神經外科工作手冊
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Hypertension |
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神經外科的病人有許多疾病上的差異，他們的生命較危急，在接觸時必需記得態度要更親切，言語要柔和，患者的家長或親戚也比通常來的擔心，憂慮，所以我們言談中要感同身受，多為他們設身處地想一想．
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星期二 |
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7:30pm |
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星期三 |
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12:30am |
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星期四 |
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星期五 |
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7:30am |
3. 門診時間表:
a. 星期一夜診, 三，五上午
9:00-12:00
OP Day: 星期二,四
a. 根據病歷書寫要點完成病歷
b. 更新或 D/C iv.
Fluid, narcotics, antibiotics, Foley
b. 查看有否新照會
c.
Check bandages too tight?
d. Sedation for all child
needs a study and not cooperative
e. Check New patient and
Pre-OP order and Labs
f. Discharge note: as
detail as possible. The following items are most important:
1. Discharge
diagnosis: should include all problems diagnose in admission including
meningitis, pneumonia, DM, DI, hypertension and major diagnosis
2. List of procedures
performed: surgical procedures as well as invasive floor procedures such as
spinal tap, lumbar drain, CVP, ect.
3. Make discharge order
and Complete discharge note and transfer note the day before discharge if you are sure patient will discharge on
next day.
4. Write all transfer note
and 診斷書 (何時入急診,何時入院,何時出院, 何時入加護病房,何時轉出加護病房,手術日期及名稱,開顱手術,腦室腹腔引流手術,椎弓切除術,脊椎內固定術,脊椎骨融合術…….and also
include discharge diagnosis and list of procedures performed.
**.
If there were any problems please notify senior resident or attending doctor
immediately.
g.出院患者請約一週後回診藥物要帶足夠
1. 頭部外傷及腦中風Cranioplasty術後患者先以Dilantin
IV drip 三天如果沒有發作, 改為口服但是兩者要Overlap
ie. 60kg:
Dilantin (250) 15mg/kg---900mg – 4amp in NS 200ml
run > 30mins; then 5mg/kg/day------100mg
ivd q8h
第三天改Dilantin
1#tid and DC IV Dilatin CM
2. Hypertension患者要給regular
anti-hypertension藥物再加prn. ie. Adalat
(5) 1#qid and 1# SL q4h prn, keep SBP< 160mmHgh #. Fluid
< 10 kg......100 x BW ------- 4ml/kg/hr; 10-20 kg.....50 ------- 2ml/kg/hr
>20 kg.......20X (BW-20)-----
1ml/kg/hr, So BW
> 20kg need least 1500ml/D
I. Transfusion:
WB: Hct:30-35% Rate:0.5ml/kg/hr for first 20-30min; not over 6ml/kg/hr in child Dose: 3 ml/kg will increase Hct 1% or Hb:0.38/d
PRBC: Hct:70-90% Rate:don't over 5ml/kg/hr in child
Dose:1ml/kg
will increase Hct 1% or Hb:0.3mg/dl PRBC ml=BW x 80ml/kg x (理想 Hb- 現在 Hb)÷ 23
*. Following surgery, Decardron
(Dexan) is usually tapered over a period of range. Taper slower in a patient
has been on it for a long time (>1 month).
For example. If a patient is on 5mg q6h, you could order: 5mg q8h x 1 day, 5mg
q12h x 1 day and 5mg qd x 1 day then d/c.
Also notice the side effect of steroid:
a. GI bleeding: use antacid or H2 blocker for prevention Tagamet 5mg/kg/dose q6h
b. Hyperglycemia: If glucose rise above 250, consider a more quicker taper.
c. Immunosupression: Mask fever, If patient develops an infectious complication, strongly consider a rapid taper.
d. Poor wound healing
*. For intractable cerebral edema:
Lasix 1mg/kg + Mannitol 0.5mg/kg q6h, hold for Osm> 320
For adult: Lasix 20mg + Mannitol 50gm q6h, hold for Osm> 320
Watch for rising creatinine, metabolic alkalosis, hypokalemia
a. Following surgery in the region of pituitary stalk (3rd ventricle tumor, craniopharyngioma, pituitary adenoma, optic glioma)
b. Monitor urine output and urine sp. gr. q2h and check serum Na q4h for 24 hrs.
c. If urine output > 4cc/kg/hr and urine sp. Gr. < 1.003
d. Mx:
1. consult 內分泌
2. fluid supply:
a). if u.o. < 42 cc/m2/hr--D51/4S at 42cc/ m2/hr
b). if u.o > 42 cc/m2/hr--D51/4S to match the cc for cc up to a maximal 125 cc/ m2/hr
if on this regimen, the srum Na rise above 150meq/dl, then the maxiaml fluid replacement may be liberalized to 250 cc/m2/hr or add glypression
To use glypression:
qa). Reduce IV fluid to 42 cc/m2/hr
b). Start Glypression 0.0125ml nasal instilation q12h to qd or DDAVP 1/2 vial iv qd to q12h, if not enough, may increase dose
To limit fluid intake when using Glypression or it may lead to SIADH
All NS hypertensive cases need to rule out IICP before treating it.
Perdipine
(10mg/10ml) : run 2ml/hr. or 5amp/50ml NS run 4ml/hr
Labetolol (Trandate 25mg/amp): IV infusion, 8amp in 250 ml D5W run
10ml/hr ,Hold Labetolol when HR< 60
Nipride50mg/500cc D5W at BW/3/hr cc, Not use Nipride over 24-48 hrs
NTG
50mg/500cc D5W at BW/3/hr cc…………..Weaning off iv. Anti-hypertensives
血壓的控制：有高血壓病史的病人，MAP>130 mmHg 即需開始降血壓， 且對於剛開顱手術者其MAP不高於110 mmHg。
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若SBP> 230mmHg或DBP > 140 mmHg，且重覆5分鐘測量，連續2次都高需快速降壓時，應考慮給予Nipride |
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收縮壓在180-230mmHg之間，舒張壓在105-140mmHg之間，或平均動脈壓>130mmHg，且每20分鐘重覆測量，連續2次都高時，可給予Labetalol 10-40 mg bolus 後，再5-100mg/h間歇性靜脈注射，或連續點滴。若有氣喘病不能使用labetalol時，可使用Perdipine 靜脈注射。 |
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收縮壓＜180mmHg，或舒張壓＜105mmHg，暫時尚可不必使用降壓藥。 |
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若收縮壓＜90mmHg時，則必須給升壓劑。首先應先給補充體液，以增加體液容量，如等張生理食塩水isotonic-saline、colloids 或FFP，且以CVP或PAWP 監測。若此法尚不能提升血壓，則可給Pre-mix Dopamine +
1 amp Levophed run 20cc/hr將SBP提升至100mmHg以上。 |
M. Increased Intracranial Pressure IICP: drug
a). Give iv. Gram + prophylaxis for patient with ICP monitor
b). Head up to 30 degree or greater, remove all neck restriction
c). Diuretic + Mannitol to keep serum Osm (290-320)
d). Hyperventilation to PCO2 of 30-35
e). Drain CSF
f). Sedation without paralysis: Fentanyl 100-200ug/hr +/- Versed 1-2mg/hr
g). Sedation with paralysis: Vecuronium 0.1mg/kg, then after 20 mins, start 1ug/kg/min upto 1.3 ug/kg/min
for long-term sedation and paralysis Pancuronium is better dosage as Vecuronium
h). Pentobarbital coma: Load 10mg/kg over 30min, then 5mg/kg q1h x 3, then 1mg/kg/hr, titrated to keep serum pentobarb 3-4m/dl or to maintain a "Burst-suppression pattern" on EEG.
i). Control Body temperature
By NSAID, Ibuprofen, Cool blanket
N. Hyponatremia:----先看看有否使用mannitol if so, may tape it first and ----
Na < 133: fluid restriction to 1500-800ml/day and check Na, K Cl qd
Na< 126: 3% NaCl 30cc/hr and check Na, K, Cl q6h till Na> 126, then DC 3% NaCl change to NS run 90cc/hr and check Na, K, Cl q12h till Na > 130
Na < 120: 3% NaCl 50cc/hr and check Na, K, Cl q4h till Na> 126, then change to 3% NaCl 30cc/hr and check Na, K, Cl q6h till Na > 130
O. Pressors for vasospasm in SAH:
1. Goals: MAP>100mmHg, CVP > 8-10cmH2O, Cardiac index >5
Dopamine 200mg/250cc D5W at 6-20ug/kg/min
If Dopamine fail or tachycardia
Add Phenylephine 10mg/500ml NS at 40-180ug/min
If failed add
Dobutamine 250mg/250cc NS at 5-15ug/kg/min
Correct acidosis
P. Care for Ventricular drainages EVD:
1. Simple Ventriculostomy:
2. Ventricular catheter with a butterfly drain: Shunt-dependent patient has had shunt removed for a shunt infection
3. Externalized shunt --- used when a patient with a VP shunt has had abdominal surgery or an abdominal infection, requiring temporary removal of the peritoneal shunt catheter
Control ICP by two methods:
a. Elevate the drainage bag at 10-20cm above ear EAC
b. Continue drain 8-10cc/hr (adult),
Formation of CSF:
Neonate: 28.8ml/day, 0.02ml/min, 1.2ml/hr
Infant:200ml/day, 0.14m/min, 8ml/hr
Adult:500ml/day;0.3-0.4ml/min, 18-24ml/hr
估計 0.3ml/kg/hr
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EVD不通時切勿irrigate
it without notify senior resident or attending doctors
1. Elevated ICP: elevate 30 degree
2. S/P VP shunt:
keep head down initially after surgery and slowly advance the head of bed
3. During catheter drainage of Chronic SDH:
Keep head down to prevent reaccumulation for 3 days or till the drain clean
4. S/P spinal surgery with dura opened:flat in bed
5. Cranial CFS leak: Keep head elevate 30 degree or greater, unless pneumocephalus
6. Spinal surgery with fusion: reverse Trendelenberg position 0-10 degree until back brace availble
Wound-healing cocktail: Vit. C 1gm qd, Zn 220mg 1d, Vit. A 50000 units qd
T. Analgesia/Sedation: drug
Post-Craniotomy analgesia: Codeine 30-60 mg po/im q3-4hr [ 1mg/kg po q3-4h]
Scanol 10mg/kg/dose po/pr q3-4h
Post-spinal surgery: Morphine 6-10mg sq/im q3-4hr [0.1mg/kg/dose iv. Q2-4h]
Demerol 50-100mg im q6-8h
PCA pump
Sedatives:
Benedryl 25-50mg im/po/iv q2-4hr
Haldol 0.5-4mg po/im/iv q2-4hr
Sedation for ant
child needs a study and night not cooperative --- chloral hydrate 50mg/kg po/pr upto 2gm
Fentanyl 100ug for normal size adult [ 1-3ug/kg/dose]
*. Take with Narcan, Ambu bag
1. Non-enhanced head CT
2. Enhanced head CT
3. Check electrolyte
4. Check anticonvulsant level and correct it
5. Check LFT/CBC
Check for leg tenderness/swelling for a leg thrombophrebitis
6. Consult PT or speech therapy
7. Consult social worker
1. Chest care to prevent pneumonia and aspiration is very important for patient of depressed consciousness and alertness and lower cranial nerve palsy
2. All patients not full awake and ambulatory without a good cough should be on Bronchodilator and chest physical therapy q4h. Initial with Ventolin 0.5cc/2.5cc NS via neb. q4hn or Isoetharine (Bronkosol) 0.5cc/2cc NS via Neb q4h
Patient with thick sputum: add mucomist (Acetylcysteine) 3-5ml 20% solution via neb q6h( Don't use mucomist alone)
Copious secretions: Glycopyrolate (Robinal) 0.1mg iv/im q4h
For stridor: Racemic epinephrine (Vaponefrin) nebulizer 0.3cc/2.5cc NS q4h
Low tidal volumes has trouble to wean off ventilator: Theophylline 100mgpo/iv q6h) and check by level to increase diaphragm excursion
Aspiration pneumonia: Clindamycin 600mg iv q6h+ GM 80mg iv q8h
Chronic or intubated patient with empiric pneumonia: Cetazidime 1gm iv q12h+ Ani-pseudomonal aminoglycoside
For patient received posterior fossa surgery: check cough and gag reflex before first diet.
1. Focal seizure: no consciousness loss: no acutemedication, check anticonvulsant level, Electrolyte, Glucose, Mg2+, Ca2+
2. Grand mal: Treat aggressively drug
CSF routine
Vancomycin 1g iv. Q12h + Ceftriaxone 1g iv. Q12h
Tracing CSF culture result antibiotics
Most common in first 24 hr
Attention to BP control
Any new, unexpected neuro deficit in a post-op patient warrants a stat head CT
Notify Senior or attending doctors
All who are not full-ambulatory patient should be on Pneumoboots and start Heparin on post-op day 1(5000 units sq bid or 3000 sq bid for age>70)
Check for leg swelling daily, remember DVT when patient start to have sudden tachypnea, hypoxia, pleuritic chest pain and call for VQ scan and venous ultrasound
Solumedrol (500) : 30mg/kg stat. for 15 mins; then 5.4mg/kg/hr 以60kg patient為例: 1800mg stat, then 5amp in 500ml IVF run 60 cc/hr (300mg/hr)
< 3hr give 23hr, > 3 hr give 48hr