Neuro- LGH document

Question 1

Craniotomy vs Cranioplasty vs Craniectomy

Answer 1

Craniotomy = surgical opening into the skull

Cranioplasty = surgical procedure to correct a defect in the skull

Craniectomy: removal of part of the skull

Question 2

T/F: if increased ICP is a concern, you should avoid midazolam

Answer 2

True (sedation can lead to hypoventilation/hypercapnia and lead to swelling of the brain and increased ICP )

Question 3

What are some things you want to know about your neuro patients?

Answer 3

1. Baseline BP
2. Baseline neuro status
3. MRI- any edema, midline shift, ventricular changes
4. Lytes- may have abnormalites due to diuretics
5. anticonvulsants

Question 4

Mannitol concentration and dosing

Answer 4

12. 5mg/50mls

0. 25-1mg/kg over 10 minutes

Question 5

Dosing of furosemide - why might you give this instead of mannitol?

Answer 5

10-20mg

-for patients with cardiac disease who may not tolerate excess volume load

Question 6

Nitroglycerin - what should you dilute it down to?

Answer 6

40mcg/ml

> 400mcg/1cc –> dilute in 9cc NSS for final concentration of 40mcg/ml

Question 7

Why might you want to avoid fluids with dextrose in neuro patients?

Answer 7

because it exacerbates ischemia – increases neuronal lactate production > increases edema

Question 8

What is a concern with NSS and what would you do if it were developing? How would you know?

Answer 8

Hyperchloremic metabolic acodisis

-check ABG and BMP

Question 9

What part during the case would you want to hyperventilate and why?

Answer 9

immediately post induction > cerebral vasoconstriction, decreases ICP

Question 10

Where does Dr. D want PaCO2?

Answer 10

28

Question 11

Where should your MAP be for a craini and why?

Answer 11

> 80 to maintain CPP (MAP-ICP or RAP)

CPP = ….. i forget lol

Question 12

Why would you give labetolol prior to emergence?

Answer 12

bc there is a signficant correlation b/t emergence hypertension and hemorrage

Question 13

When should you reverse the crani patient?

Answer 13

After the dressing is on the head

Question 14

What should you give prior to suctioning for emergence?

Answer 14

Lidocaine 1.5mg/kg 90 seconds prior to suctioning

Question 15

How much free water is in 1L LR?

Answer 15

100mls

Question 16

What is a cue that mayfield pins will be going in soon and that you should give a bolus of prop and/or fent like now.

Answer 16

when they ask for a headrest clamp

**HAVE THEM READY TO GO

Question 17

It pt is in pins, how much roc should you give

Answer 17

10mg/hr (but it also says to check twitches, so what if they have none….)

Question 18

What can be used as a first line agent if the patient becomes hypertensive?

Answer 18

Propofol!

Question 19

What should the temp be maintained at?

Answer 19

normothermia to low normal

Question 20

What does hyperthermia do?

Answer 20

increase swelling and worsen damage

Question 21

A decrease in temp by ____degrees is neurologically protective

Answer 21

2 degrees

Question 22

HOB degrees if in pins and why

Answer 22

15-30 degrees

-facilitates venous drainage/CSF drainage

Question 23

How are the arms positioned for crani?

Answer 23

on armboards at side (get extension)

Question 24

Order of incision: Skin > _____ > _______

Answer 24

Skin > Bone > Dura

Question 25

What’s important to know about closing (2 things)

Answer 25

skin/dura closure is painful and may require more anesthetic

2. make take up to an hour to close

Question 26

How much prop should you give for a sudden spike in BP? What else should you do?

Answer 26

50-100mg

deepen gas

Question 27

When would mannitol be requested if it’s gonna be? and how much?

Answer 27

25g (100mls)

• bring filters
• make sure foley is present

Question 28

2 cardiac meds not typically used for BP control due to long duration of action and what’s their normal dosing

Answer 28

1. Labetalol: 5-10mg bolus

2. Hydralazine: 5-10mg bolus

Question 29

How is metopropol supplied, what do some dilute it down to and what dose is typically given?

Answer 29

5mg/5ml = 1mg/ml
dilute in 5cc NSS - 0.5mg/ml

push 1-2.5mg/time unless on metoprolol at home (discuss with provider)

Question 30

If someone is on prednisone, what should you grab form omnicell?

Answer 30

Solumedrol 100mg - may need periop stress dose

Question 31

What should you be aware of if an inpatient is on decadron?

Answer 31

Dosing regimen and last dose given time