds 5% to 10% or after seizure occurs
  21. Rationale and intraoperative medication related problems of intravenous narcotics
    postoperative sedation may be pronounced
  22. Rationale and intraoperative medication related problems of inhalation agents
    inceased ICP due to venous vasodilation
  23. Rationale and intraoperative medication related problems of
    maintain low pCO2 and vasoconstriction
  24. Rationale and intraoperative medication related problems of nitrous oxide
    only as a supplement to other anesthetics
  25. Rationale and intraoperative medication related problems of Muscle paralysis agents
    for induction and intubation but not when stimulating excitable structures (nerves and brain) for locating muscle or EMG response
  26. Rationale and intraoperative medication related problems of local anesthetics
    on vocal cords during induction to decrease ICP and skin incisions to decrease overall need for general anesthetic
  27. Rationale and intraoperative medication related problems of hypertensives (pressors)
    persistent hypotension intraoperatively
  28. Intraoperative monitoring for cardiovascular system
    • Pulse
    • ECG
    • pulmonary artery catheter for CO
    • blood pessure by indwelling arterial cannula or external automatic sef-inflating cuff
  29. intraoperative monitoring of respiration
    end-tidal expired CO2
  30. intraoperative monitoring of air embolism
    end-tidal expired CO2 precordial doppler
  31. Intraoperative monitoring of specific sturcture monitoring
    • facial nerve stimulatino and EMG recording
    • spinal cord evoked potentials during decompresion or fixation
    • peripheral nerve monitoring during repair
    • EMG recording during selective rhzotomy
  32. Intraoperative managment components
    • determining proper surgical postion
    • types of perioperative monitoring required
    • how to minimize complications of infx, bleeding, peripheral nerve plasies due to pressure
  33. Lateral position - risks
    • ulnar nerves should be carefully padded
    • axilla should be well protected
  34. severe complication associated with sitting position
    • air embolism
    • the greater the elevation of head over rt atrium the greater the risk
  35. advantage to sitting position
    less venous oozing
  36. surveillence for air emboli
    • precordial doppler
    • monitoring end tidal CO2 for decrease caused by room air filling alvioli
  37. if air emboli is detected
    • halt air flow by
    • raising venous pressure
    • tamponadeing the wound with wet sponges
    • lowering pt to allow blood to egress
  38. unchecked air embolism may cause
    severe rise in R heart pressure due to pulmonary embolism
  39. Early post operative problems
    • Subarachnoid/intaventricular blood
    • Vasospasm flowing SAH
    • CSF leak from operative site
    • Respiratory insufficiency
    • Seizures
    • Postoperative clot formation
    • Infection
    • Inappropriate serum dilution
  40. SAH/IVH managment
    CSF drainage from subarachnoid space
  41. Vasospasm following SAH managment
    Maintain blood volume and pressure
  42. CSF leak from operative site managment
    CSF drainage, proper positioning
  43. Respiratory insufficiency
    • treat atelectasis
    • intubation if severe
  44. Seizure management
    remove source of cortical irritation and hemorrhage
  45. Postoperative clot formation
    may require direct evacuation of clot
  46. infection management
    early or late: abx, drainage, debridement
  47. inappropriate serum dilution management
    • fluid restriction
    • hypertonic saline

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