Pre-OP and Post-OP Cares 要點
A. Pre-operation General orders要點:
a. Pre-OP NPO時抗癲癇, 氣喘藥物與降血壓藥物不可停藥
甲、抗凝血藥物藥需停藥10-14天
b. 2小時內的手術不必on Foley
c. 所有手術下刀前半小時內要注射一劑Cefamezine
d. Pre-OP Data. EKG,
CXR 要主動去追. 如果有異常請通知主治醫師特別注意凝血功能及有心臟/肺部疾病史的病患
g. Time of NPO pre-operatively:
1. <
3yr:禁water pre-op 4 hr; 禁milk preop 6 hr
2. >
3yr:禁water pre-op 6 hr; 禁milk preop 8 hr
h. 小於兩歲且 NPO
時 IV. Fluid 每 500ml fluid 要加兩支 50%
Glucose
water ie. D5D1/4 500ml + 50% G/W 2 amp run xxxcc/hr
i.
年紀大的及有Pulmonary, cardiac disease
history 的患者,在spine instrumentation手術後,可以住加護病房
j. 手術日自動到開刀房幫忙
C-Spine 手術
1. Pre-op與general/ L-spine 雷同
2. Post-OP 特別注意
1. 傷口有否腫脹甚至影響患者呼吸
2. 注意患者手腳力量.感覺.神經系統是否與術前一樣
3. 躺在床上不需要戴頸圈. 要起床前記得戴頸圈至少3個月
4. hemovac <5cc可拔
B. Pre-OP survey:
1. CBC, D/C, Platelet, ,PT, APTT, Sugar, Na, K, Cl, BUN, Cr, GOT.GPT, CXR, EKG, L-spine dynamic XR: AP + lat+ Flex + Ext自己開單並勾選以免護士沒勾到
2. Spine for OP age > 60
甲、Cardiac echo
乙、Pulmonary function test
丙、Consult 麻醉
丁、Consult CV if problems
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TPS, cages |
PRBC6u, FFP 6u |
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S-SAH (Aneurysm) |
PRBC 6u, FP 6 u |
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L-HIVD, VP shunt |
只要Hb大於10就不必備血 |
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Hypertensive ICH |
PRBC 6u, FP 6 u |
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C- and L-laminec- tomy >2-level |
PRBC 2 u |
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Spontaneous ICH |
PRBC 6u, FP 6 u |
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C-Spine injury |
PRBC 2 u |
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IVH for EVD only |
No blood needed |
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MVD for TN/HFS |
PRBC 2u, FFP 2 u |
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Traumatic EDH, SDH, ICH |
PRBC 6u, FFP 6 u |
Cefamezine 1 vial iv. Q6h, voren,
dorsiflex, iwell, sennocort
甲、首要注意患者手腳力量.感覺.神經系統是否與術前一樣
乙、手術後在床上可以正常活動
丙、訂背架
丁、拔除後Hemovac才開始換藥
戊、術後裝置PCA的患者在拿掉PCA之前勿拔掉Foley, 注意有否腹脹,便秘,嘔吐….如果發生要 call 麻醉
己、Hemovac少於30-50cc即可拔除最多放4天, 如果Hemovac內有CSF則Hemovac改為不加壓,重力引流,一天後拔掉. 拔掉時記得帶3-0 Nylon把hemovac 的洞縫緊.
庚、Remove HemoVac連串步驟
i.
Check L-spine AP+ Lat(限於有內固定器)
ii.
Change dressing
iii.
DC iv. CM.
iv.
DC antibiobics CM.
v.
Remove Foley
辛、Spine 有打內固定器的患者,要等穿上背架以後才能下床活動
壬、一般7天拆線
如果是redo的要等14天所以乾脆門診回來再拆
a. Remove scalp and spine sutures at 7th day如果是Re-Open case最好等兩星期
b. 頭上裝有EVD, ICP monitor, hemovac及 spine 有Hemovac 的患者一定要給第一線抗生素,等到拆除管線後才開始換藥並DC antibiotics
c. IV 抗生素停掉以後不需要給口服 抗生素
e. 術後裝置PCA的患者在拿掉PCA之前勿拔掉Foley
f. Hemovac少於30-50cc即可拔除, 如果Hemovac內有CSF則Hemovac改為不加壓,重力引流,一天後拔掉. 拔掉時記得帶3-0 Nylon把hemovac 的洞縫緊.
i. Stroke and brain injury 患者住院中不可以開外傭申請書,勞保傷病診斷,殘障診斷書等
1. antibiotics iv. x 7 days
2. Dilantin iv x 3 days then change to oral
3. hemovac < 50ml 可拔
4. 傷口等拔掉HV才開始換藥
5.
住院7天. 一般14天拆線,
1. GCS, ICP, VS q1h
2. I/O q2h
3. Head up 30 degree
4. N/S run 60cc/hr
5. Cefamezine 1 vial iv. Q6h
6. Zantac 1amp iv. Q12h x 3 days
7. Mannital 75cc iv q4h if ICP> 20mHg
8. Keep CPP> 70 if ICP > 20mmHg
9. Call me if ICP > 30mmHg
10. Dilantin 6vial iv. Slowly st.
11. Dilantin 1 vial IV drip q8h
12. check serum OSM qd if use mannitol, keep Sosm< 300
13. Record HV q8h
14. 傷口等拔掉HV/ICP才開始換藥
15. 一般7天拆線
16.Moring care, 抽痰 前5分鐘Dormincum 1amp iv.
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1.Order for head injury =
Sign OP & Anesthesia permit =
NPO 視手術時間及年齡而定 =
D5S 500ml + 50% G/W 2amp run ___ cc/hr (< 2 歲) = 剃光頭 =
Prepare PRBC x units, FFP x units =
Cefamezine 1vial to OR = Take
Dilantin x amp to OR =
ICU orientation =
Send patient to OR on call |
2. Order for Vertebroplasty =
Sign OP & Anesthesia permit =
NPO post-midnight =
D5S run 90cc/hr =
不必備血 =
Send patient to OR on call coming morning |
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3. Order for Lumbar
Laminectomy & microdisectomy, Cranioplasty =
Sign OP & Anesthesia permit =
NPO post-midnight =
D5S run 90cc/hr = Prepare PRBC 2 units(兩節以上的 Laminectomy) =
Cefamezine 1vial to OR = Send patient to OR on call coming
morning |
4. Order for Lumbar TPS and
Cages = Sign OP(脊椎手術and 椎體護架同意書) & Anesthesia permit =
NPO post-midnight =
D5S run 90cc/hr
= sign PCA, Cages, Burr 自費同意書 =
Prepare PRBC 6 units, FFP 6units =
Cefamezine 1 vial to OR = Send patient to
OR on call coming morning |
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6. Order for Cervical
spine*. Patient with Skull traction =
Sign OP & Anesthesia permit =
NPO post-midnight =
D5S run 90cc/hr =
Prepare PRBC 4units, FFP 4units =
Cefamezine1vial to OR = 睡翻轉床 coming
morning on call = Send patient to OR with soft neck
collar on call coming morning |
5. Order for Cervical spine*. Posterior fixation/ Halifax/Laminoplasty =
Sign OP & Anesthesia permit =
NPO post-midnight =
D5S run 90cc/hr =
Prepare PRBC 4units, FFP 4units =
Cefamezine 2vial to OR = 睡翻轉床
coming morning on call = Send patient to OR with soft neck
collar on call coming morning |
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7. Order for
MVD (Microvasculae decompression) for Trigeminal neuralgia/Hemifacial spasm = Sign OP(腦部手術) & Anesthesia permit =
NPO post-midnight = 不剃頭 = 術後轉SICU 訂床 =
D5S run 90cc/hr =
Prepare PRBC 4units, FFP 4units =
Cefamezine 1vial to OR = Send patient to
OR on call coming morning |
8. Order for V-P shunt,
EVD, =
Sign OP & Anesthesia permit ( V-P shunt) =
NPO 視手術時間及年齡而定 = D5S 500ml + 50% G/W 2amp run ___
cc/hr = 剃光頭 =
Cefamezine 1 vial to OR =
*. (If Hb > 10 不必備血) = Send patient to OR on call coming
morning |
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9. Post-Vertebroplasty Orders
1. Vital sign q30min x2, Q2h x2, Q4h x2 then q8h
2. Check Neurological state q30 mins x 4: evaluate lower extremities
for any motor or sensory deficit
3. IVF: D5S run 60 cc/hr x 1day
4. Cefamezine 1 vial q6h x 4 doses
5. Notify Dr. 莊活力 immediately for any of
following conditions
acute short of breath
Increased back or extremities pain
Any neurological change
6. Check gauge q 30 mins x 4
7. Lie flat for 2 hours
8. Check L-S spine X-ray CM |
10. Order for supratentorial craniotomy: brain tumor, Aneurysm, AVM =
Sign OP & Anesthesia permit =
NPO 視手術時間及年齡而定 = D5S 500ml + 50% G/W 2amp run ___
cc/hr = 剃光頭 = Prepare PRBC 6 units, FFP 6 units =
Cefamezine 1vial to OR =
SICU orientation = Send patient to OR on call coming
morning |
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11. Order for transsphenoid
hypophysectomy =
Sign OP & Anesthesia permit =
NPO post-midnight =
D5S run 75cc/hr = Solucortef 2 amp in D5W 500ml run
20cc/hr = 剪鼻毛 =
Prepare PRBC 4 units, FFP 4 units =
Cefamezine 1vial to OR =
SICU orientation = Send patient to OR on call coming
morning |
12. Order for stereotactic
biopsy =
Sign OP & Anesthesia permit =
NPO 視手術時間及年齡而定 = D5S 500ml + 50% G/W 2amp run ___
cc/hr = 不剃頭 =
Cefamezine 1vial to CT room = Send patient to CT room on call coming
morning |
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13. Order for Cervical spine*. Anterior disectomy/Caspar plate =
Sign OP & Anesthesia permit =
NPO post-midnight =
D5S run 90cc/hr = Prepare PRBC 2units = Send patient to OR with soft neck
collar on call coming morning |
7. Order for hyperhidrosis, Scalp mass,
Carpal tunnel syndrome..... = We will do Pre-OP Chest XR CBC at
OPD = Post-OP order: Cefamezine 1 vial
stat =
Cataflam 1# qid x 5days =
Gowell 1# qid X 5 days =
Keflex 1 # qid x 3 days =
Return to Clinic 1 week later |
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