Care of Head-Dressings and Measures to Prevent Post Operative Infections - Examples

Care of Head-Dressings and Measures to Prevent Post Operative Infections - Examples

Sample 1: Post Op Infections

Intracranial Monitoring Patient Protocol
Preoperative

PICC line placed for reliable IV access.

Intraoperative

Standard preoperative antibiotic administration in the OR prior to incision.

Meticulous galeal closure to prevent CSF leak.

Each exiting electrode is secured with purse-string suture to prevent CSF leak.

Bacitracin applied to incisions and electrode exit sites, followed by headwrap dressing.

Postoperative

Ceftriaxone 2G IV administered BID during course of monitoring.

Decadron 4mg q6hr for first 48hrs to reduce brain and soft tissue swelling.

Dressing inspected daily for drainage. Dressing is left intact until electrodes are removed, unless drainage is noted, indicating need for dressing change. For prolonged recordings (>1 week), dressings are removed on a weekly basis, electrode exit sites inspected for signs of infection or drainage, and head rewrapped.

Sequential compression devices in use at all times to prevent DVTs.

Aggressive daily use of incentive spirometry to prevent atelectasis.

Sample 2: Post Op Infections

CARE OF PATIENTS WITH INVASIVE EPILEPSY ELECTRODES

1. Patients will come out of the OR with a head wrap on. Underneath the wrap will be a telfa/tegaderm dressing.

1. Patients typically spend 1 night in the ICU and then go to the EMU on the 10th floor for monitoring.

1. Patients should get postoperative imaging the evening after the OR (preferably before midnight) while in the ICU. They cannot be transferred to the Epilepsy Monitoring Unit and hooked up for monitoring until this is done:
2. Postop head CT to look for hemorrhage
3. Postop high resolution CT scan to evaluate for electrode position
4. Postop MRI to evaluate electrode position (Postop DBS protocol)
5. AP/lateral skull XR
6. Patients remain on antibiotics throughout the monitoring period
7. Ancef 2g IV q8h or Vanco 1g IV BID

1. Neurosurgery handles all surgical issues, neurology manages AEDs.

1. It is imperative to watch for CSF leak. If a leak is noted, the source should bedetermined and a stitch placed to stop it.

1. The headwrap should be changed as needed due to drainage or movement.

1. On postop day 2, the original dressing should be removed and a new dressing placed over the electrode exit site (the main incision does not need a new dressing) with a new headwrap.

1. A small amount of bacitracin ointment may be placed at the electrode exit sites only

1. Staples remain in place.

1. SQ heparin may be started on postop day 2.

1. Patients may be out of bed to a chair.

1. The foley catheter may be removed at the patient's discretion.

13. THE MANAGEMENT OF SEIZURES AND STATUS EPILEPTICUS IS THE SAME IN THE PATIENTS AS IN ANY OTHER PATIENT

Sample 3: Head Dressing

POLICY AND PROCEDURES

Care of Patients with Intracranial Electrodes

PURPOSE: To provide guidelines for the safe care of patients with extra-operative implanted intracranial electrodes.

POLICY: Maintenance of safety and quality of recording during extra-operative seizure monitoring with implanted intracranial electrodes.

Prevention of post-operative infections

1. Head Dressings:

1. Managed by the neurosurgery team only. No other personnel are to manipulate the head dressing or the wires as they enter the head dressing.
2. Head wraps are removed and replaced every 72 hours.
3. During replacement of head wrap, wire exit sites are inspected and cleaned with ChloraPrep.
4. Any evidence of infection (redness, warmth, pus, etc) necessitates immediate notification of the neurosurgeon.
5. Any evidence of compromised wiring (kinks, insulation breaks, etc) necessitates immediate notification of the neurosurgeon and the EMU physician and associated EEG technicians.
6. Replacement head wrap will utilize sterile dressing materials.

1. Post-operative Safety Procedures:

1. Head dressings managed by neurosurgery team only, as above.
2. Prophylactic peri-operative antibiotics include nafcillin and/ or vancomycin with individualized exceptions made as indicated (eg allergies)
3. Baseline post-implantation thin cut CT scan is performed en route from PACU to ICU
4. Baseline skull x-rays are performed en route from PACU to ICU
5. Skull x-rays are performed as needed (at least every 48 hours) to confirm stable position of intracranial electrodes
6. Patients will be maintained in ICU at least 24 hours for close observation post-implantation
7. Throughout the admission, the neurosurgeon will be notified in any change in mental status, focal neurological changes, or fevers

Sample 4: Head Dressing

INTRACRANIAL ELECTRODES – PATIENT CARE

PROCEDURE

1. Upon discharge from PACU, the patient is admitted to the EMU on 9 East.

1. The EMU Monitor Tech connects the patient to video telemetry as soon as possible.

1. The patient and their family member (s) are instructed on pushing the event button and nurse call bell for every seizure, upon visible onset or patient’s aura.

1. Seizure precautions and nursing responsibilities are the same as outlined in “Neurological: Seizure” Standard of Practice with the added charge of preventing the dislodgement of the intracranial electrodes.

1. The physician changes the initial dressing, and the surgical team replaces the head bandage every 5 days at the bedside, using sterile technique. The nurse will routinely observe for signs and symptoms of local infection at the cranial electrode entry sites such as redness, erythema and/or drainage. Vital signs are monitored and documented, including temperature. The physician will be notified of findings outside of established parameters and/or deviations from baseline data.

1. Measures are taken to provide EMU patients with adequate privacy, such as keeping the door of the monitor room closed to prevent passers-by from viewing patients on the monitor screens. If patients object to being recorded during personal care activities, the curtain is pulled and the camera is re-directed until activities are completed.

1. Optimal activity is maintained and encouraged. Post-operatively, the head of the bed is elevated 30 degrees. The patient is assisted out of bed on the first post-op day, then up as tolerated thereafter. Patients will be permitted to disconnect from the EEG telemetry system to ambulate at least daily.

References:

1.)Hickey, J. (2009). Management of Patients undergoing Neurosurgical Procedures & Seizures and Epilepsy. In The Clinical Practice of Neurological and Neurosurgical Nursing (6th ed., pp. 320 & 657-658). Houston: Lipincott Williams & Wilkins.

2.)Voorhies, J., & Cohen-Gadol, A. (2013). Techniques for Placement of Grids and Strip Electrodes for Intracranial Epilepsy Surgery Monitoring: Pearls and Pitfalls. Surgical Neurology International,4, 98-98.