Neurosurgical Nursing

PRCC in Peri-operative Nursing

2021-2022
APN LEUNG CHUI SHAN
OT/PYNEH

1
 Content
• Theatre setting
• Positioning
• Preparation of equipment
• Preparation and the use of instrument
• Specific intra-operative care and post-
operative care on nuerosurgery cases

2
Theater Setting
In major operation such as
craniotomy, prepare

• 2 Biopolar forceps
• 1 Monopolar diathermy
pen
• 2 Suction units which
suction force are
adjustable (100mmHg
after dural opened)

3
 Theater Setting
Shaving trolley
• Surgical clipper
• Green gauze
• Elastoplast
• Marking pen
• Benderm/tegaderm
tap the eyelids closed
to protect from
solution and foreign
objects
4
 Theatre Setting
• Operating Table • Headrest system
• Headrest system

5
 Operating table
• Compatible with Headrest system
• Extreme positioning possibilities
• Low table height

Headrest System
• To firmly hold the head to the operating table
• Mayfield headrest system
• Stainless steel or radiolucent
6
Adaptor for OT Table

7
 Mayfield Headrest System

• Adaptor for OT
Table
• Base Unit
• Swivel Adaptor
• Horseshoe
Headrest
• Skull Clamp
• Crossbar Adaptor
8
 Mayfield Headrest System
Base Unit Swivel Adaptor
Use with head rest
and skull clamp

9
 Mayfield Headrest System

Horseshoe Headrest
• Adult
• Pediatric
• Stainless Steel
• Radiolucent

10
 Mayfield Headrest System
Skull Clamp
• Provides 3-point rigid cranial fixation
• Flexibility and safety in positioning of
skull pins around critical areas
• Quick-release lock
• 80lb Torque Screw Option
60lb for Adult
40lb for Children

11
 Mayfield Headrest System
Skull Pins
• Allow rigid cranial
fixation
• Stainless Steel and
Radiolucent
• Adult and pediatric
• Reusable and disposable

12
 Mayfield Headrest System

Crossbar Adaptor

• For sitting up position

• Allow unobstructed viewing
to occipital areas
• Compatible with most
currently available OT tables

13
 Radiolucent Headrest System

• Carbon fiber material

• For X-ray imaging compatiblity

•Digital Subtraction
Angiography (DSA)

14
 Positioning

Goals of surgical positioning

• Provide optimum exposure and access to the

surgical site
• Maintain body alignment, supporting
circulatory and respiratory function
• Prevent Pressure injury
• Prevent Nerve Injury
15
 Positioning

• Supine
• Lateral
• Prone
• Sitting up

16
 Positioning - Supine
Supine ( Frontal, parietal, temporal)
Head on Mayfield headrest/ Skull Clamp fixed at
desired position by 3 skull pins
Arms tucked, padded & supported
Pillow under knees
Sequential compression device stockings on
both legs
Both heels padded
Safety belt
17
 Positioning - Prone

Prone
With skull pins:
Occipital, posterior
fossa, laminectomy
surgery (upper part)
Without skull pins:
Laminectomy surgery
(lower part)
18
 Positioning - Prone
Prone
Anesthetized on the stretcher in the supine position
ETT secured and the eyelids taped
A softly padded headrest to avoid applying pressure to
the eyes and nose and to provide for airway access
The anesthetist must ensure the endotracheal tube is
not dislodged
Body alignment: no torsion or twisting
Arms if tucked at the side, the palms should lie neutral
against the body 19
 Positioning - Prone
Accessories for Prone Position

20
 Positioning - Prone
Accessories for Prone Position – OSI table

21
 Positioning - Prone

To prevent postoperative visual loss, slight reverse

trendelenburg (head up) position

Postoperative visual loss:

associated with prolong spinal surgery with

instrumentation
the head spending a prolonged period in the down-tilt
position, causing decreased venous out-flow from the
cranium

22
Positioning - Prone

23
 Positioning - Prone
Accessories for Position
Perforated-foam Pad

24
 Positioning - Prone
Accessories for Position
 Positioning - Lateral
Lateral (Retromastoid craniotomy)
Skull clamp applied
Shoulder support on chest
Upper arm is tucked and secured
Lower arm extended by arm board
Upper leg lies straight, lower leg bends
Pillow between legs
Safety belt on lower limbs

26
Positioning - Lateral

27
Positioning - Lateral

28
 Positioning – Sitting up
Sitting up
Rare use
Ultrasound Doppler applied
to detect air embolism

29
 Preparation of Equipment

Ultrasound machine & transducers

CUSA
Navigation System (BrainLab)
Microscope

30
 Preparation of Equipment
Ultrasound machine & transducer
• Assess the lesion size and depth
• Assess the blood flow
• Verious types of transducer for
different operations

Burr-hole Cranial Spinal Cord

Guidance Guidance Guidance
Transducer Transducer Transducer
31
 Preparation of Equipment
CUSA (Cavitron Ultrasonic
Surgical Aspirator)
• Ultrasonic surgical system
• Destroy and emulsify the
target tissue’s cell membrane
• Which are irrigated and
removed through a built-in
suction tube
• Different diameter and length
of tips
Please suck water/NS after each
use to prevent blockage 32
 Preparation of Equipment
Navigation System -BrainLab
• Allow more accurate
preoperative diagnostic and
well-defined surgical planning
• Reduce procedure invasiveness
and risk
• Computer-assisted technology to
guide or navigate within the
confines of skull/vertebral
column during surgery
• Image-guided stereotactic
system 33
 BrainLab
Preparation before operation
• Equipment: Pointer, mayfield
reference clamp, vario reference
clamp, Z Touch

Application procedure
34
 BrainLab
Registration - Surface matching
• A laser is used and the light reflection
is recognized by a special camera
• Use the laser to scan the face
• Camera pick up the laser point and
construct the facial contour
• Facial contour fused with the CT/MRI
3D model
• Don’t hit onto the OT bed when
doing registration
• Don’t hit onto the reference array
even after having registration done
• Safely placed the pointer on table
when in use 35
 Preparation of Equipment
Microscope
• Maneuverability
• Illumination
• HD image
• Integration with navigation system
• ICG vascular fluorescence
• Oncological fluorescence

Prevent collide of
microscope when in
use

36
 ICG Vascular Fluorescence
• IV injection of IndoCyanineGreen
(ICG) dye
• Visualize, check and interpret
intraoperative blood flow quickly
and reliably
• Visualize intraoperative blood flow
in bypass, cerebral aneurysm
surgery, before and after AVM
interventions and to detect
cerebral vessel branch occlusion
• Set up the microscope for
INFRARED 800 before surgery
 ICG Vascular Fluorescence
• Surgeon announces the need a few
minutes ahead of time
• 25mg ICG per injection prepared
• Zoom and focus adjusted, Surgeon IR 800

activates infrared 800 mode

• The ICG must be injected as a bolus
• The fluorescence image appears on
the screen in 10 to 30 second after
ICG administration
• Ensure the field of view is dry in this
period
38
 Oncological Fluorescence
• For patient with malignant glioma
• Patient drink solution containing 20mg
of 5-aminolevulinic acid (5-ALA) before
operation
• Sufficient light intensity in blue light
mode give surgeon the benefit of
observing the tumour
• Side effects: sensitive to light so need to
take nursing care to protect patient -
dark room and protect patient exposure
to light
• Set up the microscope for BL 400 before
surgery
 Anaesthesia for neurosurgical operation

Total Intravenous Anaesthesia (TIVA)

• A method of inducing and maintaining general
anaesthesia exclusively by intravenously
administered drugs
• Standard anaesthetic technique for neurosurgical
operation
• Drugs for TIVA: Propofol (hypnotics), Remifentanyl
(analgesics) and Atracurium (muscle relaxants)

40
 Advantages of TIVA
• Allows rapid and predictable titration of anaesthesia
• Quick induction and reversal
• Swift recovery of consciousness and respiration even
after prolonged administration

41
 Preparation and the use of Instrument

Working trolley setting

Steps of the operation (craniotomy)
Power instrument
Special instrument
Aneurysm Clip
Consumables used in neurosurgical operation

42
 Working Trolley Setting
Skin Prepation Trolley Layout
Disposable towel 75cm X 75cm (with adhesive tape)
LA (2% Xylocaine with Adrenaline)
Short raytec gauze
Abdominal Swab
Hibitane Scrub 4%
Betadine
ChloraPrep (alcohol-based)
Marking pen
+/- Ioban
43
 Draping

1. Disposable drape sheet 2. Disposable 75x75cm x

with the edge placed just 4 & Ioban applied
below the patient’s chin

3. Injecting LA 4. Craniotomy drape

44
Side Tray Setting

45
 Incision & Creating
Muscle Flap
Instruments for scalp
bleeding:
• Raney clip
• Curve-on-side artery
forceps

46
Retract muscle flap

Surgical yasargil spring hooks

47
 Bone Perforation and Dissection
Hudson Brace
 Use in Burr Hole

Power Instrument System

Pneumatic or Electric
High speed drill from 200
- 75000 rpm
Various Attachments
Various Dissecting
Tools 48
 Creating the burr hole and bone flap

• 3 burr holes maybe made by

perforator and burr or bone
flap is separated with dissecting
tool .

• The bone flap is wrapped with

wet gauze and put into a
kidney dish for later use.

49
 Irrigation
• NS is irrigated by irrigation ball with short
blunt needle during operation.
• Temperature of irrigation fluid should be kept
as close as human body temperature (37+/-
2℃).

50
 Opening the Dura
• Dura hook and knife (no11 blade)
• Dura scissors (Jamison)
• Tooth Forceps (Adson/Jefferson)
• 3/0 Mersilk
• *Suction force ↓100mmHg
Dura opened and fixed by
dura stitch held by
straight cushing artery

51
 Surgical Instruments
Self Retaining Retractor - Layla Retractor
• Glove drain is used for preventing direct pressure
onto the brain tissue
• Tighten the arm to ensure the stiffness to maintain
retraction force

52
 Surgical Instruments
Bipolar Forceps
• Various length and size
• Some with irrigation port
• Some with different angle
• Non-stick
• Clean with wet gauze after
using

53
 Surgical Instruments
Micro Instruments (Bayonet
shape)
• Microforceps
• Scissors
Direction on using
• Needle Holder bayonet shape
instruments
• Dissector

54
 Surgical Instruments

Sucker
• Pressure adjustable micro-sucker
• Tear drop shape side port
• Various size & length

55
 Surgical Instruments

Tumor Grasping Forceps

• Various size & length
• Cup shape
• With/without tooth

56
 Surgical Instruments
Aneurysm Clip
• Coil-spring device used to treat
aneurysm
• Isolate aneurysm from the normal
circulation without blocking off any small
perforating arteries nearby
• Variety of blade shapes, lengths, angles
and closing force
• Temporary, permanent , fenestrated
• Function as a vascular clamp or implant
57
Aneurysm Clip

58
 Haemostasis and Closing
Valsalvas manoeuver
• A technique done by anaesthetist to increase the intrathoracic
pressure so that incracranial pressure will be increased in order
to check any venous bleeding
• +/- raw area laid with surgicel

Closing
• Close the dura
• Bone flap fixed with 3 pieces of Craniofix
• Disposable vacuum drain inserted
• Closure of muscle layer
• Closure of skin layer
59
 Consumables for Neurosurgical
Operation
Patties
• Soft & pliable
• X-ray detectable
• Various sizes
• Dip in NS before use

60
 Consumables for Neurosurgical
Operation
Haemostatic Agents
• Bone Wax
• Gel Foam
• Surgical TachoSil
• Tisseel Frozen
• Keep dry before use

61
 Consumables for Neurosurgical
Operation
Dura Substitutes
• Protect brain & spinal cord
• Prevent CSF leakage
• Biological or synthetic
• Non-suturable or suturable
• Various size

62
 Cerebrospinal fluid (CSF) diversion
Permanent CSF diversion
• For hydrocephalus patient: an accumulation of CSF
occurs within the brain
• Ventriculoperitoneal (VP) Shunt
• Ventriculoatrial (VA) Shunt VPSHUNT VASHUNT

63
 Consumables for Shunt
1. Ventricular catheter
2. Various pressure valve: low, medium, high and
adjustable(with siphon-control device)
3. Peritoneal Catheter
3
• Antimicrobial impregnated
2
catheter: BACTISEAL

1
64
 Consumables for Shunt
Adjustable Valve/Programmable valve
• Can change pressure/flow performance level
• setting of the valve with out the need for a revision
surgery

65
 Possible intraoperative complications
 Hypertension
 Raise ICP with intracranial mass lesion due to
direct vasodilatation
 Hypotension
 Hypovolemic shock due to haemorrahge
 Septic shock
 Cardiogenic shock: MI
 Neurogenic shock: paralysis due to spinal cord
injury. Blood pools in venous capacitance
vessels
 Anaphylaxis shock 66
 During Intra-operation
• Ensure T & S and blood transfusion consent
• Monitor blood loss regularly, aware of sudden
increasing blood loss
• Medication administration: anticonvulsant drug,
steroids
• Keep irrigation fluid in body temperature
• Specimen handling

67
 Possible post-operative complications
and care

 Deep vein thrombosis (DVT): Sequential pump

 CSF leakage: observe any S/S
 Facial nerve damage: observe any S/S
 Shock: BP monitoring/?fluid replacement
 Stroke: observe any S/S
 Wound infection: wound site condition/body T

68
 Post-operation Nursing Care in RR
 Monitor vital signs frequently
 Assess the neurological status frequently
 Elevate the head of the bed to 30 degree
 Change the position slowly with proper
support to the head and neck
 Access the wound and drain site for any
oozing and disconnected catheter
 Observe amount of drainage from drain

69
 Post-operation Nursing Care in RR
For EVD care:

The collection system is

maintained in the upright
position by the IV drip
stand

The EVD remains

clamped during transport
to ward to prevent
overdrainage

70
END