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Neurologic Preoperative Risks
- Increased ICP
- Coma
- Seizuers
- Contaminated or open wound
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Management of increased ICP
- CSF drainage
- Steroids
- Controlled anesthesia induction
- Hyperventilation
- Narcotics
- Manitol
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Management of Coma
- Early intubation, assessment and systemic stabilization
- ICP management
- Treatment of urinary retention: bladder catheter
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Management of Seizures
- Parenteral medication with loading dose
- Treatment of status epileptics.
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managment of contaminated or open wound
abx to cover skin contamination and prompt debridement and secondary closure
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Systemic preoperative risks by system: Cardiovascular
Control HTN, hypotension, arrhthmias
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Systemic preoperative risks by system: Respiratory
- Assess complicating lesions and need for bronchodilation with
- PFTs
- CHX
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Systemic preoperative risks by system: Endocrine
- Diabetes managment
- Pituitary assessment
- Steroid coverage for stress managment
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Systemic preoperative risks by system: Hematologic
- Coagulation disorders and platelets
- Anemia evaluation
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Systemic preoperative risks by system: Gastrointestinal
- Risk of spiration
- General nutrition for healing
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Systemic preoperative risks by system: Genitourinary
Managment of urinary infx and drainage
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Systemic preoperative risks by system: Renal
Need dialysis in pt with renal compromise
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Systemic preoperative risks by system: Fluids and electrolytes
- Metablic balance
- Control of electrolytes
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Systemic preoperative risks by system: Infection
- Indentification of source
- Treatment of antibiotics
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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
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Rationale and duration of perioperative antibiotics
- First dose prior to anesthesia
- Continue throughout surgery until skin closed, unless infx or wound contamination
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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
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Rationale and duration of Hypertonic solutions perioperatively
- Mannitol 1g/kg for increased ICP to help retraction;
- 3% saline for persistent hyponatremia
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Rationale and duration of antihypertensives perioperatively
To prevent immediate postoperative bleeding and for managment of subarachnoid hemorrhage
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Rationale and duration of anticonvulsants perioperatively
full preoperative load when risk of seizures exceeds 5% to 10% or after seizure occurs
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Rationale and intraoperative medication related problems of intravenous narcotics
postoperative sedation may be pronounced
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Rationale and intraoperative medication related problems of inhalation agents
inceased ICP due to venous vasodilation
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Rationale and intraoperative medication related problems of
maintain low pCO2 and vasoconstriction
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Rationale and intraoperative medication related problems of nitrous oxide
only as a supplement to other anesthetics
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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
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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
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Rationale and intraoperative medication related problems of hypertensives (pressors)
persistent hypotension intraoperatively
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Intraoperative monitoring for cardiovascular system
- Pulse
- ECG
- pulmonary artery catheter for CO
- blood pessure by indwelling arterial cannula or external automatic sef-inflating cuff
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intraoperative monitoring of respiration
end-tidal expired CO2
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intraoperative monitoring of air embolism
end-tidal expired CO2 precordial doppler
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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
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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
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Lateral position - risks
- ulnar nerves should be carefully padded
- axilla should be well protected
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severe complication associated with sitting position
- air embolism
- the greater the elevation of head over rt atrium the greater the risk
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advantage to sitting position
less venous oozing
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surveillence for air emboli
- precordial doppler
- monitoring end tidal CO2 for decrease caused by room air filling alvioli
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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
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unchecked air embolism may cause
severe rise in R heart pressure due to pulmonary embolism
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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
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SAH/IVH managment
CSF drainage from subarachnoid space
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Vasospasm following SAH managment
Maintain blood volume and pressure
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CSF leak from operative site managment
CSF drainage, proper positioning
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Respiratory insufficiency
- treat atelectasis
- intubation if severe
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Seizure management
remove source of cortical irritation and hemorrhage
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Postoperative clot formation
may require direct evacuation of clot
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infection management
early or late: abx, drainage, debridement
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inappropriate serum dilution management
- fluid restriction
- hypertonic saline
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