Fever in the Neurosurgical Patient

Postoperative fever falls under the category of nosocomial fever, not incubating at the time of surgery. Early postoperative fever is more likely to be a part of the cytokine-mediated physiologic response to surgery and does not always need an infectious workup. Other important noninfectious causes of postoperative fever in neurosurgical patients include dysautonomia and central fever, which are often diagnoses of exclusion after infectious etiologies have been ruled out. Infections in neurosurgical patients can be secondary to the surgical procedure, such as postoperative meningitis, cerebrospinal fluid shunt and drain infections, cranial or spinal epidural abscess, and osteomyelitis and surgical site infections. Other hospital-associated infections, such as nosocomial pneumonia, sinusitis, diarrhea, urinary tract infections, bloodstream infections, and acalculous cholecystitis, are other important causes to be considered as part of the infectious workup. Hyperthermia-induced brain injury is a significant concern in neurosurgical patient population. Therefore, careful management of fever in this patient population is imperative to improve patient outcomes and decrease the cost of medical care.

Management of Bleeding Disorders in the Neurosurgical Patient

Postoperative patients are carefully monitored for bleeding due to its potential to result in dire situations, including death. Patients undergoing neurological surgeries are at heightened risk of morbidity and mortality from postsurgical bleeding due to compact neuroanatomical spaces and flow-sensitive organs. Hospitalists are regularly involved in the management of neurosurgery patients for preoperative risk assessment and medical co-management and must therefore have a good understanding of the predisposing factors that identify at-risk patients to avoid or minimize postoperative bleeding. The major factors to consider while assessing the risk of postoperative bleeding can be broadly divided into surgical and patient-related (nonsurgical). Patients on antiplatelet or anticoagulant agents pose a special management challenge in the perioperative period because interruption of these medications can increase the risk of cardiovascular or thromboembolic events postoperatively. This chapter outlines the general principles of perioperative management of bleeding disorders and postsurgical bleeding in neurosurgery patients admitted for elective or emergent surgeries. Management of patients primarily admitted for intracranial hemorrhage, spinal cord hematoma, or trauma will be discussed separately. This chapter also discusses interventions and therapies to reduce chances of perioperative bleeding in those with patient-related risk factors and reviews current practice guidelines on perioperative adjustment of anticoagulant or antiplatelet agents in patients undergoing neurosurgery.

Antiepileptic Medication Use in Neurosurgical Patients

When caring for neurosurgical patients, many will either be started on a new antiepileptic medication or will be continued on a regimen that had been started prior to hospitalization. Because of this, it is important for a hospitalist to be familiar with the potential risks and benefits of these medications, even though they may be initiated by a neurosurgeon or neurologist. This chapter discusses several common antiepileptic drugs and their uses in the inpatient setting. This is not intended to be an exhaustive discussion; as of this writing, there are at least 27 unique antiepileptic medications available in the United States alone, with more being studied and produced.

Role of Hospital Medicine in Management of Intracranial Brain Tumors

Intracranial tumors reflect a broad range of benign and malignant processes that are often managed by neurosurgeons and medical oncologists. Patients presenting with new brain tumors will undergo biopsies or resection for tissue diagnosis and resolution of neurological symptoms. These patients have significant perioperative risk factors that must be addressed to ensure the best possible outcomes. Hospitalists play a pivotal role in identifying these risk factors and offering management strategies prior to the development of an operative plan. This chapter provides insight into the range of preoperative considerations and postoperative complications that a hospitalist may face when managing brain tumor patients.

Common Neurosurgical Procedures

Medical management of the neurosurgical patient can be complicated. These patients may suffer from a difficult neurosurgical pathology while still living with challenging comorbidities. As a result, this population often requires cooperation between multiple teams including neurosurgeons, neurologists, neurointensivists, and hospitalists. In this chapter, the authors review common neurosurgical procedures that the neurohospitalist encounters, including ventriculoperitoneal shunting, craniotomy and craniectomy, cervical spine decompression with or without fusion, lumbar spine decompression and/or fusion, and cerebral angiograms. The authors aim to highlight the methodology, indications, and issues of perioperative medical management. Understanding these procedures is vital to minimizing adverse events and providing the best possible care for neurosurgical patients.

Palliative Care in the Neurosurgical Patient

Palliative care is specialized medical care for people living with serious illness. It focuses on improving quality of life of the patient. Many neurosurgical patients have a life-altering, serious illness and benefit from palliative care expertise. This chapter describes key roles for palliative care, including understanding the difference between palliative care and hospice care and when and how to identify appropriate patients for palliative care referral. A framework for the effective communication of difficult information is discussed. An approach to symptom management for both pain and nonpain symptoms, like nausea, constipation, and delirium, is provided. Finally, identification of patients appropriate for hospice referral is reviewed.

Blood Glucose Management in the Neurosurgical Patient

It is well established that both hyperglycemia and hypoglycemia are important markers for poor outcomes and increased inpatient mortality in both critically ill and general floor patients. Similar, hyperglycemia and hypoglycemia are associated with adverse outcomes in neurosurgical patients. However, the presence of central nervous system injury and its treatment result in significant differences in various aspects of blood glucose management in these patients compared to the general patient population. The purpose of this chapter is to give a brief overview of blood glucose management before, during, and after neurosurgery. Particular emphasis is placed on blood glucose goals in the different inpatient settings, management of blood glucose levels in patients taking glucocorticoids, and the role of nutrition in blood glucose management.

Diagnosis and Management of Sodium Disorders in the Neurosurgical Patient

Sodium disorders are the most common electrolyte abnormality among hospitalized patients and even more common in the neurosurgical patient population. Timely diagnosis and careful correction of serum sodium is an essential skill for the neurosurgical hospitalist and may greatly mitigate the risk of significant harm to the patient. Water dysregulation is the primary feature of sodium abnormalities and may manifest as hyponatremia due to syndrome of inappropriate antidiuretic hormone (SIADH) secretion or hypernatremia due to central diabetes insipidus (DI). Therapy for the correction of serum sodium must take into consideration the etiology of dysregulation, unique risks associated with different neurologic pathologies, and the risk of osmotic fluid shift associated with fluctuations in serum sodium. Rapidly correcting sodium levels may lead to a variety of unintended sequelae, including osmotic demyelinating syndrome (ODS), cerebral edema, seizure, pulmonary edema, and death. Since neurosurgical patients are at elevated risk for severe morbidity due to osmotic fluid shift, it is crucial that neurosurgical hospitalists have a firm understanding of water and sodium pathophysiology, expertise in the diagnosis and treatment of sodium abnormalities, and nuanced appreciation for the risks and features unique to neurosurgical diseases. This chapter outlines the most common etiologies of sodium disorders in the neurosurgical patient population and offers recommendations for their diagnosis and treatment. Hyponatremia due to hypovolemia, cerebral salt wasting (CSW), SIADH, and adrenal insufficiency (AI) will be highlighted first, followed by hypernatremia due to free water deficit in the setting of central DI and inadequate oral fluid intake.

Preoperative Evaluation of Neurosurgical Patients

All patients undergoing noncardiac surgery are exposed to a risk of adverse surgical, anesthesia, and medical complications. Unlike procedural risk, the medical risks are often modifiable, and therefore stratification of patient medical risk prior to surgery forms the basis of reducing postoperative morbidity, mortality, and length of hospital stay. Patients undergoing neurosurgical procedures pose several unique challenges and require special focus. This patient subgroup also carries a high risk for thrombotic events from immobilization and interruption of pharmacological prophylaxis. Cardiovascular events occurring in the postoperative period are the primary focus of risk assessment in noncardiac surgery, and this is also true for neurosurgical procedures, many of which are performed emergently or urgently. The authors discuss cardiovascular risk stratification based on a patient’s functional status, exercise capacity, and prior cardiac history. They review risk assessment scales to aid decision-making and how to select patients for further testing. Bleeding complications can be devastating and are of great concern in neurosurgery; the chapter discusses assessment of bleeding risk using an approach that combines basic laboratory testing with a thorough history and physical exam. The authors address the risk of thromboembolic events in neurosurgery patients and provide recommendations for preoperative assessment and postoperative prophylaxis. This chapter covers a broad approach from the point of view of a hospitalist physician evaluating a patient preoperatively, including a review of current guidelines, recommendations, and future directions on risk stratification for cardiac, thrombotic, and bleeding complications.

Rehabilitation Medicine in the Neurosurgical Patient

The rehabilitation of the patient with neurologic injury encompasses a vital role in the recovery process for the patient. As hospitalists, it is essential that we understand the post-acute care needs of the neurologically injured patient, so that we can better prevent and treat sequela of neurologic injury. The chapter is split into two parts, addressing separately patients with brain injury and patients with spinal cord injury. Among the issues discussed are sleep disturbance disorders; musculoskeletal disorders; cardiovascular, respiratory, and GI disorders; urological disorders; nutrition; endocrine disorders; skin-related problems such as pressure injury, and bone-related disorders such as heterotopic ossification (HO).