White

Inpatient Algorithms by Pathology

• The purpose of this section is to instruct you how to create TRAC for the first time (as a same day or from consult note) and guide the universal daily care.

• The unique parts of TRAC for every pathology are included only, universal details that should be on every TRAC are omitted for brevity purposes (e.g. attending, Lines/Meds/Diet).

• Boxes and notes you should add to TRAC the first time around are those listed below +/- anything unique in the consult note or unless instructed otherwise. Every piece of information should be purposeful. Do not need to clutter every TRAC with all the possible item pertinent to every patient.
• e.g. a ruptured intubated aneurysm on bleed day 0 do not need PT/OT/SLP/PMR/Dispo.
• e.g. sEEG patients do not need I/Os (irrelevant, and no one is documenting that in EMU)

• Associated consult guides for some pathology are listed as reference for more knowledge, but the focus here is on the daily inpatient care once a patient is already admitted.

Vascular

Aneurysmal subarachnoid hemorrhage

Vasospasm (bleed day 3-21)

• Triple-H therapy is the core tenet of subarachnoid hemorrhage care to prevent vasospasm
• hypertension: permissive blood flow
• hypervolemia: increases perfusion
• hemodilution - reduces viscosity of blood to improve circulation

• All patients stay in the ICU for q1-2h neuro-monitoring during the spasm window but sometimes leave as early as BD 14, discretion per chief/attending based on patient’s course.

• Every patient spasms in a different way, and once the patient has spasmed once it’s critical you pass this on when signing out a patient or even helpful to put it as a line under exam pointing that out (e.g. ”spasm sx: L CFW”), very helpful for night floater.

• Spasm from all territories will generally be picked up with your universal neuro exam when rounding, but there are subtleties to territorial spasms you should be aware of.
• ACA:
• leg-predominant weakness (remember the homunculus)
• increasing frontal behavior/agitation
• abulia
• mutism (bilateral)
• urinary incontinence (medial frontal micturition centers)
• MCA:
• Face/hand predominant weakness (remember the homunculus)
• aphasia (receptive and/or expressive)
• visual deficit: (contralateral homonymous hemianopia from optic radiations)
• L hemineglect (if R MCA)
• gaze preference (towards lesion, frontal eye field)
• dysarthria
• PCA
• occipital lobe: visual field deficits (contralateral HH), cortical visual loss, Prosopagnosia (cannot recognize faces), visual agnosia (cannot recognize objects)
• midbrain: CN3 palsy, contralateral hemiparesis, ↓ LOC (reticular formation)
• thalamic: contralateral sensory loss, hemiataxia or ataxic hemiparesis

• Transcranial dopplers: these must be done daily starting on BD3 (sometimes chief asks for earlier)
• Cerner Order: “US Transcranial Dop Intracranial LTD”
• TCD pager: 87298; if not documented by 1-2pm, page and ask status
• Courtney from TCDs cell phone #: ‭+1 (724) 456-8519‬ - call if you really need

• Electrolyte repletion: Mg > 2, Phos > 3, K > 4

• Euvolemia actually means positive 500-750 cc due to insensible losses. in the absence of cardiopulmonary contra-indications to volume overloading, generally better to err on the side of ~1L positive (but this must be discussed with CCM). this needs to be checked at least twice daily, 4am and 4pm.
• it helps to have a continuous nursing communication order saying “please kindly update all I/Os by 4am and 4pm” —> it actually works.

• nimodipine: generally, do Nimotop spasm for 21 days after a bleed. If someone is going home, you just d/c since it's way too expensive. 

• Milrinone and MAP floors: TBA

• Working up spasm
• CTH/CTA/CTP
• CTP may show ↓ cerebral blood flow or ↑ mean transit time in the territory in question

Ruptured AVMs

• Generally speaking, we do not operate on these acutely, we let the brain tamponade the bleed and relax after the acute insult, patients stay in the ICU the whole time for monitoring until the OR 2-4 weeks after.

• There are definitely exceptions to the above that will not be expanded on here, talk to your chief.

Intra-parenchymal / Intra-ventricular Hemorrhage (IPH/IVH)

• generally these are stroke patients unless we place EVD or if it turns out to be a hemorraghic lesion requiring operation.

Carotid stenosis

• If we are involved in carotid stenosis it’s because we are going to operate.

• Unless NSGY direct admitted these patients as a transfer, these will generally be brought to our attention by stroke service, and if we operate on them we transfer post-op.

Swell Watches (Malignant cerebral edema)

• these are generally not our patients, they belong to stroke.

• Our main involvement is through swell day 5 here therefore disposition is not our focus.

• MJL anti-herniation cocktail: To temper someone getting really close to herniating, MJL will often do the following alternating q8 (therefore q4):
• q8H 23% HTS w/ q6 Na+, as long as Na < 155
• q8H 0.5 mg/kg mannitol w/ q6 serum osm as long as Sosm < 320
• (effectively this will often be ~25 mg as easiest for pharmacy to do)

Elective Endovascularly Treated Lesions

• These are patients with non-bleeding lesions (dural AV fistulas, AVMs, aneurysms) admitted after their procedure coiling/emboliation/pipelines/stenting for 1-2 days monitoring.

• Generally these patients are admitted to ICU from angio, OOU on PAD1 and often home from the ICU on PAD1 as well.

• In the absence of serious complication, will go home (no IPR).

• These patients cannot leave the hospital without meds to beds (see below)

Functional

Stereo EEG (Phase 2)

• Phase 1 EEG generally refers to EMU admission with continuous EEG and we are generally not involved (neurology admisison). Phase 2 refers to when we place depth electrodes into the brain for more precise localization of the seizures.

• Under notes, keep Home AEDs listed at all times, and update EMU changes daily.

• The typical ramp-up in provoking seizures by EMU is: medication taper → sleep deprivation direct stimulation by neurology → and rarely patients are given alcohol.

• Consider doing qOD labs on these patients, that way if seize and need sEEG removal the next day / same day, you have labs but no need to waste resources and stick daily.

• These patients can sit around for at least a week sometimes, so it’s prudent to make sure they are pooping (do not add LBM to TRAC).

• Discharge after leads removed: You may remove the head-wrap before leaving the hospital, but you may also keep it on for comfort if you would like. If you do go home with the headwrap, please remove no later than 24-48 hours after leaving the hospital. After removal, you may use baby shampoo and gently run water over your head, but do NOT direct high pressure water or scrub forcefully anywhere over your head until you are seen in follow-up at around 2 weeks post-op, as you have small incisions throughout your head where the leads were that are still healing.

Seizure Focus Resections

• Part of doing this TRAC is understanding this patient’s history by knowing the outcome of their Phase 2 sEEG trial usually a few weeks prior. Put the date of admission and summarize outcome in one line.

• MRI is typically ordered routinely either on the evening of surgery or the day after (not typically urgent unless JGM has a reason).

• Order: MRI Brain without contrast, special instructions “Epilepsy protocol post seizure focus resection.”
• The operating resident should order this but may not.
• We are looking for strokes the exact anatomy removed so no contrast is needed.
• In some cases if patient is too large / too complicated to get an MRI JGM ok with outpatient MRI prior to follow-up.

• If no significant deficits after surgery, these patients go home.

• If there are deficits, these patients need an early PMR consult and early engagement of case management for rehab disposition.

Responsive neurostimulation

• In absence of complication, these pts will go home on POD1-2

DBS Stage 1

• in absence of complication, these patients will go home on POD1-2

• These patients either have essential tremor or Parkinson’s disease

Same Day Surgeries

• The following surgeries are generally same-day discharges from the PACU, in the absence of complication. The only TRAC they need is left side stating the attending and procedure, right side saying pre-op exam, and box saying d/c home.

• Below are specific instructions for discharging these patients.

• Cranial incisions: closed with nylons, open to air.

• Chest Incision/Dressing care: in surgery you place baci/telfa/tegaderm and in depart instruction pt to keep on for ~3 days. After that, can gently run low-pressure water over incisions and pat dry after showering. 

• Follow up: 2 week follow up for wound check with Theodora.

• Incision/Dressing care: in surgery you place baci/telfa/tegaderm and in depart instruction pt to keep on for ~3 days. After that, can gently run low-pressure water over incisions and pat dry after showering. 

• Follow up: 2 week follow up for wound check with Theodora.

• D/c Rx: Keflex 500 bid x 5 days, Tylenol, silver sulfadiazine cream 14 days BID

Intra-axial Tumors

Gliomas

• generally will be admitted to ICU for one night of observation

• For gliomas, CGH usually likes tapers dex to 1 BID indefinitely over 2 weeks

• A minority of patients may go home, but high likelihood of requiring IPR dispo due to prolonged bedridden course and/or deficits.

General Cranial

NPH

• majority of these patients will go home on POD1-2 but not uncommonly, they are elderly requiring SNF or IPR

• imperative to note what sx of the classical triad patient had before, as some may improve immediately after surgery

• If pt had a LD trial or high-volume LP trial prior to surgery, need a summary of that in 1 line
• e.g. “LD trial 10/16-10/17 DGI 1—>5) or LP -25cc w/ improved gait 10/16

IIH

ETV (Colloid Cyst)

• may go to ICU vs. floor post-op

• In absence of complication, dispo is home

Attending Preferences

Michael Lang

Case Booking

Follow-ups

• Lang's PA at Mercy is Sarah Kwiatkowski NP, can be contacted at kwiatkowskise@upmc.edu for specific questions; (412)232-5522 or (412) 471-4772

• Please try not to put follow up with 2 weeks with Dr. Lang because patients get mad when Dr. Lang isn't at their appointment personally removing their staples.

Brad Gross

Costas Hadjipanayis

Case Booking

• Craniotomies: craniotomy with Mayfield w/ pins, synaptive modus robotic exoscope, Neuromonitoring (SSEPs, MEP, EEG)

• Biopsies: stereotactic biopsy with ROSA, Neuromonitoring (SSEPs, MEP, EEG)

Other

• For biopsies/tumors/anything image guided in general: order MRI Brain with/without in comments put "synaptive protocol"

• likes to have his staff copied for all emails pertinent to his patients:

Jorge Gonzalez-Martinez

Gamma Knife

Random Notes

• How to email neuro-oncology: https://www.pittnsgy.com/references/hospital-how-tos/neuro-onc-email/

• Meds-to beds is where UPMC outpatient pharmacy delivers prescriptions to patients to their room
• commonly done on white service because the fate of a fresh stent or pipe cannot be at the whim of a patient picking up their meds on the way home, pharmacy being open, etc.
• depart the patient like normal
• send prescriptions to the presby shop with at least one of the meds with special comments saying “please deliver all meds to bedside before patient leaves the hospital”
• call pharmacy and ensure the message was seen
• call patient’s nurse and tell them patient has critical meds requiring meds to beds
• nurses want to discharge patients too so they will bird dog this as well for you