A to Z of Neurosurgery



A to Z of Neurosurgery

ACDF (Anterior cervical discectomy and fusion):

• All patients need X-rays post op

• Request C-spine; AP & lateral

Anaesthetists:

• Often found on ward 6 (neuro ICU) or in Costa

• SpR (bleep 2822) can be contacted to assist if patients need input

Anti-Coagulants:

• Always ensure senior doctors know if pre-op patients are taking aspirin, warfarin, clopidogrel, dipyridamole etc.

• Ideally, cranial patients need to be off aspirin for 10 days prior to surgery as aspirin has been associated with a significant haematoma risk post-operatively.

Antimicrobials:

• Discuss with microbiology (x23962, x26986) and check Trust policy on intranet

• For CNS infections discuss with Dr Sethi (x25034) if possible

• Always document indication and duration on drug chart & notes

• Restricted antimicrobials need a form (intranet) ± code from microbiology

• Some antimicrobials need specific charts (vancomycin, gentamycin)

• Patients who need 6 weeks or longer of abx (e.g. for ventriculitis) should be booked for a PICC line. Telephone acute theatres (x25303) and ask for them to be put onto Dr Oram’s PICC line list on the next available Wednesday.

Audit:

• All SHOs are expected to undertake an audit during their 4/6 months with us

• These will be presented towards the end of the job

• We have lots of ideas if you are in need of a topic!

Bluespier (aka CIS):

• All ward handovers done on Bluespier

• All patients need a provisional discharge letter on Bluespier on day of discharge

• All op notes on Bluespier, inc post-op instructions

• Ward attenders need Bluespier assessments completing

Clerking:

• All patients need the following charts:

o Drug chart

o VTE risk assessment

o MRSA chart

o O2 chart

o Fluid chart

• All patients should have an up-to-date FBC/U&E/Clotting/G&S as a minimum (note bloods from other hospitals do not count)

• Always document:

o Source of admission

o Type of admission (acute/elective)

o Responsible consultant

o Left of right handedness (cranial patients)

• Contact the SpR on call to inform them that a patient has arrived and confirm a plan

• If in any doubt, keep all acute admissions NBM

Discharges:

• Are very important in a tertiary centre

• All patients being discharged need a TTO and a letter

• Discharge letters must be written using the Bluespier software and four copies should be printed off and signed at the time of discharge

• Try to anticipate any discharges in advance, especially on ward 45 when many patients will go home over the weekend. These discharge letters should have been written on the Friday beforehand

Drains etc:

• If uncertain RE: type, check operation note

• Subgaleal – can be removed on ward (often by the nurses), do not require a suture

• Subdural/extradural – should pull out once drain stitch cut, will usually require a single, interrupted nylon suture to close the wound

• ICP monitor – do not usually require a suture, a simple dressing will suffice

• EVD – remove under strict aseptic technique, send a sample of CSF to micro for gram stain & M/C/S immediately prior to removal, keep tip sterile and send to micro for the same. Will require a suture to close the wound site. Observe for CSF leak

• Lumbar Drain – as above

• Arterial line and central line tips should also be sent to microbiology when removed

• IF YOU ARE PULLING A DRAIN OUT AND THERE IS RESISTANCE, IT MAY BE SUTURED IN THE WOUND – DO NOT RISK FRACTURE OF THE DRAIN, ASK A SENIOR TO REVIEW

Flexion/Extension Views:

• Used to assess neck stability

• Performed in X-ray

• You may need to hold head out-of-hours (go to x-ray, put on gloves & lead apron, hold in neurtal position, remove collar, then support head in midline as patient tries maximal tolerated flexion followed by maximal tolerated extension, put head back in collar)

• Check x-rays on screen to see if they are adequate before leaving department – if inadequate, don’t be afraid to ask for films to be repeated

• Abort procedure if patient in agony or develops neurological defecit during procedure

GCS:

• When using GCS, always document the breakdown e.g. (E4,V5,M6)

• In neurosurgery, motor scores are the most reliable

• E4,VT,M6 indicates a patient with tracheostomy

Halo:

• May attend for tightening of pins or check x-rays

• Use torque wrench for head pins and spanner for nuts/bolts (both supplied with Halo and kept in the “red bag” (patient should bring these)#

• Get help if in doubt

• Follow-up x-rays need doing every 2 weeks to assess healing and position.

Handover Notes:

• Must be kept up-to-date using the Bluespier system

• No other handover sheets/systems should be used

• We are developing a written handover system for on-call and night staff but this is not yet up and running

• It is important to handover any remaining jobs to the on call doctor at the end of your shift – good communication is key

• Previous cohorts have left weekend handover lists in the seminar room on Fridays to help the weekend on call SHO

HDU: (x25536)

• Ward rounds with SpRs and anaesthetic consultant daily

• Document in “ABCD” format

• Examine all patients and write in all notes daily, including weekends

Intrathecal (IT) antibiotics:

• Prescribe/administer with extreme care!

• Strict aseptic technique

• Always get prescription/drug/patient checked with another member of staff

• You may be asked to give these drugs on ICU also

• Sign drug chart & document in notes

• Do not perform unsupervised until confident of correct technique

Medical Notes:

• Trust guidelines are that notes are written in every day

• Always document date/time/name/bleep/signature

• Bare minimum of one entry per patient over weekend although should strive to do this daily

Morning (Trauma) Meeting:

• Starts at 7:45am prompt, seminar room, G Floor, Jubilee Building

• All referrals/admissions from previous day discussed

• Extremely useful to attend this meeting as you learn about what has been happening on the wards

• This is where the night SHO should handover to the day doctors

Neuro Exam:

• All patients need documented neurological examination pre-op and post-op

Posterior Fossa Surgery:

• Many will need HDU beds post-op

• Always check that gag reflex is intact post-op as CN IX/X may be affected by surgery

Post-Op Notes:

• Some consultants paste onto Bluespier, some do not.

• Order post-op imaging early; tumour post op scans must be performed within 48 hrs to avoid swelling-related ambiguity

Pre-Assessment Clinic: (x25354)

• In Brotherton wing, near medical outpatients

• Use the proforma

• Sign and document (± act upon) previous clinic’s results

• Remember to complete a drug chart

• Visits are valid for 3 months. Patients who are admitted electively following attending clinic do not need more than a cursory clerking. Patients who attended more than 3 months ago or who did not attend clinic need a full work up again

Registrar Bleep:

• The SpRs do 24 hours on call and this is only possible if they get some rest

• Any on-call bleeps (e.g. from A&E or other hospitals) will be diverted to the SHO bleep after midnight.

• If you receive a referral, the most important information to get is the patient details and contact details for the person who has referred the case to you. Make a note of as much information as you can get and tell the referrer that you will call them back as appropriate. Always ask that they send any imaging electronically from their PACS system to ours.

• Discuss the referrals with the on-call SpR

• SHOs do not have to take the SpR referrals in the first month of the job if they do not feel that they are ready to do so.

Repatriation:

• Getting people back to their local hospital is very important to keep beds available in our unit and also for patients to be nearer to their homes and families

• Different hospitals have different points of contact but generally speaking you will need to ‘phone an SpR who will accept the patient on behalf of his consultant

• You then need to complete a transfer letter for the patient (using the discharge letter template on Bluespier) and inform the nurse in charge that the patient has been accepted and by which consultant

• Once identified as fit for repatriation, patients must be referred within 24 hours

Rota:

• In overall charge of the rota is Ryan Mathew (SpR), assisted by Ian Anderson (SHO)

• All requests for leave should be made via e-mail to Ryan in the 1st instance and Ian if Ryan is on leave etc. Only e-mail requests will be considered. All leave requests must be made with at least 6 weeks notice.

• No more than 2 SHOs can be on leave at any one time (whether study/annual etc)

• There is a second, fortnightly rota of ward allocations, all doctors who are un-allocated will be placed in the OT/OPC column and are free to go to clinic/theatre.

Scans (CT/MRI etc):

• Neurosurgical doctors do not need to discuss CT head requests with a radiologist; fax a card to CT and ‘phone the scanning room (X23617) or on-call CT radiographer to confirm the scan

• If asked to arrange a CT head, always ask if contrast is needed. Generally speaking, “Plain CT Head” is requested to look for hydrocephalus and bleeding and “CT Head ± Contrast” is requested when looking for infection or tumour.

• CT-angiogram requests should be discussed with the neuroradiology consultants (Drs Goddard and Patankar) and it should be written on the card that they are aware of the request

• MRI scan requests must be discussed with a consultant neuroradiologist. The best way to get a scan for an inpatient urgently is to go and discuss with the appropriate consultant (usually found in MRI) in person… we have a good relationship with the team and they are amenable, provided you know the indication for MRI and the clinical details

Shunt Care Pathway:

• Patients with shunts have direct access to wards by telephone. They may be advised by senior nursing staff or doctors that they need to attend the ward if there is a question of a blocked shunt.

• If patents attend with a ? blocked or infected shunt, they need history and examination, a CT head, shunt series (X-rays of skull, neck, chest and abdomen) as well as bloods FBC/U&E/CRP/G&S/Cultures – they will also need discussion with the on-call SpR

Sodium:

• Important to differentiate between SIADH (water retention) and CSW (cerebral salt wasting) in hyponatraemic patients

• Diagnosis requires: U&S, serum/urine osmolality, spot urine U&E, 24hr urine U&E

• SIADH – need endocrine review, fluid restriction

• CSW – in mild cases can be treated with oral sodium (Slow Sodium 2 tablets QDS), dioralyte (5 sachets in 1 litre water over 24 hours) ± fludrocortisone 50micrograms BD (starting dose)

• More severe cases may require 1.8% IV sodium chloride (aka “double strength” or “sticky saline”) will usually also require HDU

• Hypernatraemia may be due to diabetes insipidus and may require IV fluids and DDAVP (desmopressin) treatment, pending endocrine review

Subarachnoid Haemorrhage:

• Will almost always require HDU beds

• All need arterial line, central line as clinically indicated

• All require nimodipine 60mg 4-hourly (02:00, 06:00, 10:00 etc) for 21 days to help prevent spasm (if BP drops with this, amend to 30mg 2-hourly)

• Keep well-filled with IV fluids

• Need a CT-angiogram if not already performed

• Generous laxative use (to avoid straining)

• Monitor sodium daily

• If high urine output/abnormal U&Es – need daily serum & urine osmolality and urine U&Es

• If CT-angiogram suggests no aneurysm, stop nimodipine (after discussion with seniors)

Teaching:

• MDT & neuroradiology meeting (optional) – Wednesday after ward round, radiology academy, B floor

• SpR-led teaching sessions – Wednesdays 11:30, check venue as subject to change, usually in anaesthetic department seminar room, Martin Wing, C Floor

• Mr Tyagi’s SHO teaching – Usually Friday (occasionally Thursday) morning after handover meeting

Trigeminal Surgery:

• Always check corneal reflex post-op

• If corneal reflex is absent, need discussion/review by ophthalmology

Tumours:

• Start all tumour patients on steroids (dexamethasone 16mg OD) pre-op

• All patients need PPI cover while on steriods, typically ranitidine 150mg BD

• Post operatively, decrease steroids as follows: 12mg OD for three days then 8mg OD for three days, then 4mg OD for three days, then 2mg OD for three days

• Once weaned as above STOP steroids if the tumour is low grade, continue long-term on 2mg OD if tumour is high grade

Vasospasm (Post Subarachnoid Haemorrhage)

• High morbidity and mortality

• If aneurysm secured treat with “Triple H” (Hypertensive-hypervolemic-hemodilution therapy) – aim for CVP 10-12 and MAP of 110-120

• Urgent neurovascular intervention may be required (stenting or intra-arterial nimodipine)

• ALWAYS ALERT A SENIOR ASAP IF A PATIENT DEVELOPS VASOSPASM

Venflons/Cannulae:

• Strict aseptic technique must always be used, as per trust induction

• Fill in cannula documentation and file accordingly

Ward Attenders:

• Usually on ward 45 but occasionally elsewhere

• See as an acute: quick clerking plus investigations

• Complete template on CIS/Bluespier

Ward Rounds:

• After the handover meeting the SpRs attend the paediatric and ICU ward rounds – use this time to prepare yourself for the ward rounds

• SHOs should present the patients on rounds and be the leader for the round

• Check with the night staff and nurse in charge for any new issues since yesterday’s rounds when you arrive on the ward in the morning

• Make sure you know the latest blood and microbiology results for all of the patients – keep these up-to-date on Bluespier for your colleagues.

Weekends:

• We do ward rounds of all the patients on Saturday and Sunday mornings. The exact timing varies from SpR to SpR

• Try to write in all the notes daily, especially important on HDU

• Make sure you hand over about the unwell patients to the on call doctor for the weekend, together with any jobs that need doing

• The weekends can be very, very busy; please try to anticipate discharges, drug charts to transcribe etc on a Friday to ease the burden for your colleagues

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