Blue (Skull Base/Vascular)

Inpatient Algorithms by Pathology

Chiari

Dx: Chiari

O1 SOC
+ preop sx: ***
exam

NOTES:
D/c home
SQH POD2
NOTES:
  • these patients generally leave early on POD1
  • Pain:
    • Ketamine gtt overnight, discontinued 6am POD1 (cancel while you are chart rounding)
    • APAP 1g q6 scheduled
    • Oxy 5-10mg q4h PRN
    • Robaxin 500-1000mg q6h PRN
  • Nausea: Zofran 4mg q8h PRN +/- Compazine, Reglan and Phenergan, Scopolamine patch, Dexamethasone 4mg q6h while inpatient
  • SOC dressing to be removed POD1
  • Discharge considerations:
    • Medrol Dose Pack to start next day
    • Pepcid x 7 days during MDP taper
    • 3 stool softeners': MiraLAX / Senna / Colace – SCHEDULED
    • Acetaminophen, Oxycodone, Robaxin
    • Anti-emetic – prefer sublingual dissolvable Zofran tabs
Follow-up 2-Wednesdays no imaging

Trigeminal Neuralgia

Dx: Trigeminal neuralgia

O*
+ pre-op sx: (Side, pain quality and location in V1-V3, state if had numbness)
pre-op exam

NOTES:
D/c home ASAP
 
NOTES:
  • These patients will generally go to floor then discharged on POD1
  • Tapering TN medications post-op
    • Immediately taper to 0.5 dosing (Tegretol, Trileptal, Gabapentin)
      • Consider other diagnoses that patient may be on Gabapentin for before cutting dose
      • The operating resident should know this, but you should check then ask your chief if you should taper if they haven’t.
    • Wean off of remaining TN medication by titrating dose over 1-2 weeks (until follow-up).
    • Consider recent fills of medications by patient and dose available to assist with wean.
  • Nausea/vomiting is a common reason to keep these patients longer than POD1, so it is prudent to round on them in the PM and ensure this is not a problem, have a low threshold for scheduled Zofran/Reglan and even dex (if chief cleared).
  • Post-op exam: make sure you check hearing and sensation in V1-V3.

EEA

  • This template of care is generally applicable for pituitary adenoma, apoplexy, craniopharyngioma, skull base meningioma, chondrosarcoma, chordoma.
Dx: 3.5cm pituitary adenoma

O1 EEA

CAP 150

I/O/N _____ / ______ / ______
pre-op exam

Recon:
Packing:
SQH POD2
ENT recs
Endo recs
QM/R LED
 
NOTES:
  • Ensure all patients are ordered ocean nasal sprays (operating resident should know too).
  • Common post-op boxes that are likely, but will be per sign-out from operating resident
    • MRI pituitary post-op (GAZ usually does want)
    • DI watch (some approaches will be nowhere near pituitary)
    • POD1 cortisol / prolactin 0700 (or do POD1 if patient received steroids in surgery)
      • normal is cortisol ≥ 15 and prolactin ≥ 2
  • Daily rounding exam should include:
    • CSF leak check (provoke chin to chest for 30-60 seconds) - this is especially true if operating resident signs out a high-flow leak / large defect
      • Take a video if suspected leak present
      • Know when the last administration of nasal saline spray occurred
    • Vision check (acuity and fields)

Cushing’s Disease

  • These patients need to be on monitor at all times if on floor
  • Monitor for cortisol crash “lethargy, fatigue, poor appetite, hypotension, tachycardia” - feels “hit by a bus” (keep on cardiac monitor)
Make boxes for the following:
  • Q6h cortisol's to monitor for the “crash.”
    • Goal for indicating Cushing's has been treated with surgery is cortisol <2 twice.
    • Timed for and drawn at 7a/1p/7p/1a (cannot be added to 4am labs)
  • POD 1 ACTH and PRL at 7am
  • SQH POD1 – High plasma cortisol levels stimulate the production of factor VIII so these patients are at a higher risk for blood clots
 

Precautions

no IS, no nose blowing, sneeze with mouth open, avoid constipation, no smoking/vaping, nothing inserted into nares, no PPV

Nasal Packing for Dummies

Packing
Use
Notes
Absorbable
gel foam
most flexible
Absorbable
nasopore
bulkier, used in most recons
Non-absorbable
merocel
recon support if c/f high flow leak
remove by day 7
Non-absorbable
Doyles
stabilizes septum, avoids scarring between lateral wall and septum
removal day 5-7
notion image

Antibiotics

PACKING
RE-DO
ABX
Merocel
No
- IV Ancef 2g q8h x 48h
- PO Doxycycline 100mg BID until packing removal
Merocel
Yes
- IV Ancef 2g q8h x 48h
- IV Levaquin 500mg QD x 48h
- PO Doxycycline 100mg BID only until packing removal
Nasopore
No
- IV Ancef 2g q8h x 48h
- PO Doxycycline 100mg BID x 72 more hours
total of 5 days on abx
Nasopore
Yes
- IV Ancef 2g q8h x 48h
- IV Levaquin 500mg QD x 48h
- PO Doxycycline 100mg BID x 72 more hrs
total of 5 days on abx
Doyles only
Any
- IV Ancef 2g q8h x 48h
- PO Doxycycline 100mg BID until packing removal

Tri-phasic Response

This is the theoretical response you should be aware of but also note that only the rare patient (<10%) will develop the complete triphasic pattern.
Post-op Day
Expected Phase
Pathogenesis
0–4
Transient DI (Phase 1)
Axonal shock → transient cessation of ADH release
5-6
Possible normalization or SIADH (Phase 2)
Degenerating posterior pituitary neurons release stored ADH
7–10+
Recurrent / permanent DI (Phase 3)
Depletion of ADH stores + irreversible hypothalamo-neurohypophyseal injury
The practical matter is that most will have:
  • isolated transient DI on POD 0-3
  • isolated SIADH-related hyponatremia around POD 4-7

Kassam Protocol for DI

IF:
  • UOP > 300 mL/hr for 2 consecutive hours (NOT averaged)
THEN STAT send:
  • Urine spec grav (NOT dipstick)
  • Urine osmolality
  • Serum Osmolality
  • Serum Na+
Go see the patient or find out from nurse:
  1. Look at urine in foley or urinal (dilute = super clear means more likely in DI)
  1. Ask them do you feel thirsty? Are you drinking water? Is it quenching your thirst?
  1. Know the overall fluid status (input/output/net)
  1. Know whether they are on fluids and exactly what
Generally the criteria for treating diabetes insipidus are:
(1) rising sodium
(2) U Sg ≤ 1.005
(3) Usm low (<150)
  1. STAT PAGE Endo if the criteria are met or if they are borderline met and you are concerned for whatever reason (really high Na jump, you were signed out this is a critical patient, etc.)
  • Call Chief with Endo plan (if not overnight)
  • Typical dosing is:
    • PO dosing 0.05mg DDAVP
    • IV 1mcg DDAVP
    • MAKE SURE YOU ARE CAREFUL WITH THE DOSING (microgram vs milligram)
 
NOTES:
  • Endo typically will not schedule DDAVP within 72 hrs post-op even if they keep triggering (still considered transient window)
 

Follow-ups

ENT:
  • f/u w/ Snyderman / Choby / Wang in clinic to remove packing as per ENT notes
  • use chlorasept sprays as needed (Rx provided)
Endocrinology
Need to send patient with
  • fluid restriction instructions (typically 1L from POD4-14)
  • Lab scripts (usually BMP on POD7)
    • put in digital prescription special instructions to fax results of BMP to NSGY 412-647-0989 Endo falk clinic 412-586-9726
Optho
  • Dr Stefko / Bonhomme for HVF for significant pre/post-op deficits

Beta 2 Transferrin

1. ensure lab is ordered as "stat"
2. call the lab so that the serology tech is called in to run it.
All of the above is especially true on weekends.
 
ATL procedure for Weekend STAT Beta 2 Transferrin:
1. The neurosurgery resident or fellow requests that a stat test be done by calling the Automated Testing Laboratory (ATL) at 412-647-1022 and talking to a Lead Tech or Supervisor.
2. The ATL Lead Tech or Supervisor will notify the Pathology resident who will call the medical director to determine if the stat test is approved. The resident will call back to the Lead Tech/Supervisor and let them know if the test is approved or denied.
3. The Lead Tech/Supervisor will make sure that the sample is LIQUID (minimum, volume is 50µl) and will put the sample in the IMMUNO rack where it can be easily located by the Serology tech.
4. The Serology tech will call the ATL laboratory at 412-647-1022 at 9 am on Saturday and Sunday mornings. The tech will ask to speak to the Lead Tech or Supervisor. If there is an APPROVED test the tech will come in to perform testing. At this time, the Serology tech should also get the phone number of the Pathology resident on call. The specimen must be in the ATL lab when the tech calls. Any request after 9am on Saturday that are approved will be run on Sunday morning. Likewise, any approved request after 9 am on Sunday will be run on Monday. The Serology techs will make only one phone call each morning at 9 am. The serology tech will notify the Pathology resident on call with the patient results when the test is completed.
Given the delay this will cause in patient care, I encourage both you and Dr Nturibi to consider risk mastering the process and perhaps additional evaluation of the current procedure can be considered.  In the future, maybe all orders from neurosurgery on the weekend should be considered stat and reviewed by the lab and the clinical pathologist (resident) on call to better triage these cases. This would provide extra coverage in the off chance a Beta 2 Transferrin is ordered as routine by the neurosurgical clinical team.
Please feel free to reach out to Dr Shurin and Dr Wheeler to discuss the matter further.
Best,
Yannis "Yanni" Hadjiyannis, MD
P: 86649 | T: 740-464-8083
Email: hadjiyannisy@upmc.edu

Blue Discharges

  • Start by referring to the general discharges reference page:
PUH Discharges
  • All patients need to be added to the Blue Discharges list (ask someone on blue team to share)
  • Discharge summaries generally need to be done in 24-48 hrs (should be done by end of week when Blue discharges email to attendings goes out)
  • If have LD, determine plan for suture (dissolvable vs. Nylon)
Attending:
Dates of Admission:
Diagnosis:
Procedures:
Dispo:
Follow-ups:
Labs/Rads: e.g. BMP on 1/26/24 - fax results to Endo clinic, fluid restriction starting 1/24/24 (detailed below)
Pt presented on DATE for XYZ..
Pt underwent surgery on ____ by Dr x
Pt had an uneventful postoperative course overall and recovered well, and was discharged home on the first post-operative day.
Neuro exam at discharge:

Attending Preferences

Georgios A. Zenonos

• Keppra 500-1000mg BID x 7 days s/p craniotomy

Robert M Friedlander

• Keppra 500-1000mg BID x 30 days s/p craniotomy
 

Miscellanous

  • Decadron plans / PPI with Decadron; taper plan. If concern for lymphoma requiring biopsy, do not start Dex
  • If patient is not diabetic, and Decadron is completed – discontinue glucose checks and insulin therapy
  • Acetazolamide (Diamox) must be ordered as 250mg tab NOT 500mg ER tab – these are different medications!
  • Yes - we order LEDs bi-weekly, but if the patient is on systemic AC – they do not need them unless JUSTIFIED – vascular lab will appreciate your consideration in these cases