Transcript Essentials of NSU and Cardiothoracic Surgery

Essentials of
Neurosurgery
Michelle Miller, PA-C
Primary Care Associate Program
July 12, 2005
Introduction
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Conditions treated by Neurosurgery
Other surgical specialties
Role of Primary Care Providers
Diagnosis
When to refer
Post-operative follow-up
Common post-operative conditions
Conditions Treated by
Neurosurgeons
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Hydrocephalus
Trauma to head or spine
Degenerative spine diseases
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Disk herniations
Spondylotic disease
Spinal instability
Neurovascular disease
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Aneurysms & arteriovenous malformations of the brain & spinal cord
Carotid stenosis
Intracranial hemorrhage of any etiology
Conditions Treated by
Neurosurgeons
Conditions Treated by
Neurosurgeons
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Neurooncology
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Tumors
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Brain & meninges
Pituitary gland
Spine & spinal column
Conditions Treated by
Neurosurgeons
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Peripheral nerve injury or entrapment
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Carpal tunnel syndrome
Congenital malformations
Medically intractable disorders
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Movement disorders (Parkinson’s)
Epilepsy
Chronic pain
Other Surgical Specialties
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Orthopedic Surgery
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Spinal instrumentation
Traumatic injuries
Plastic Surgery
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Peripheral nerve
entrapment
Other Surgical Specialties
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Vascular Surgery
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Carotid endarterectomy (CEA)
Role of Primary Care Provider
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Initial diagnosis and treatment
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Symptom management
Referral to specialty care
Identification of emergent versus urgent conditions
Coordination of care
Pre-operative clearance
Post-operative care
Healthcare Maintenance
Record-keeping
Case Study
35 year old female presents to your office following her
vacation for c/o of chronic headaches, described as
“sinus pain,” for approximately 6 months. She denied any
recent illness, fever or congestion. She did mention that
during her vacation she fell, but denied any injury. She
stated, “ I lost my balance.”
Discussion
Brain Tumors
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Primary brain tumors
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Benign versus malignant
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Glial cells
Neuronal cells
Meninges
Primary malignant brain tumors rarely metastasize but are locally
invasive of surrounding parenchyma
Benign tumors are encapsulated
Grade IV astrocytoma (glioblastoma) is the most common
primary brain tumor of adults
Glioblastoma Multiforme (GBM)
Brain Tumors
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Metastatic disease (secondary brain tumors)
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Malignancies with the greatest tendency to metastasize to
brain
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Lung
Breast
Renal
thyroid
Corticosteroids in Neurosurgery
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Introduced into Neurosurgery in the 1960’s
Radically improved the acute management of brain
tumors
Steroids are used to treat edema caused by recent
surgical manipulation
How do they work?
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By stabilizing the blood-brain barrier, corticosteroids
effectively reduce vasogenic edema in the brain or spinal cord
associated with tumors
Corticosteroids in Neurosurgery
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Decadron (dexamethasone)
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Most commonly used corticosteroid
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Pure glucocorticoid with no mineralcorticoid effect (unlike
prednisone or hydrocortisone)
Can be given enterally or intravenously
Side effects
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GI bleeding
Hyperglycemia
Immunosuppression
Poor wound healing
Psychosis
Long-term steroid use: osteoporosis, fat redistribution, myopathy
Seizures
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Caused by synchronous paroxysmal discharge from
cerebral cortex
Frequently, a seizure is the first presentation of an
intracranial lesion, especially with brain tumors
Anticonvulsant prophylaxis
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Before & after surgery
Titrated according to blood levels and seizure control
Anticonvulsants
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Dilantin (phenytoin)
Luminal (phenobarbital)
Tegretol (carbamazepine)
Depakote (valproic acid)
Neurontin (gabapentin)
Keppra (levetiracetam)
Dilantin
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Most commonly used first-line anticonvulsant for a
patient with a new presentation of generalized or focal
seizures
Dilantin allergies
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Red macular rash
Unexplained fever
Altered liver function
Dilantin overdose
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Arrhythmias
Hyperreflexia
Dysarthria
Confusion
Nystagmus
ataxia
Blood Pressure Control
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During & after intracranial surgery, control
of hypertension is critical for the
prevention of brain hemorrhage
Fluid & Electrolyte Management
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Volume status
Hyponatremia
Disorders of ADH regulation
Hyponatremia
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Should be avoided in neurosurgery patients
because it exacerbates brain edema and lowers
seizure threshhold
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Normal adult values: 135-145 mEq/L
Ventriculoperitoneal (VP) Shunt
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A Ventriculoperitoneal shunt is surgically placed
to relieve intracranial pressure caused by
hydrocephalus
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Intracranial hemorrhage, spina bifida, brain tumor,
meningitis, encephalitis
Ventriculoperitoneal (VP) Shunt
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When ventricles become enlarged with cerebrospinal
fluid
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Brain tissue becomes compressed against the skull
Excess fluid accumulates around the brain causing an
increase in intracranial pressure
Serious neurological problems result
Shunting is necessary to drain the excess fluid and
relieve pressure in the brain
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Excess pressure can cause a decrease in blood flow to the
brain leading to brain damage
Ventriculoperitoneal (VP) ShuntCraniotomy for Cerebral Shunt
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Performed in the OR
under general anesthesia
A flap is cut in the scalp
and a small hole is drilled
in the skull
A small catheter is
passed into a ventricle of
the brain
A pump (valve which
controls flow of fluid) is
attached to the catheter
to keep fluid away from
the brain
Ventriculoperitoneal (VP) Shunt
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The fluid is shunted from the ventricles of the
brain into the abdominal cavity
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In some cases, the fluid is shunted to the pleural
space in the chest
A pump controlling fluid flow is attached to the
catheter to keep the fluid away from the brain
Another catheter is attached to the pump
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It tunnels under the skin, behind the ear, down the
neck and chest and into the abdominal cavity
When to Refer
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Emergent referrals
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Emergency Department
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Mental status changes
Cauda equina syndrome (nerve compression)
Motor deficits
Sensory deficits
Bowel/bladder incontinence or retention
radiculopathy
Urgent referrals
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Neurosurgeon
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Conservative therapies fail
Post-operative Follow-up
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Surgery date?
Suture/staple removal
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Wound care
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Laboratory follow-up?
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Infection, drainage, swelling, pain?
Drug levels
Chemistries
Medication management
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Long & short term management
Antiepileptic
Sleep aides
GI upset
Post-operative Follow-up
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Pain management
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Physical Therapy
DMV clearance
Support groups
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Precautions
Drug interactions
Depression
Issues of death & dying
Chemotherapy and Radiation
Catheters
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Hickman catheter
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Long-term, central venous indwelling catheter with external
port(s)
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Venous placement- subclavian, under clavicle
Placement in OR or via radiology
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Infusion of blood products, nutrition, chemotherapy
Must be meticulously cared for to prevent infection
Fluoroscopy-guided placement
Requires CXR to confirm placement prior to use
Hickman Catheter
Review Questions
Questions
A 6 year old male is struck by a car while riding
his bicycle. He is reported to be unconscious for
2 min following the accident. He is conscious
and alert upon arrival to the ED, but within 45
min, he begins to vomit and shortly thereafter
he becomes completely unresponsive. Which of
the following most likely explains the child’s
injury?
Answer
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Acute subdural hematoma
Chronic subdural hematoma
Acute epidural hematoma
Acute traumatic subarachnoid hemorrhage
Grade III concussion
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Acute subdural hematoma
Chronic subdural hematoma
Acute epidural hematoma
Acute traumatic subarachnoid hemorrhage
Grade III concussion
Answer
This is a classic history of an epidural hematoma. The typical
presentation is that of a child who sustains a hard blow to the
head and experiences a brief loss of consciousness, followed
by a lucid interval, when the child is awake and alert. As the
hematoma expands, the patient experiences a headache
followed by vomiting, lethargy and hemiparesis and may
progress to coma if left untreated. This injury usually results
from a temporal bone fracture with a laceration of the middle
meningeal artery or vein and less often a tear in a dural venous
sinus. Epidural hematomas are treated with surgical evacuation
of the clot and ligation of the bleeding vessel.
Question
Which of the following is/are true of lumbar
disc herniation?
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Most common at the L5-S1 disc
Radiating pain to the buttocks, thigh, calf, and
foot
Often associated with a positive straight leg
raise test
May be complicated by cauda equina syndrome
All of the above
Answer
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B.
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Most common at the L5-S1 disc
Radiating pain to the buttocks, thigh, calf, and
foot
Often associated with a positive straight leg
raise test
May be complicated by cauda equina syndrome
All of the above
Answer
A herniated lumbar disc compresses the nerve root, resulting
in a radicular pain called lumbar radiculopathy. The pain
characteristically radiates to the buttock, thigh, leg, and foot.
When the pain is severe, the pain can be worsened by straight
leg raising and may be limited to 20 to 30 degrees. The patient
may have decreased or absent reflexes, weakness, and
paresthesias or decreased sensation in a dermatomal
distribution. It is most common at the L5-S1 disc followed by
the L4-L5 disc.
Question
The most common intracerebral neoplasm is:
Answer
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B.
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Glioma
Meningioma
Lymphoma
Metastasis
adenoma
Answer
A.
B.
C.
D.
E.
Glioma
Meningioma
Lymphoma
Metastasis
adenoma
Answer
Glioma account for nearly 50% of primary
brain tumors. The remainder are meningiomas
(15%), pituitary tumors (7%) and other
tumors.
Break
Essentials of
Cardiothoracic Surgery
Michelle Miller, PA-C
Primary Care Associate Program
July 12, 2005
Conditions Treated by
Cardiothoracic Surgeons
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Coronary Artery Bypass Graft (CABG)
Valve Replacement or Repair
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Tissue
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Mechanical
Video Assisted Thoracotomy (VATS)
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Xenograft (porcine or bovine)
Homograft (cadaveric human)
Tumor ressection
AAA Repair
Trauma
Transplant Surgery
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Heart
Lung
Coronary Artery Bypass Graft
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Cardiac bypass surgery is an operation to restore the
flow of blood through the arteries that supply blood to
the heart, when a blockage or partial blockage occurs in
these arteries.
The arteries that supply the heart muscle with oxygen
and nutrients are known as the coronary arteries. The
word "coronary" means a crown, and is the name given
to these arteries that circle the heart like a crown. The
narrowing of the arteries of the heart is known as
coronary artery disease, which is the most common
form of heart disease.
Coronary Artery Bypass Graft
Coronary Artery Bypass Graft
Saphenous Vein Harvest
Saphenous Vein Harvest
What to Expect Following CABG
Surgery
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Cardiologist follow-up in 7 to 10 days after
discharge from hospital
Discuss recovery
 Make lifestyle change recommendations
 Fine tune medications as needed
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What to Expect Following CABG
Surgery
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6 weeks post-op:
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most people resume almost all of their regular activities
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As activity increases, strength increases
Patient should be able to walk 2-3 miles in an hour
Driving
Travel
Sexual activity
Return to work
Avoid overexertion
What to Expect Following CABG
Surgery
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Sternum
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12 weeks to heal
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Should avoid the following:
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Heavy lifting
Golf
Tennis
Vigorous swimming
Light activities are o.k.
Graft site
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Leg, arm or both
Wound healing
pain
CABG Discharge Instructions
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D/C Home Instructions
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Call your Surgeon to report any of the following
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No driving while taking narcotic pain medications
No lifting anything heavier than 10 lbs
No baths or swimming
May shower, must “pat dry” incision
Fever greater than101F
Bleeding or pus draining from incisions
Difficulty breathing
Chest Pain
Surgical site pain unrelieved by prescribed medication
F/U in clinic with surgeon approximately 2wks (1 wk if patient
has staples)
F/U with referring cardiologist 4 wks
Valve Replacement
Valve Replacement
Valve Replacement
Valve Replacement
Valve Replacement
Valve Replacement
Valve Replacement
Discharge Instructions
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Discharge Medications
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ASA or Coumadin
B-Blocker
+/- ACE inhibitor
Isosorbide or Ca-channel Blocker if radial artery graft used
Pain medications
Previous prescription meds
Anticoagulation
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Aspirin
Coumadin
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PT/INR monitoring
Pro time
International Normalized Ratio
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A comparative rating of PT ratios (representing the observed PT ratio
adjusted by the International Reference Thromboplastin)
The PT is an important screening test used during management of
oral anticoagulant therapy (Coumadin)
Prothrombin is a protein produced by the liver for clotting of blood
Surgical Population
 In the United States, the fastest growing population
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segment includes people 65 or older
More than half of these individuals will require some
form of surgery in their lifetime
Improvements in surgical techniques, anesthesia and
ICU’s have made surgery in this population possible
1
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Delirium
 Post-operative delirium
 Overall incidence
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 5-10% all age groups
 10-15% elderly patients
Incidence varies with type of surgery
 1-3% following cataract surgery
 5-10% following general surgery
 28-61% following major orthopedic surgery
 47% following cardiac surgery
Delirium
 A significant proportion of these patients will
experience postoperative cognitive impairment
 The most common forms are:
 Delirium
 Postoperative cognitive dysfunction (POCD)
Frequency of POCD
 Definition
 “Deterioration of intellectual function presenting as impaired
memory or concentration.”
 Clinical features
 Range from mild forgetfulness to permanent cognitive
impairment resulting in a loss of independence
 POCD diagnosis can only be made if cognitive decline can
be corroborated by the results of neuropsychological testing
presurgical and postsurgical
 Post-operative cognitive dysfunction
 Overall incidence
 20-60% following coronary artery bypass surgery
 10-16% elderly patients following major non-cardiac surgery
Primary Care Issues
What are your thoughts?
Primary Care Issues
Endocarditis Prophylaxis
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High-risk category
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Prosthetic cardiac valves
Previous bacterial endocarditis, even in the absence of heart disease
Complex cyanotic congenital heart disease
 Single ventricle states
 Transposition of the great arteries
 Tetralogy of Fallot
Moderate-risk category
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Most congenital cardiac malformations
Rheumatic & other acquired valvular dysfunction
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvular regurgitation
Endocarditis Prophylaxis
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Dental procedures
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Extractions
Peridontal procedures
Endodontic procedures (root canal)
Prophylactic cleaning where bleeding is antipated
Other surgical procedures
Endocarditis Prophylaxis
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Oral Antibiotics
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Amoxicillin
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2 grams 1 hour before procedure
Clindamycin
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600mg 1 hour before procedure
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Cephalexin
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2 grams 1 hour before procedure
Azithromycin or Clarithromycin
 500mg 1 hour before procedure
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Post-operative Complications
Post-operative Complications
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Wound infection
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Atrial Fibrillation
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Neurological deficits
Pulmonary Embolus
Transplant
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anticoagulation
Stroke
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Sternum
Chest tube sites
Graft site
Rejection of organ
Other systemic infections
Death
Post-operative Follow-up
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Pain management
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Physical Therapy
DMV clearance
Support groups
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Precautions
Drug interactions
Depression
Transplant
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Primary Care
Discussion