Published Jun 3, 2009
I am trying to find a source for education for pre and post anesthesia nursing care for anterior cervical spine surgery. I can find all kinds of information on the intraop portion of these procedures but nothing on the recovery phase. We are starting to explore doing these procedures and would like to provide the best care possible for our patients. Any suggestions, anyone?
Thanks for sharing.
Southern Fried RN
From my experience, most of my co-workers and I groan and dread these anterior cervical spine cases. The majority of them tend to come out bad---you know, screaming/moaning/crying/thrashing. They all seem to require a large amnt of Dilaudid and Valium (or Versed.) I don't know why, I look through their home meds and many of them are chronic po narc users so I guess it's a tolerance issue. Anyways, the benzos seem to help as they tend to have muscle spasms. The few times I have seen these pts now come out bad is when anesthesia given 8-10 mg IM morphine about 30-60 mins before the case ends.
I've seen 2 pts post ACDF have a bleed requiring emergent return to OR. It was very scary as they came quite close to losing their airway due to the bleeding.
PostOpPrincess, BSN, RN
I agree with above poster about pain management. The chronic pain patients need to have a Pain Management Consult BEFORE they come out of OR and have drugs on board already.
Otherwise it is an uphill battle getting the pain under control and recovery can extend as long as 2-3 hours more than necessary.
One must be VERY COMFORTABLE in giving large doses of narcotics.
As the other posts stated they can be somewhat of a chalenge with pain control post op as many neck and back patients have been on po pain meds for quite a while. As far as bad outcomes we do not see this as a rule with our patients. Most are very stable. For post-op care airway is always a factor but especially for those patients like these where the surgical site is so close to the airway. For our post op assessment of course you do a full body assessment but extrememty muscle strengths and sensation are important to assess on these patients due to the close proximity of the surgical site to the nerves and spinal cord. you should be assessing their hand grasp strength, leg strength, and dorsi flexion and extension. One of the things you would want to know from the circulator during report is what type of deficits they had pre-op such as weakness, numbness, pain, and or tingling and what extremeties were involved. The other thing to remember is that the patient's symptoms may not be relieved right after surgery due to swelling from the procedure. For those patients that wake up and complain that they still have whatever symptoms they had pre-op it is important to reassure the patient that it may take a while to see results and that this is normal. Hope this helps a little.
I have to say that I've not had any problems with my anterior spine cases -they've all woken up peacefully and remained that way,with pain well controlled - likely due to having an excellent anesthetist - we have a number of those,and,of course,and the one or two that you wouldn't wish on your worst enemy...
We're finding the pts in the best post op pain control are those who've received multi-modal analgesic support preoperatively which,quite often in this PACU, is
-Acetaminophen (usually 975mg)
-Celecoxib (if not contraindicated)
Someone mentioned it above and I echo it that,since most,if not all,of these pts are narcotic tolerant,it is essential that one develops comfort with giving large doses of narcotic. For example, 4mg Hydromorphone IV in an hour wouldn't be an unusual dose.
My greatest challenges to date have all been pain management of terminally ill cancer pts who've had palliative bone surgery (e.g. pathalogical hip #). Their pain is on an inconceivable level - boy,those are tough. It takes massive amounts of narcotic analgesic to get these folks comfortable again. You do have to suspend your fears while being very observant.
Thanks for the helpful responses. I will pass on the information to my nurses and to the physician who will be doing the cases. It is always scary to start doing something new and helpful to hear from those that have already experienced it.
We recover the ACDF patients frequently in our PACU and I agree, most of these patients are chronic pain med users. We find it VERY helpful if they get the "cocktail" PACU Jennifer talked about -- Tylenol, Oxycontin, Celebrex. If we are having trouble managing pain we will also give them their first dose of Vistaril for the muscle spasms.
We recover alot of ACDF pts in my PACU. I have personally only seen 2 "go bad" and have to return to surgery for bleeding puposes. These were both in a short period of time, and the doctor stopped prescribing Toradol as a result. We have not had a problem since(it has been 2 years). One of the doctors has us monitor the patient for 2 hours in pacu, while the other two let us discharge to the floor when we feel they are ready. The biggest things to watch for are airway issues (have them swallow while touching their throat to check tracheal deviaton), neuro response(do a full neuro assessment), and making sure their vocal cords are intact. The doctors want to know if they can say "eee" and if they are moving everything as soon as they come to the bedside. We generally send all of our ACDFs to the floor on 2LNC. If we do not send the patient on O2, we make sure there is a prn order for one in the chart and that there is a flowmeter in the patient's room.
Pain control is another issue many times. It is not uncommon for us to give the entire PACU protocol to chronic painers. Our protocol is total: 250mcg Fentanyl, 10mg Morphine, 50mg Demerol, and 25mg Phenergan all IV. However, one of the doctors has an order for 75-100mg Demerol and 25mg Phergan IM. This seems to work better than anything I ever give IV. We give the Demerol/Phenergan IM, then 50mcg Fentanyl IV and the patient calms down and reports pain control. I have never had to give more narcotic to a patient that I have given this coctail to.
Many times the patient will have the same symptoms they were having preop (pain/numbness in arms or hands) and this is completely normal. The nerves were probably pinched for quite some time, and it takes time for the feeling to become normal again. We often have to reassure patients because having the same symptoms scares them and makes them think the surgery was unsuccessful. Make sure you check the H&P for preop symptoms, because new symptoms need to be reported to the doctor.
A little update: I had a C5-6 cordotomy,allograft, and fusion with plates just yesterday,a 44yr old man with history of anxiety (medicated)- Dr B. said the pt had been very anxious preop,healthy otherwise. Just the usual ~4" anterior incision (neuro here uses dermabond over their incisions).Came in calm and comfortable (I think I needed to give only 0.4mg Hydromorphone in total). When I asked him how he was doing re:the anxiety,he gave me the 'thumbs up'.
Spinal checks and neck circumference were all normal and remained that way. All three of the neuro anesthetists here are exceptional doctors,as are the neurosurgeons. He was a dream case.
I have had 2 ACDFS; very painful, to say the least. My first procedure was done with bone graft from my hip. Although many patients state the hip pain is the pits,
it wasn't bad at all for me. I found ice to the sites (neck and hip) really helped! The first time around, my surgeon would only use IM Demerol, and it helped, but I was getting 200 mgm q4 hours due to pre-op narcotic use for pain control. I would not recommend this analgesia to anyone..takes too long to work when pain relief is needed "today, not tomorrow!"
The second time around, a PCA Dilaudid was a Godsend! Went home the next day, unlike the 1st time; I was hospitalized for 4 days. There was absolutely no use of Toradol; suppresses the inflammatory response. I had no issues with vocal cords the 1st time around d/t surgical technique. However, the 2nd time the surgeon (a different one), went in through the right side of my neck, and I ended up with hoarseness and dysphagia, necessitating a laryngoscopy and an esophagoscopy. This prolonged my recovery. Positioning was a "biggie" in the PACU; one pillow under each arm, and one under the neck..provided much comfort.
As a former PACU nurse, I took care of a patient who had a cervical fusion done with a posterior approach. His dressing was saturated with blood upon arrival to the PACU. He MAE; when I took the drsg down, there was no further bleeding, and there was no further movement, either. He had an epidural hematoma! A stat page to the surgeon got him back to the OR PDQ; all turned out well, his paralysis lasted for 15 minutes..evacuation of the hematoma did the trick; there was no residual paralysis..check the dressing, as well as neuro status FREQUENTLY!
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