a blood vessel that carries oxygen and nutrients to the brain blocked by a clot or bursts/ ruptures that caused brain cells to die

1. STROKE CARE OF PATIENT
WITH POST DECOMPRESSIVE
CRANIECTOMY
By Wong Pei Yin (Charissa)
BSN, SRN

2. STOKE CARE OF PATIENT IS
IMPORTANT???
“We treat human as a whole,
not treating the disease itself”

3. blocked by a clot
or bursts/ ruptures
blood vessel that
carries oxygen and
nutrients to the brain
brain cells die
STROKE

4. ISCHEMIC STROKE (CLOTS)
• Majority 87%
of all strokes.
• A blood vessel
supplying
blood to the
brain is
obstructed.

5. HEMORRHAGIC STROKE (BLEEDS)
• Occurs when a
weakened blood vessel
(aneurysms and
arteriovenous
malformations AVMs)
ruptures.
• The most common
cause of hemorrhagic
stroke is uncontrolled
high blood pressure.

6. • used in urgent or emergent conditions where the brain
swelling from bleeding, stroke or infection, the pressure
in the brain can build inside the skull and causing
further damage.
DECOMPRESSIVE CRANIECTOMY?
• The bone flap is surgically removed but is not returned
to the skull after surgery.

7. Role of Decompressive Craniectomy
for stroke
1. Increases Buffering Capacity Of Cranium.
• Allows outward herniation of brain tissue.
- preventing compression of brainstem structures.
2. Intracranial Pressure
- (ICP) reduction 15-85% depending on size of
bone removed.
3. Improves neurological status and quality of life
- Decompressive craniectomy performed within
24hours may improve overall mortality and functional
outcomes.

8. Monroe-Kellie doctorine
• The cranium is a rigid structure that contains 3
main components: brain, cerebrospinal fluid,
and blood.
• An increase in the volume of one component
will result in the decrease of volume in 1 or 2
of the other components.

9. The figure above showed measurements of ICP before,
during, and after the operation, indicating a significant
alleviating effect of DC on intracranial hypertension.

10. Complications Associated With
Decompressive Craniectomy
Early
•Hemorrhage (hematoma expansion)
•External cerebral herniation
•Wound complications
•Seizures/epilepsy
Late or delayed
•Hydrocephalus
•Syndrome of the Trephined

11. HAEMORRHAGE
Hematoma
expansion, and
subdural collection
post craniectomy.
newly developed subdural or
epidural hematomas
potentially within the first
few hours (for epidurals) or a
few days postoperative.

12. Post Cerebral Contusion Expansion
Usually occurs
within first two days.

13. External Cerebral Herniation
From the craniectomy site.

14. Surgical Site Infection
Dehiscence
• Defined as a diastase of facing flap borders
occurring along the line of suture, with
different degrees of exposure of underlying
tissues

15. Ulcer
• Defined as a loss of substance occurring inside
the skin flap, usually distant from the line of
suture, constantly presenting with underlying
tissues exposure

16. Seizures/Epilepsy
• Possible effect of stretching of the scar due to
sinking scalp flap

17. Post Traumatic Hydrocephalus
Post traumatic
hydrocephalus can
occur one month
post-operative.

18. Syndrome of the Trephined
Sinking skin flap occurs
following removal of a
large skull bone flap

19. NURSES SHOULD KNOW ABOUT CARE
FOR PATIENT POST OPERATIVE
DECOMPRESSIVE CRANIECTOMY
• The NICEPOD (2011) report found that
postoperative patients are at risk of clinical
deterioration.
• Knowledge and understanding of the key
areas and local policies will help reduce
potential problems (National Patient Safety
Agency, 2007)

20. POST OPERATIVE
NURSING INTERVENTION
Provide the following care after admission to critical care
unit or acute care unit:
a. Close Observation And Monitoring
 Continue for 24 hours after procedure.
 Sign of impending brain herniation, Cushing response:
irregular respirations, hypertension and bradycardia
 High blood pressure causes reflex bradycardia and
brain stem compromise affecting respiration.

21. B. Assessment Neurological Status
 Assess mental status (GCS) hourly and deterioration in
conscious level usually is sign of rising ICP.
 Pupillary changes such as pupillary dilatation, bilateral
ptosis, impaired upgaze often seen in association with
raised ICP.
c. Risk Of Develop Seizure
 Monitor seizure activity, increase the risk of postoperative
seizure activity especially in first 24 hours after surgery.
 Fluctuation of neurologic status may indicate subclinical
seizures.
 Administer anticonvulsants as prescribed.
 Provide seizure precautions (available for airway, pads on
the bed rails, and suctioning equipment set up)

22. d. Position
 Keeping neck in midline neutral position and head of the bed
at 30 degrees that help venous drainage from the brain and
lowers ICP.
 Avoid extreme rotation of the neck and extreme hip flexion
which may further raise ICP by increasing intrathoracic
pressure and obstructing cerebral venous outflow
e. Monitor Respiratory Status
 Maintain mechanical ventilation and slight hyperventilation
for first 24 to 48hours as prescribed to prevent increased ICP.
 Respiratory difficulty due to decreased level of consciousness
and inability to protect airway.
 Maintain Spo2> 95%, obtaining ABG as needed.

23. f. Drains
Know the location of each drain and label
them clearly.
Requires monitoring and measurement of the
drainage.
Inform the physician if drainage is more than
the normal amount of 30-50ml per shift.

24. g. Incision Care
 Inspect the incision on the head to ensure edges remain
well approximated, and staples/ sutures are intact.
 Monitor for redness around the incision, discharge, and
other signs of infection.
h. Pain Control
 Assess pain via pain score (scale 1–10)
 Administer specific pain management medications as
prescribed by doctor to prevent elevate of blood pressure
result in vasoconstriction.
 Short acting agents, such as fentanyl are preferred
especially because reversal agents are available, making
certain that a neurologic exam is possible.

25. i. Monitor intake and output of fluid
• Common signs and symptoms of
hypovolemic shock results from
general fluid loss, tachycardia,
decrease BP, shallow and rapid
respirations, decreased urine output
(10-25ml/hour).
• Fluid resuscitation is directed toward
maintaining normovolemia. Isotonic
and hypertonic saline are generally
used.
• IV fluid with dextrose should be
avoided due to risk of increasing
blood glucose and potential
worsening of cerebral oedema.

26. j. Blood glucose
Hyperglycemia potentially disrupts the blood-
brain barrier and increases cerebral edema.
Maintain normoglycemia, 4-8mmol/l.
k. Adequate nutrition
nutrition guaranteed by using high protein
enteral or parenteral solutions.
nutritional needs necessary to help facilitate
appropriate wound healing.

27. Example Case
• 59 years old, male
• U/L DM, HTN, IHD done bypass 2001, AF
• Found by family member patient was lying down
flat on floor at 10am 21/9/19
• +Vomitus
• +Less responsive
• +Facial asymmetry, unsure fitting episode prior
fall.
• No headache

28. • Patient on arrival ED 11.30am 21/9/19,
• GCS 10/15 E4V1M5, not obey command. Pupil
2mm/2mm reactive.
• BP: 192/67mmhg, HR: 84/min, Temp: 37◦c,
• Spo2: 92%-93% under HFM 15L/min
• Blood glucose: 18.4mmol/l
• Cardiac monitoring: AF rate controlled
• Vomited x2 at ED
• Left Facial Palsy, Left Gaze Preference, Right sided
body weakness, Gag Reflex Absent
• Decided for intubation, airway protection 12.30pm

29. • 1st CT brain: MCA densed sign, no midline
shift, ASPECT 5
• CTA brain: no co-lateral, not for mechanical
thrombectomy.
• 2nd CT brain: mass effect noted.
• Diagnose: Left MCA infarct

30. Post Operative Management
• Left decompressive craniectomy done 11.30am 22/9/19
• Post operation admitted to neuromedical acute care unit
for close monitoring.
• Wean off sedation and aim for extubation.
• IV Zinacef 750mg TDS for 3doses then off (prophylaxis).
• Drain charting- full vacuum.
• IV drip maintenance 5 pints
• Start feeding 6hours post op and taper drips as
tolerating.
• Repeat blood investigation, to optimize if Hb low or
coagulopathy.
• Repeat CT brain earlier if indicated.
• For wound inspection on D3, and STO D7.

31. Post Operative Result day 1-day 3
• GCS 11/15, E4VtM6, open eyes spontaneously
and obey command.
• Able to move left sided.
• BP: 150-180/80-100 under low dose antiHPT
supported
• Spo2: 100% under ventilator supported
• Blood glucose: 8-11mmol/L under IV infusion
insulin supported
• Intake/Output chart: Positive 300-600ml/day
under IV drips normal saline maintenance
• Drain chart: below 60ml/day
• Repeated CT brain: No hemorrhage, No midline
shift