Nursing concerns associated with radical skull base surgery: a case study.

Historically, surgical management of extensive neoplasms of the cranial base has been limited by anatomical boundaries. However, major theoretical and technological advances now permit radical surgical resections. The perioperative nursing care of these patients is challenging and requires a wealth of knowledge and skills. The complexity of caring for patients undergoing radical skull base surgery is highlighted through a case study.

Codman Award paper--the experience of intensive care unit nurses providing care to the brain dead patient.

The brain dead patient is a by-product of advances in biomedical technology and the findings of this study confirm the view in the literature that caring for the brain dead patient is an emotionally laden process. This personal distress is directly related to two sources of inconsistencies. First, the nurse may possess coexisting beliefs, perceptions, values, opinions, knowledge and actions which are discrepant. Second, the nurse's personal values, knowledge, and behaviours may be in direct opposition to those of her nursing and medical colleagues and those of the family. The presence of the subjective tension results in the use of distancing tactics and/or the designation of a third person as the target of nursing care in an effort to reduce the personal and interpersonal dissonance.

Temporary vessel occlusion and barbiturate protection in cerebral aneurysm surgery.

In a review of 147 patients with intracranial aneurysms surgically treated by one surgeon (FAD) between 1980 and 1987, 36 selected patients received intraoperative barbiturate protection with sodium thiopental during temporary arterial occlusion. Thiopental doses of 5 to 15 mg/kg were used. Twenty-nine of 36 (81%) had ruptured aneurysms. Occlusion times ranged from 3 to 93 minutes, with a mean of 16.2 minutes. Seven patients had new neurological deficit in the immediate postoperative period, but in only two did these persist. Twenty-one patients (72%) with subarachnoid hemorrhage and 6 with incidental aneurysms made a good recovery. Of the 9 patients with significant permanent deficit, all but 2 were related to either the severity of the initial hemorrhage or to delayed vasospasm. In only one instance might temporary arterial occlusion have led to permanent neurological sequelae. Temporary arterial occlusion with barbiturate protection is a safe technique. For aneurysms that are more surgically complex, it allows for complete dissection of the aneurysm neck and identification and preservation of the surrounding vascular anatomy, while reducing the risk of intraoperative rupture and postoperative stroke.

A monitoring and trending system and intracranial pressure.

A prototype of a portable microprocessor-based system for monitoring and displaying intracranial pressure, systemic arterial pressure, and cerebral perfusion pressure data has been developed. This system reduces the data for long-term logging and subsequent display as a trend plot and an array of computed histograms. Included in the system is the capability of presetting alarms to identify and alert clinical staff to potentially hazardous conditions. An initial technical and clinical evaluation indicates that the objective of improving patient care while controlling capital and operating costs has been met. The alarm system and the trended data display can be used to routinely detect conditions that previously were not immediately identified because of inherent limitations in currently available equipment. The precise minute-to-minute and retrospective evaluation of clinical events is now facilitated by a consistent, concise record and analysis of ICP and related data.