The postoperative management of pain from intracranial surgery in pediatric neurosurgical patients

OBJECTIVE Surgical site infections (SSIs) are costly to patients and the health care system. Pediatric neurosurgery SSI risk factors are not well defined. Intraoperative protocols have reduced, but have not eliminated, SSIs. The effect of preoperative intervention is unknown. Using quality improvement methods, a preoperative SSI prevention protocol for pediatric neurosurgical patients was implemented to assess its effect on SSI rate. METHODS Patients who underwent a scheduled neurosurgical procedure between January 2014 and December 2015 were included. Published evidence and provider consensus were used to guide preoperative protocol development. The Model for Improvement was used to test interventions. Intraoperative and postoperative management was not standardized or modified systematically. Staff, family, and overall adherence was measured as all-or-nothing. In addition, SSI rates among eligible procedures were measured before and after protocol implementation. RESULTS Within 4 months, overall protocol adherence increased from 51.3% to a sustained 85.7%. SSI rates decreased from 2.9 per 100 procedures preintervention to 0.62 infections postintervention (p = 0.003). An approximate 79% reduction in SSI risk was identified (risk ratio 0.21, 95% CI 0.08–0.56; p = 0.001). CONCLUSIONS Clinical staff and families successfully collaborated on a standardized preoperative protocol for pediatric neurosurgical patients. Standardization of the preoperative phase of care alone reduced SSI rates. Attention to the preoperative in addition to the intraoperative and postoperative phases of care may lead to further reduction in SSI rates.

Download Full-text

Management of Postoperative Neurosurgical Patients

Journal of Neuroanaesthesiology and Critical Care ◽

10.1055/s-0039-1689055 ◽

2019 ◽

Vol 06 (02) ◽

pp. 080-086

Author(s):

Nidhi B. Panda ◽

Shalvi Mahajan ◽

Rajeev Chauhan

Keyword(s):

Postoperative Care ◽

Fluid Management ◽

Surgical Techniques ◽

Postoperative Management ◽

Therapeutic Interventions ◽

Team Collaboration ◽

Good Communication ◽

Neurosurgical Patients ◽

Special Subset ◽

Unique Individual

AbstractNeurosurgical patients are a special subset of patients requiring postoperative care. Challenging neurosurgical disease processes, advanced surgical techniques, and unique individual patient requirements advocate the need for meticulous postoperative care to ensure safe transition toward recovery. Timely detection of systemic and neurological changes allows early diagnostic and therapeutic interventions. The mainstay of postoperative care revolves around airway, maintenance of hemodynamics, sedation, analgesia, nutrition, fluid management, and management of disease-specific complications. In addition to standard monitoring, multimodal neuromonitoring should be used in neurosurgical patients. Hence, four key elements in the postoperative management of neurosurgical patients involve profound insight, rapid response, good communication skills, and team collaboration.

Download Full-text

Postoperative management of adult central neurosurgical patients: Systemic and neuro-monitoring

Best Practice & Research Clinical Anaesthesiology ◽

10.1016/j.bpa.2007.06.002 ◽

2007 ◽

Vol 21 (4) ◽

pp. 449-463 ◽

Cited By ~ 7

Author(s):

David Pfister ◽

Stephan P. Strebel ◽

Luzius A. Steiner

Keyword(s):

Postoperative Management ◽

Neurosurgical Patients

Download Full-text

Intracranial pressure monitoring after elective intracranial surgery

Journal of Neurosurgery ◽

10.3171/jns.1988.69.4.0540 ◽

1988 ◽

Vol 69 (4) ◽

pp. 540-544 ◽

Cited By ~ 47

Author(s):

Shlomi Constantini ◽

Shamay Cotev ◽

Z. Harry Rappaport ◽

Shlomo Pomeranz ◽

Mordechai N. Shalit

Keyword(s):

Risk Factors ◽

Intracranial Pressure ◽

Postoperative Management ◽

Clinical Deterioration ◽

Icp Monitoring ◽

Repeat Surgery ◽

Content Type ◽

Intracranial Surgery ◽

Tumor Bed ◽

Fine Print

✓ A retrospective study of 514 consecutive patients whose intracranial pressure (ICP) was monitored after elective supratentorial or infratentorial surgery is reported. Of the 412 patients operated on in the supratentorial region, 76 (18.4%) had a postoperative sustained ICP elevation exceeding 20 torr. Abnormally high ICP occurred after 13 (12.7%) of the 102 infratentorial operations. Risk factors for postoperative ICP elevation were: resection of glioblastoma in 27.2% of cases, repeat surgery in 42.9% of cases, and protracted surgery (> 6 hours) in 41.7% of cases. Of the 89 patients with elevated ICP, 47 (52.8%) had an associated clinical deterioration. In 19 of these, the rise in ICP occurred before this deterioration was noticed, leading as a rule to quick diagnostic and management response. In eight patients clinical deterioration was noticed before the rise in ICP, and in 20 it happened simultaneously. The higher the level of ICP elevation, the greater were the chances of associated deterioration. The most common findings on computerized tomography scanning in 35 of the 89 patients with elevated ICP were brain edema (19 cases) and bleeding in the tumor bed (15 cases). Mannitol, thiopental, additional hyperventilation, and reintubation (in patients who were previously extubated) were used to reduce ICP, in addition to surgical decompression whenever indicated. Thirteen patients with raised ICP and clinical deterioration underwent reoperation. The postoperative infection rate was 1.2% (six cases). In only one patient could infection be attributed to ICP monitoring. It was concluded that ICP monitoring is advantageous in the immediate postoperative management after elective intracranial surgery and is almost risk-free. It should therefore be used liberally, especially when risk factors for ICP elevation can be identified prior to the end of surgery.

Download Full-text

Development of an Early Prediction Model for Postoperative Delirium in Neurosurgical Patients Admitted to the ICU after Elective Craniotomy (E-PREPOD-NS): A Secondary Analysis of A Prospective Cohort Study

10.21203/rs.3.rs-271659/v1 ◽

2021 ◽

Author(s):

Hua-Wei Huang ◽

Guo-Bin Zhang ◽

Hao-Yi Li ◽

Chun-Mei Wang ◽

Yu-Mei Wang ◽

...

Keyword(s):

Prediction Model ◽

Risk Score ◽

Postoperative Delirium ◽

Risk Model ◽

External Validation ◽

Multivariate Logistic Regression Analysis ◽

Early Prediction ◽

Intracranial Surgery ◽

Neurosurgical Patients ◽

History Of

Abstract Background: Postoperative delirium (POD) is a significant clinical problem in neurosurgical patients after intracranial surgery. Identification of high-risk patients may optimise individual perioperative management, but an adequate and simple risk model for use at super early phase after operation has not been developed.Methods: Adult patients were admitted to the ICU after elective intracranial surgery under general anaesthesia. The POD was diagnosed as Confusion Assessment Method for the ICU positive on postoperative day 1 to 3. Multivariate logistic regression analysis was used to develop the early prediction model (E-PREPOD-NS) and the final model was validated with 200 bootstrap samples.Results: Among 800 patients included in the study, POD occurred in 157 cases (19.6%). We identified nine variables independently associated with POD in the final E-PREPOD-NS model: age > 65 years [odds ratio (OR) = 3.336, 95% confidence interval (CI) = 1.765-6.305, 1 risk score point], education level < 9 years (OR = 2.528, 95% CI = 1.446-4.419, 1 point), history of smoking (OR = 2.582, 95% CI = 1.611-4.140, 1 point), history of diabetes (OR = 2.541, 95% CI = 1.201-5.377, 1 point), supra-tentorial lesions (OR = 3.424, 95% CI = 2.021-5.802, 1 point), anesthesia duration > 360 min (OR = 1.686, 95% CI = 1.062-2.674, 0.5 point), GCS <9 at ICU admission (OR = 6.059, 95% CI = 3.789-9.690, 1.5 points), metabolic acidosis (OR = 13.903, 95% CI = 6.248-30.938, 2.5 points), and positioning of neurosurgical drainage tube (OR = 1.924, 95% CI = 1.132-3.269, 0.5 point). The area under the receiver operator curve (AUROC) of the risk score for prediction of POD was 0.865 (95% CI = 0.835-0.895). After internal validation by bootstrap, the AUROC was 0.851 (95% CI = 0.791-0.912). The model showed good calibration (Hosmer-Lemeshow P = 0.593).Conclusions: The E-PREPOD-NS model based on nine perioperative risk factors can predict POD in patients admitted to the ICU after elective intracranial surgery with fairly good accuracy. External validation is needed before use in clinical practice.

Download Full-text

Dose escalation safety and tolerance study of the N-methyl-d-aspartate antagonist dextromethorphan in neurosurgery patients

Journal of Neurosurgery ◽

10.3171/jns.1996.84.5.0860 ◽

1996 ◽

Vol 84 (5) ◽

pp. 860-866 ◽

Cited By ~ 57

Author(s):

Gary K. Steinberg ◽

Teresa E. Bell ◽

Midori A. Yenari

Keyword(s):

Side Effects ◽

Experimental Studies ◽

Serum Levels ◽

Experimental Models ◽

Cerebral Injury ◽

Content Type ◽

Intracranial Surgery ◽

Brain Levels ◽

Neurosurgical Patients ◽

Csf Levels

✓ Experimental studies have shown that dextromethorphan, a noncompetitive N-methyl-d-aspartate antagonist is neuroprotective in experimental models of ischemic cerebral injury. The authors studied the safety and tolerability of oral dextromethorphan (DM) in humans, and correlated serum levels of this drug with cerebrospinal fluid (CSF) and brain levels. Neurosurgical patients undergoing intracranial surgery or endovascular procedures were given ascending doses of oral DM prior to and 24 hours after surgery. Serum, CSF, and brain levels of DM and its active metabolite, dextrorphan, were measured. One hundred eighty-one patients received a total of 212 courses of DM treatment in dose ranges of 0.8 to 9.64 mg/kg. Serum DM levels correlated highly with CSF and brain DM levels. Brain levels were 68-fold higher than serum levels, whereas CSF levels were fourfold lower than serum levels. The maximum DM levels attained were 1514 ng/ml (serum), 118 ng/ml (CSF), and 92,700 ng/g (brain). The maximum dextrorphan levels were 501 ng/ml (serum), 167 ng/ml (CSF), and 6840 ng/g (brain). In 11 patients, brain and plasma levels of DM were comparable to levels that have been shown to be neuroprotective in animal studies. Frequent side effects occurring at neuroprotective levels of DM included nystagmus (64%), nausea and vomiting (27%), distorted vision (27%), feeling “drunk” (27%), ataxia (27%), and dizziness (27%). All symptoms were reversible and no patient suffered severe adverse reactions. This study demonstrates that potentially neuroprotective doses of DM can be administered safely to neurosurgical patients. Brain and CSF levels of DM can be estimated from serum levels of the drug. Side effects, even at the highest levels, proved to be tolerable and reversible. Administration of DM to patients at risk for cerebral injury should be further explored.

Download Full-text

Managing the Postoperative Neurosurgical Patient

Neurocritical Care ◽

10.1093/med/9780199375349.003.0021 ◽

2018 ◽

pp. 224-232

Author(s):

Daniel Ripepi ◽

Colleen Moran

Keyword(s):

Management Strategies ◽

Postoperative Nausea And Vomiting ◽

Preoperative Assessment ◽

Postoperative Management ◽

Sodium Balance ◽

Anesthetic Techniques ◽

Postoperative Fever ◽

Specific Complication ◽

Neurosurgical Patient ◽

Neurosurgical Patients

Managing the postoperative neurosurgical patient involves timely recognition and management of specific issues that arise in the immediate postoperative period. The likelihood that a specific complication will arise for a given patient is influenced by the nature of the procedure, the anesthetic techniques used, and the patient’s preoperative comorbidities. The risk of some complications can be reduced with appropriate preoperative assessment and medical optimization. The management and treatment of postoperative complications is equally important, and often management techniques used are unique among neurosurgical patients. Included among the common postoperative management issues in neurosurgical patients are postoperative nausea and vomiting, pain control, sodium balance, postoperative fever, airway management, blood pressure management, and fluid therapy. Management strategies along with rationale for these postoperative concerns are discussed in this chapter.

Download Full-text

Management of Postoperative Neurosurgical Patients

Indian Journal of Neurosurgery ◽

10.1055/s-0039-1698001 ◽

2019 ◽

Vol 08 (03) ◽

pp. 179-184

Author(s):

Rajeev Chauhan ◽

Summit Dev Bloria ◽

Ankur Luthra

Keyword(s):

Elective Surgery ◽

General Rule ◽

Postoperative Management ◽

Secondary Brain Injury ◽

Basic Principles ◽

Patient Profile ◽

Organ Systems ◽

Neurosurgical Patients ◽

Major Organ ◽

Neurosurgical Intensive Care Unit

AbstractThe patient profile undergoing neurosurgery varies from neonates to elderly, and from patients undergoing elective surgery to patients undergoing emergency surgeries. The goals of postoperative management include prevention of secondary brain injury and taking care of the major organ systems till the time patient recovers from the primary insult. Postsurgery, patients may be shifted to a neurosurgical intensive care unit or managed in a neurosurgical ward. As a general rule, all patients should be nursed 30-degree head up. We will be discussing the basic principles of postoperative management of neurosurgical patients.

Download Full-text