Caring Behavior in Patients with

Awake Brain Surgery

MG Enny Mulyatsih, Skep, Ns., M.Kep, Sp.KMB

Nursing Faculty – Universitas Airlangga, Surabaya Indonesia
National Brain Centre Hospital, Jakarta Indonesia
MG Enny Mulyatsih, S.Kep, Ners, M.kep, Sp.KMB
 Doctoral Student of Nursing Faculty, UNAIR
 Chair of the Nursing Committee, NBC Hospital
 President of Indonesian Neuroscience Nurses
Association (INENA)

2
 Outlines
01 Background
02 Brain Tumor
03 Awake Brain Surgery
04 the Swanson’s Caring Theory
.

Caring behavior in Patients with Awake

05 Brain Surgery

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 Background
Incidence NBC Nursing Diagnosis

The incidence of
Brain Tumor: 517 Knowledge deficit
brain tumors in the
patients (2020) Anxiety
last 20 years is (Hickey, 2014)
increasing in all ages;
however, it has ABS: 56 patients
grown more than 40 (2019-2021)
percent in adult
person
Profesional, high
moral, and “Caring”
 Effect of Caring Problem
QoL

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 Brain Tumor

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 Signs & Symptoms
• Headache Increased of ICP:
• Nausea Decreased LOC
• Vomiting Trias Cushing:
Hypertension,
• Seizure
Bradycardia, abnormal
• Hemiparesis breathing
• Other neurological
deficit
Hydrocephalus

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 Supratentorial
• Frontal: dysphasia,
dysarthria, emotion,
personality, hemiparesis
• Temporal: aphasia,
memory deficit
• Parietal: sensory
impairment, calculate
impairment
• Occipital: visual
impairment, visual field
impairment

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 Infratentorial
Cerebellum: balance
disturbance, ataxia,
tremor
Hemiparesis
Cranial Nervous
disturbance: diplopia,
ptosis, dysarthria,
audio disturbance,
vertigo, dysphagia

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 Brain Tumor
The association between incidence and mortality of brain
cancer and human development index (HDI): an ecological
study (Khazaei et al, 2020)

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 Awake Brain Surgery

Awake Brain Surgery or Awake Craniotomy is a

neurological procedure in which the patient is conscious
during part of the procedure (Lekka and Olldashi, 2015)

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Awake craniotomy: indications, benefits, and techniques
(Zhang & Gelb, 2018)

• To maximize tumor resection

• Neurological function could be monitor by using
the IOM
• To minimize neurologycal deficit
• To decrease aLOS
• Less cost

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 Morbidity & Complication LOS
Mortality
Postoperative
neurological deficit in
The total number of only 13%. Complication Six percent of
patients who rates were higher in patients required
developed patients who had treatment in the
complications was 33 gliomas, previous intensive care unit,
(16.5%) and the neurologic deficits, and the average
mortality is 1% undergone radiation Length of Stay at
therapy or previous hospital was 1 day..
surgery
 Result of awake surgery for pediatric eloquent brain area
tumors: single center experience (Talabaev et al, 2020)
14 ABS= 12 pediatric patients with
glial tumor at the cortex area
Areas of Brain Tumor
8
7
Neuromonitoring intraoperatif 7
6
5
4
4
3
2
1
1
0

Speech Motor Visual

Total tumor resection: 8 Area Area Area
cases (66,7%)

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 Nursing Diagnosis:
Knowledge deficit and
Anxiety

CARING

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 Swanson’s Caring Theory (ALLIGOOD, 2013)

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 Assumes of Caring by Swanson

HUMAN BEING NURSING

Unique Need other sciences
Bio-psycho-socio-spiritual Recovery, healthy and well
Chane and to be change being
CARING

HEALTH
 healthy and prosperous
 The unity of spirituality, thoughts,
feelings, intelligence, creativity,
femininity, masculinity, and sexuality
ENVIROMENT
 Situational
 influence or be affected by the client cultural,
political, economic, social, biophysical,
psychological and spiritual
18
 Nursing Care of
Awake Brain Surgery Patients

Ward Ward
OPD OR PICU
 Caring behaviour for Awake Brain
Surgery Mantaining belief

Offering a hope
Believing in
Believing in Maintain optimism

 Be a good  Provide information

listener
 Speak in easy to be understand
 Be empathy
 Understand  Support patient to be confidence

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 Out Patient Department
Mantaining Enabling
belief

Taking anamnesis with a warm

attitude, listening with full
attention, not interrupting the
patient's conversation,
respecting the patient's privacy
and dignity, respecting the
patient's values, culture, and
religion

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 Neurological Ward (Pre-Surgical)
ERAS (wang et al, 2022)

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Being with Doing for

 Patient should be fasting 6 hours before

surgery
 Patient drinks 200 ml of glucose 3-4
hours before surgery
 Patient Baths with Chlorhexidine
 Available blood supply as indication
 Evaluate of GCS, respiratory system
and cardiovascular
 Basic Laboratory
 Encourage patient to continue previous
routine medications, such as
antihypertensives or corticosteroids
Intra Operative – Awake Brain Surgery
 Anesthesia Nurse
 Scrub Nurse
 Circular Nurse
All nursing interventions during surgical
are aimed to:
 increase the patient’s well being.
improve patient safety and comfort
maintain patient privacy
respect patient dignity

24
Surgical Safety Checklist

The WHO checklist was pilot tested in a global cohort of 3995 patients in
eight countries and showed a reduction of mortality from 1.5% to 0.8% and
post- surgical complications from 11% to 7% with the introduction of the
checklist (Haynes, 2019)
25
Surgical Safety Checklist

26
Anesthesia Technique for Awake Craniotomy

AWAKE Awake-Asleep-Awake
CRANIOTOMY

Maintain patient in
1.Menggunakan anastesi
conscious sedation or umum dengan LMA atau
neurolept analgesia. ETT untuk pengelolaan jaln
napas selama kraniotomi
Sedation will be
2.Saat testing, pasien
discontinued before dibangunkan dan LMA atau
the start of ETT dilepas

stimulation testing 3.Setelah testing dan

reseksi tumor, pasien
Generaly none dilakukan anastesi umum
kembali dan dipasang LMA
airway manipulation atau ETT

4
 Role of Nurses during ABS
(Zhang & Gelb, 2018)

• The goal is to transition smoothly and rapidly without

agitation, confusion, or drowsiness from sedation to
an awake patient.
• The patient needs to be engaged, cooperative,
pain-free and comfortable for mapping and tumour
resection.
• All agents are stopped, although it is sometimes
useful to keep a very low dose of remifentanil (0.01–
0.05 μg/kg/minute or 0.2–1 ng/mL) running or
administering small doses of fentanyl for analgesia.

28
Patient’s Assessment by Anesthesia Nurse
• Introduce as OR Nurse
• Patient's identification bracelet
• Verify for patient's weight and height
• Assess the patient's history of allergies,
medical history previous surgery
• Verify for dentures or there are loose front
teeth

29
Patient’s Assessment by Anesthesia Nurse
• Assess the history of any seizure
• Provide mental support
• Ensure the patient feel comfort
• Encourage patient to urinate or defecate
• Encourage patient to express his or her feeling

30
Mantaining belief

• empathy
• hand-holding
• Reassurance
• ongoing encouragement
• Coaching
• conversation are all useful
and important.
31
Being with Doing for

A sponge soaked
with ice-cold
water can be used
The patient can to wet the
be allowed to patient's lips and
move limbs and mouth for comfort
hips at
appropriate
times An air blanket is used to
provide either warm or
cool air to maintain a
comfortable temperature
 Effects of music listening on anxiety and
physiological responses in patients undergoing
awake craniotomy (Wua a et al, 2017)

• In the music experimental group, patients can choose

reference music to distract them during surgery
• Effect of music therapy for awake brain surgery
patients were decreasing the patient's heart rate
and blood pressure
• It is possible that slow music rhythms can reduce
catecholamine secretion and autonomic nervous
system activity, resulting in a decrease of HR & BP

33
Intra Operative – Awake Brain Surgery

OR_NBC_2022
34
OR_NBC_2022

35
Postoperative Complication

Hemorrhage Peri lesional edema

HYPERTENTION
INFECTION

CSF LEAK SEIZURE

INCREASED ICP
Hypertension DVT
Pain Fever
36
 ICU/ PACU Nursing Interventions:
Monitor vital sign & Neurological Status

Maintain Airway Clearence & Oxygenation

Monitor ICP

Fever Management
Fluid & Electrolite Balanced
Nausea & Vomiting
Control Seizure
Wound Care and Drain
37
ERAS (wang et al, 2022)

38

Preoperative PONV Simple Risk Assessment
Scale.
In the ERAS group, the high-risk patients
(score ≥ 3) were administered tropisetron (a
5-HT3 antagonist, 2 mg) shortly before
extubation for prophylaxis of postoperative
vomiting.
PONV is usually defined as any
nausea or vomiting occurring within
the first 24–72 h after surgery.
Patients in the ERAS group were able to
achieve earlier oral water/ food intake,
ambulation, and removal of the urinary
catheter after surgery. These ERAS
strategies could reduce postoperative
discomfort and anxiety, and improve sleep.
The ERAS patients showed improved
mental state.
39
 A randomized placebo-controlled study of
aromatherapy for the treatment of postoperative
nausea and vomiting (Karaman et al, 2019)
the CRNA dropped two drops of The aromatherapy can
ginger, lavender or rose oil or pure be used as an
water onto a 5 x 5 cm impermeable alternative or
gauze pad. This pad was given to the complementary method
patient, and he or she was asked to for managing PONV.
inhale its scent for 5 min. Fifteen Specifically, the ginger
and 40 min after the beginning of
and lavender essential
the aromatherapy treatment, the
patient’s nausea and vomiting scores
oils were superior to
were re-evaluated. If the nausea the rose oil and pure
score was higher than 1 or vomiting water for the
persisted, an intravenous (IV) aromatherapy
antiemetic drug (8mg of treatments.
ondansetron) was administered.
40
The Koivuranta Nausea and Vomiting Risk Score

• Surgery longer than 60 minutes, female gender,

history of PONV, history of motion sickness, and
nonsmoker
• Each risk factor is one point
• The risk score varies between 0 and 5 points,
where the determined score determines the
risk of nausea and vomiting after surgery

41
 Pain Management
• Monitor pain scale
• Sedation / analgetic – IV Midazolam &
Morphine
• Adequate sedation to reduce the cerebral
metabolic rate of oxygen consumption &
facilitate mechanical ventilation

42
• Early Mobilization
• ROM
How to prevent DVT
• Compression stocking
• DVT pump
• LMWH

43
 Neurological Ward – Post Surgical
Enhanced recovery after elective craniotomy: A
randomized controlled trial (Wang et al, 2022)

Implementation of an
enhanced recovery after
elective craniotomy
protocol had significant
benefits over conventional
perioperative management

44
Early, goal-directed mobilisation in the surgical intensive care
unit: a randomised controlled trial (Schaller, 2016)Level 4:
Standing
Level 3:
Sitting
Level 2:
Passive ROM

Level 1:
No Activity

Ambulation
 Conclusion
Caring behaviour is able to reduce
1 patient anxiety, expedite surgical
procedures, improve nursing quality &
increase patient/family satisfaction

Caring behaviour have to be

2 integrated into every stage
of the nursing process in
Awake Brain Surgery patients
THANK YOU
 References
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