essentials of neurosurgery

Essentials of Essentials of NeurosurgeryNeurosurgery

Michelle Miller, PA-CMichelle Miller, PA-CPrimary Care Associate ProgramPrimary Care Associate Program

July 12, 2005July 12, 2005

IntroductionIntroduction

Conditions treated by NeurosurgeryConditions treated by Neurosurgery Other surgical specialtiesOther surgical specialties Role of Primary Care ProvidersRole of Primary Care Providers Diagnosis Diagnosis When to referWhen to refer Post-operative follow-upPost-operative follow-up Common post-operative conditionsCommon post-operative conditions

Conditions Treated by Conditions Treated by NeurosurgeonsNeurosurgeons

HydrocephalusHydrocephalus Trauma to head or spineTrauma to head or spine Degenerative spine diseasesDegenerative spine diseases

Disk herniationsDisk herniations Spondylotic diseaseSpondylotic disease Spinal instabilitySpinal instability

Neurovascular diseaseNeurovascular disease Aneurysms & arteriovenous malformations of the brain Aneurysms & arteriovenous malformations of the brain

& spinal cord& spinal cord Carotid stenosisCarotid stenosis Intracranial hemorrhage of any etiologyIntracranial hemorrhage of any etiology


NeurooncologyNeurooncology TumorsTumors

Brain & meningesBrain & meninges Pituitary glandPituitary gland Spine & spinal columnSpine & spinal column


Peripheral nerve injury or entrapmentPeripheral nerve injury or entrapment Carpal tunnel syndromeCarpal tunnel syndrome

Congenital malformationsCongenital malformations Medically intractable disordersMedically intractable disorders

Movement disorders (Parkinson’s)Movement disorders (Parkinson’s) EpilepsyEpilepsy Chronic painChronic pain

Other Surgical Other Surgical SpecialtiesSpecialties

Orthopedic SurgeryOrthopedic Surgery Spinal instrumentationSpinal instrumentation Traumatic injuriesTraumatic injuries

Plastic SurgeryPlastic Surgery Peripheral nerve Peripheral nerve entrapmententrapment

Other Surgical Other Surgical SpecialtiesSpecialties

Vascular SurgeryVascular Surgery Carotid endarterectomy (CEA)Carotid endarterectomy (CEA)

Role of Primary Care Role of Primary Care ProviderProvider

Initial diagnosis and treatmentInitial diagnosis and treatment Symptom managementSymptom management

Referral to specialty careReferral to specialty care Identification of emergent versus urgent Identification of emergent versus urgent

conditionsconditions Coordination of careCoordination of care Pre-operative clearancePre-operative clearance Post-operative carePost-operative care Healthcare MaintenanceHealthcare Maintenance Record-keepingRecord-keeping

Case StudyCase Study

35 year old female presents to your office 35 year old female presents to your office following herfollowing her

vacation for c/o of chronic headaches, vacation for c/o of chronic headaches, described as described as

““sinus pain,” for approximately 6 months. sinus pain,” for approximately 6 months. She denied any She denied any

recent illness, fever or congestion. She did recent illness, fever or congestion. She did mention thatmention that

during her vacation she fell, but denied any during her vacation she fell, but denied any injury. Sheinjury. She

stated, “ I lost my balance.”stated, “ I lost my balance.”

DiscussionDiscussion

Brain TumorsBrain Tumors

Primary brain tumorsPrimary brain tumors Glial cellsGlial cells Neuronal cellsNeuronal cells MeningesMeninges

Benign versus malignantBenign versus malignant Primary malignant brain tumors rarely metastasize Primary malignant brain tumors rarely metastasize

but are locally invasive of surrounding parenchymabut are locally invasive of surrounding parenchyma Benign tumors are encapsulatedBenign tumors are encapsulated

Grade IV astrocytoma (glioblastoma) is the Grade IV astrocytoma (glioblastoma) is the most common primary brain tumor of adultsmost common primary brain tumor of adults

Glioblastoma Multiforme Glioblastoma Multiforme (GBM)(GBM)

Brain TumorsBrain Tumors Metastatic disease (secondary brain Metastatic disease (secondary brain

tumors)tumors) Malignancies with the greatest tendency to Malignancies with the greatest tendency to

metastasize to brainmetastasize to brain LungLung BreastBreast RenalRenal thyroidthyroid

Corticosteroids in Corticosteroids in NeurosurgeryNeurosurgery

Introduced into Neurosurgery in the Introduced into Neurosurgery in the 1960’s1960’s

Radically improved the acute Radically improved the acute management of brain tumorsmanagement of brain tumors

Steroids are used to treat edema caused Steroids are used to treat edema caused by recent surgical manipulationby recent surgical manipulation

How do they work?How do they work? By stabilizing the blood-brain barrier, By stabilizing the blood-brain barrier,

corticosteroids effectively reduce vasogenic corticosteroids effectively reduce vasogenic edema in the brain or spinal cord associated edema in the brain or spinal cord associated with tumorswith tumors

Corticosteroids in Corticosteroids in NeurosurgeryNeurosurgery

Decadron (dexamethasone)Decadron (dexamethasone) Most commonly used corticosteroidMost commonly used corticosteroid

Pure glucocorticoid with no mineralcorticoid effect Pure glucocorticoid with no mineralcorticoid effect (unlike prednisone or hydrocortisone)(unlike prednisone or hydrocortisone)

Can be given enterally or intravenouslyCan be given enterally or intravenously Side effects Side effects

GI bleedingGI bleeding HyperglycemiaHyperglycemia ImmunosuppressionImmunosuppression Poor wound healingPoor wound healing PsychosisPsychosis Long-term steroid use: osteoporosis, fat Long-term steroid use: osteoporosis, fat

redistribution, myopathyredistribution, myopathy

SeizuresSeizures Caused by synchronous paroxysmal Caused by synchronous paroxysmal

discharge from cerebral cortexdischarge from cerebral cortex Frequently, a seizure is the first Frequently, a seizure is the first

presentation of an intracranial lesion, presentation of an intracranial lesion, especially with brain tumorsespecially with brain tumors

Anticonvulsant prophylaxis Anticonvulsant prophylaxis Before & after surgeryBefore & after surgery Titrated according to blood levels and seizure Titrated according to blood levels and seizure

controlcontrol

AnticonvulsantsAnticonvulsants Dilantin (phenytoin)Dilantin (phenytoin) Luminal (phenobarbital)Luminal (phenobarbital) Tegretol (carbamazepine)Tegretol (carbamazepine) Depakote (valproic acid)Depakote (valproic acid) Neurontin (gabapentin)Neurontin (gabapentin) Keppra (levetiracetam)Keppra (levetiracetam)

DilantinDilantin Most commonly used first-line anticonvulsant Most commonly used first-line anticonvulsant

for a patient with a new presentation of for a patient with a new presentation of generalized or focal seizuresgeneralized or focal seizures

Dilantin allergiesDilantin allergies Red macular rashRed macular rash Unexplained feverUnexplained fever Altered liver functionAltered liver function

Dilantin overdoseDilantin overdose ArrhythmiasArrhythmias HyperreflexiaHyperreflexia DysarthriaDysarthria ConfusionConfusion NystagmusNystagmus ataxiaataxia

Blood Pressure ControlBlood Pressure Control

During & after intracranial During & after intracranial surgery, control of hypertension surgery, control of hypertension is critical for the prevention of is critical for the prevention of brain hemorrhagebrain hemorrhage

Fluid & Electrolyte Fluid & Electrolyte ManagementManagement

Volume statusVolume status HyponatremiaHyponatremia Disorders of ADH regulationDisorders of ADH regulation

HyponatremiaHyponatremia

Should be avoided in neurosurgery Should be avoided in neurosurgery patients because it exacerbates patients because it exacerbates brain edema and lowers seizure brain edema and lowers seizure threshholdthreshhold Normal adult values: 135-145 mEq/LNormal adult values: 135-145 mEq/L

Ventriculoperitoneal Ventriculoperitoneal (VP) Shunt(VP) Shunt

A Ventriculoperitoneal shunt is A Ventriculoperitoneal shunt is surgically placed to relieve surgically placed to relieve intracranial pressure caused by intracranial pressure caused by hydrocephalushydrocephalus Intracranial hemorrhage, spina bifida, Intracranial hemorrhage, spina bifida,

brain tumor, meningitis, encephalitisbrain tumor, meningitis, encephalitis


When ventricles become enlarged with When ventricles become enlarged with cerebrospinal fluid cerebrospinal fluid Brain tissue becomes compressed against the Brain tissue becomes compressed against the

skullskull Excess fluid accumulates around the brain Excess fluid accumulates around the brain

causing an increase in intracranial pressurecausing an increase in intracranial pressure Serious neurological problems resultSerious neurological problems result

Shunting is necessary to drain the excess Shunting is necessary to drain the excess fluid and relieve pressure in the brain fluid and relieve pressure in the brain Excess pressure can cause a decrease in blood Excess pressure can cause a decrease in blood

flow to the brain leading to brain damageflow to the brain leading to brain damage

Ventriculoperitoneal (VP) Ventriculoperitoneal (VP) Shunt-Craniotomy for Shunt-Craniotomy for

Cerebral Shunt Cerebral Shunt Performed in the OR Performed in the OR

under general under general anesthesiaanesthesia

A flap is cut in the A flap is cut in the scalp and a small hole scalp and a small hole is drilled in the skull is drilled in the skull

A small catheter is A small catheter is passed into a passed into a ventricle of the brain ventricle of the brain

A pump (valve which A pump (valve which controls flow of fluid) controls flow of fluid) is attached to the is attached to the catheter to keep fluid catheter to keep fluid away from the brainaway from the brain


The fluid is shunted from the ventricles of The fluid is shunted from the ventricles of the brain into the abdominal cavity the brain into the abdominal cavity In some cases, the fluid is shunted to the pleural In some cases, the fluid is shunted to the pleural

space in the chestspace in the chest A pump controlling fluid flow is attached to A pump controlling fluid flow is attached to

the catheter to keep the fluid away from the the catheter to keep the fluid away from the brain brain

Another catheter is attached to the pumpAnother catheter is attached to the pump It tunnels under the skin, behind the ear, down It tunnels under the skin, behind the ear, down

the neck and chest and into the abdominal the neck and chest and into the abdominal cavitycavity

When to ReferWhen to Refer Emergent referralsEmergent referrals

Emergency DepartmentEmergency Department Mental status changesMental status changes Cauda equina syndrome (nerve compression)Cauda equina syndrome (nerve compression) Motor deficitsMotor deficits Sensory deficitsSensory deficits Bowel/bladder incontinence or retentionBowel/bladder incontinence or retention radiculopathyradiculopathy

Urgent referralsUrgent referrals NeurosurgeonNeurosurgeon

Conservative therapies failConservative therapies fail

Post-operative Follow-upPost-operative Follow-up

Surgery date?Surgery date? Suture/staple removalSuture/staple removal

Wound careWound care Infection, drainage, swelling, pain?Infection, drainage, swelling, pain?

Laboratory follow-up?Laboratory follow-up? Drug levelsDrug levels ChemistriesChemistries

Medication managementMedication management Long & short term managementLong & short term management AntiepilepticAntiepileptic Sleep aidesSleep aides GI upsetGI upset


Pain managementPain management PrecautionsPrecautions Drug interactionsDrug interactions

Physical TherapyPhysical Therapy DMV clearanceDMV clearance Support groupsSupport groups

DepressionDepression Issues of death & dyingIssues of death & dying

Chemotherapy and RadiationChemotherapy and Radiation

CathetersCatheters Hickman catheter Hickman catheter

Long-term, central venous indwelling catheter Long-term, central venous indwelling catheter with external port(s)with external port(s)

Infusion of blood products, nutrition, chemotherapyInfusion of blood products, nutrition, chemotherapy Must be meticulously cared for to prevent infectionMust be meticulously cared for to prevent infection

Venous placement- subclavian, under clavicleVenous placement- subclavian, under clavicle Placement in OR or via radiologyPlacement in OR or via radiology

Fluoroscopy-guided placementFluoroscopy-guided placement Requires CXR to confirm placement prior to Requires CXR to confirm placement prior to

useuse

Hickman CatheterHickman Catheter

Review QuestionsReview Questions

QuestionsQuestions

A 6 year old male is struck by a car A 6 year old male is struck by a car

while riding his bicycle. He is reported while riding his bicycle. He is reported to be unconscious for 2 min following to be unconscious for 2 min following the accident. He is conscious and alert the accident. He is conscious and alert upon arrival to the ED, but within 45 upon arrival to the ED, but within 45 min, he begins to vomit and shortly min, he begins to vomit and shortly thereafter he becomes completely thereafter he becomes completely unresponsive. Which of the following unresponsive. Which of the following most likely explains the child’s injury?most likely explains the child’s injury?

AnswerAnswer

A.A. Acute subdural hematomaAcute subdural hematoma

B.B. Chronic subdural hematomaChronic subdural hematoma

C.C. Acute epidural hematomaAcute epidural hematoma

D.D. Acute traumatic subarachnoid Acute traumatic subarachnoid hemorrhagehemorrhage

E.E. Grade III concussionGrade III concussion

AnswerAnswer

This is a classic history of an epidural hematoma. The This is a classic history of an epidural hematoma. The

typical presentation is that of a child who sustains a typical presentation is that of a child who sustains a hard blow to the head and experiences a brief loss of hard blow to the head and experiences a brief loss of consciousness, followed by a lucid interval, when the consciousness, followed by a lucid interval, when the child is awake and alert. As the hematoma expands, the child is awake and alert. As the hematoma expands, the patient experiences a headache followed by vomiting, patient experiences a headache followed by vomiting, lethargy and hemiparesis and may progress to coma if lethargy and hemiparesis and may progress to coma if left untreated. This injury usually results from a left untreated. This injury usually results from a temporal bone fracture with a laceration of the middle temporal bone fracture with a laceration of the middle meningeal artery or vein and less often a tear in a dural meningeal artery or vein and less often a tear in a dural venous sinus. Epidural hematomas are treated with venous sinus. Epidural hematomas are treated with surgical evacuation of the clot and ligation of the surgical evacuation of the clot and ligation of the bleeding vessel.bleeding vessel.

QuestionQuestion

Which of the following is/are true Which of the following is/are true

of lumbar disc herniation?of lumbar disc herniation?

AnswerAnswer

A.A. Most common at the L5-S1 discMost common at the L5-S1 disc

B.B. Radiating pain to the buttocks, Radiating pain to the buttocks, thigh, calf, and footthigh, calf, and foot

C.C. Often associated with a positive Often associated with a positive straight leg raise teststraight leg raise test

D.D. May be complicated by cauda May be complicated by cauda equina syndromeequina syndrome

E.E. All of the aboveAll of the above

AnswerAnswer

A herniated lumbar disc compresses the nerve A herniated lumbar disc compresses the nerve

root, resulting in a radicular pain called lumbar root, resulting in a radicular pain called lumbar radiculopathy. The pain characteristically radiculopathy. The pain characteristically radiates to the buttock, thigh, leg, and foot. radiates to the buttock, thigh, leg, and foot. When the pain is severe, the pain can be When the pain is severe, the pain can be worsened by straight leg raising and may be worsened by straight leg raising and may be limited to 20 to 30 degrees. The patient may limited to 20 to 30 degrees. The patient may have decreased or absent reflexes, weakness, have decreased or absent reflexes, weakness, and paresthesias or decreased sensation in a and paresthesias or decreased sensation in a dermatomal distribution. It is most common at dermatomal distribution. It is most common at the L5-S1 disc followed by the L4-L5 disc.the L5-S1 disc followed by the L4-L5 disc.

QuestionQuestion

The most common intracerebral The most common intracerebral

neoplasm is:neoplasm is:

AnswerAnswer

A.A. GliomaGlioma

B.B. MeningiomaMeningioma

C.C. LymphomaLymphoma

D.D. MetastasisMetastasis

E.E. adenomaadenoma

AnswerAnswer

Glioma account for nearly 50% of Glioma account for nearly 50% of

primary brain tumors. The primary brain tumors. The remainder are meningiomas (15%), remainder are meningiomas (15%), pituitary tumors (7%) and other pituitary tumors (7%) and other tumors.tumors.

BreakBreak

Essentials of Essentials of Cardiothoracic Cardiothoracic

SurgerySurgeryMichelle Miller, PA-CMichelle Miller, PA-C

Primary Care Associate ProgramPrimary Care Associate Program July 12, 2005July 12, 2005

Conditions Treated by Conditions Treated by Cardiothoracic SurgeonsCardiothoracic Surgeons

Coronary Artery Bypass Graft (CABG)Coronary Artery Bypass Graft (CABG) Valve Replacement or RepairValve Replacement or Repair

TissueTissue Xenograft (porcine or bovine)Xenograft (porcine or bovine) Homograft (cadaveric human)Homograft (cadaveric human)

MechanicalMechanical Video Assisted Thoracotomy (VATS)Video Assisted Thoracotomy (VATS)

Tumor ressectionTumor ressection AAA RepairAAA Repair TraumaTrauma Transplant SurgeryTransplant Surgery

HeartHeart LungLung

Coronary Artery Bypass Coronary Artery Bypass Graft Graft

Cardiac bypass surgery is an operation to Cardiac bypass surgery is an operation to restore the flow of blood through the arteries restore the flow of blood through the arteries that supply blood to the heart, when a that supply blood to the heart, when a blockage or partial blockage occurs in these blockage or partial blockage occurs in these arteries.arteries.

The arteries that supply the heart muscle with The arteries that supply the heart muscle with oxygen and nutrients are known as the oxygen and nutrients are known as the coronary arteries. The word "coronary" means coronary arteries. The word "coronary" means a crown, and is the name given to these a crown, and is the name given to these arteries that circle the heart like a crown. The arteries that circle the heart like a crown. The narrowing of the arteries of the heart is known narrowing of the arteries of the heart is known as coronary artery disease, which is the most as coronary artery disease, which is the most common form of heart disease.common form of heart disease.

Coronary Artery Bypass Coronary Artery Bypass Graft Graft

Saphenous Vein Harvest Saphenous Vein Harvest

What to Expect Following What to Expect Following CABG Surgery CABG Surgery

Cardiologist follow-up in 7 to 10 Cardiologist follow-up in 7 to 10 days after discharge from hospitaldays after discharge from hospital Discuss recoveryDiscuss recovery Make lifestyle change recommendationsMake lifestyle change recommendations Fine tune medications as neededFine tune medications as needed


6 weeks post-op:6 weeks post-op: most people resume almost all of their regular most people resume almost all of their regular

activitiesactivities As activity increases, strength increasesAs activity increases, strength increases Patient should be able to walk 2-3 miles in an hourPatient should be able to walk 2-3 miles in an hour DrivingDriving TravelTravel Sexual activitySexual activity Return to workReturn to work

Avoid overexertionAvoid overexertion


SternumSternum 12 weeks to heal12 weeks to heal

Should avoid the following:Should avoid the following: Heavy liftingHeavy lifting GolfGolf TennisTennis Vigorous swimmingVigorous swimming

Light activities are o.k.Light activities are o.k.

Graft siteGraft site Leg, arm or bothLeg, arm or both Wound healingWound healing painpain

CABG Discharge CABG Discharge InstructionsInstructions

D/C Home InstructionsD/C Home Instructions No driving while taking narcotic pain medicationsNo driving while taking narcotic pain medications No lifting anything heavier than 10 lbsNo lifting anything heavier than 10 lbs No baths or swimmingNo baths or swimming May shower, must “pat dry” incisionMay shower, must “pat dry” incision

Call your Surgeon to report any of the followingCall your Surgeon to report any of the following Fever greater than101FFever greater than101F Bleeding or pus draining from incisionsBleeding or pus draining from incisions Difficulty breathingDifficulty breathing Chest PainChest Pain Surgical site pain unrelieved by prescribed medicationSurgical site pain unrelieved by prescribed medication

F/U in clinic with surgeon approximately 2wks (1 wk if F/U in clinic with surgeon approximately 2wks (1 wk if patient has staples)patient has staples)

F/U with referring cardiologist 4 wksF/U with referring cardiologist 4 wks

Valve Replacement Valve Replacement

Valve Replacement Valve Replacement Discharge InstructionsDischarge Instructions

Discharge MedicationsDischarge Medications ASA or CoumadinASA or Coumadin B-BlockerB-Blocker +/- ACE inhibitor+/- ACE inhibitor Isosorbide or Ca-channel Blocker if radial artery Isosorbide or Ca-channel Blocker if radial artery

graft usedgraft used Pain medicationsPain medications Previous prescription medsPrevious prescription meds

AnticoagulationAnticoagulation

AspirinAspirin CoumadinCoumadin

PT/INR monitoringPT/INR monitoring Pro time Pro time International Normalized RatioInternational Normalized Ratio

A comparative rating of PT ratios (representing the A comparative rating of PT ratios (representing the observed PT ratio adjusted by the International observed PT ratio adjusted by the International Reference Thromboplastin)Reference Thromboplastin)

The PT is an important screening test used during The PT is an important screening test used during management of oral anticoagulant therapy (Coumadin)management of oral anticoagulant therapy (Coumadin)

Prothrombin is a protein produced by the liver for Prothrombin is a protein produced by the liver for clotting of bloodclotting of blood

Surgical PopulationSurgical Population

In the United States, the fastest growing In the United States, the fastest growing population segment includes people 65 or population segment includes people 65 or olderolder

More than half of these individuals will More than half of these individuals will require some form of surgery in their require some form of surgery in their lifetimelifetime11

Improvements in surgical techniques, Improvements in surgical techniques, anesthesia and ICU’s have made surgery anesthesia and ICU’s have made surgery in this population possiblein this population possible

DeliriumDelirium

Post-operative deliriumPost-operative delirium Overall incidenceOverall incidence

5-10% all age groups5-10% all age groups 10-15% elderly patients10-15% elderly patients

Incidence varies with type of surgery Incidence varies with type of surgery 1-3% following cataract surgery1-3% following cataract surgery 5-10% following general surgery5-10% following general surgery 28-61% following major orthopedic surgery28-61% following major orthopedic surgery 47% following cardiac surgery47% following cardiac surgery

DeliriumDelirium

A significant proportion of these A significant proportion of these patients will experience patients will experience postoperative cognitive impairmentpostoperative cognitive impairment

The most common forms are:The most common forms are: DeliriumDelirium Postoperative cognitive dysfunction Postoperative cognitive dysfunction

(POCD)(POCD)

Frequency of POCDFrequency of POCD

DefinitionDefinition ““Deterioration of intellectual function presenting as Deterioration of intellectual function presenting as

impaired memory or concentration.” impaired memory or concentration.” Clinical featuresClinical features

Range from mild forgetfulness to permanent Range from mild forgetfulness to permanent cognitive impairment resulting in a loss of cognitive impairment resulting in a loss of independenceindependence

POCD diagnosis can only be made if cognitive POCD diagnosis can only be made if cognitive decline can be corroborated by the results of decline can be corroborated by the results of neuropsychological testing presurgical and neuropsychological testing presurgical and postsurgicalpostsurgical

Post-operative cognitive dysfunctionPost-operative cognitive dysfunction Overall incidenceOverall incidence

20-60% following coronary artery bypass surgery20-60% following coronary artery bypass surgery 10-16% elderly patients following major non-cardiac surgery10-16% elderly patients following major non-cardiac surgery

Primary Care IssuesPrimary Care Issues

What are your thoughts?What are your thoughts?

Primary Care IssuesPrimary Care Issues

Endocarditis ProphylaxisEndocarditis Prophylaxis

High-risk categoryHigh-risk category Prosthetic cardiac valvesProsthetic cardiac valves Previous bacterial endocarditis, even in the absence of Previous bacterial endocarditis, even in the absence of

heart diseaseheart disease Complex cyanotic congenital heart diseaseComplex cyanotic congenital heart disease

Single ventricle statesSingle ventricle states Transposition of the great arteriesTransposition of the great arteries Tetralogy of FallotTetralogy of Fallot

Moderate-risk categoryModerate-risk category Most congenital cardiac malformationsMost congenital cardiac malformations Rheumatic & other acquired valvular dysfunctionRheumatic & other acquired valvular dysfunction Hypertrophic cardiomyopathyHypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitationMitral valve prolapse with valvular regurgitation


Dental proceduresDental procedures ExtractionsExtractions Peridontal proceduresPeridontal procedures Endodontic procedures (root canal)Endodontic procedures (root canal) Prophylactic cleaning where bleeding is antipatedProphylactic cleaning where bleeding is antipated

Other surgical proceduresOther surgical procedures


Oral AntibioticsOral Antibiotics AmoxicillinAmoxicillin

2 grams 1 hour before procedure2 grams 1 hour before procedure ClindamycinClindamycin

600mg 1 hour before procedure600mg 1 hour before procedure CephalexinCephalexin

2 grams 1 hour before procedure2 grams 1 hour before procedure Azithromycin or ClarithromycinAzithromycin or Clarithromycin

500mg 1 hour before procedure500mg 1 hour before procedure

Post-operative Post-operative ComplicationsComplications

Post-operative Post-operative ComplicationsComplications

Wound infectionWound infection SternumSternum Chest tube sitesChest tube sites Graft siteGraft site

Atrial FibrillationAtrial Fibrillation anticoagulationanticoagulation

StrokeStroke Neurological deficitsNeurological deficits

Pulmonary EmbolusPulmonary Embolus TransplantTransplant

Rejection of organRejection of organ Other systemic infectionsOther systemic infections

DeathDeath


Pain managementPain management PrecautionsPrecautions Drug interactionsDrug interactions

Physical TherapyPhysical Therapy DMV clearanceDMV clearance Support groupsSupport groups

DepressionDepression TransplantTransplant

Primary CarePrimary Care

DiscussionDiscussion

essentials of neurosurgery

Documents

bloodbrain barrier

blood levels

vasogenic edema

recent illness

fat redistribution

astrocytoma glioblastoma

mineralcorticoid effect

greatest tendency