Neurosurgery Perioperative Orders & Functional Case Checklist

Use immediately after craniotomy, burr hole, CSF shunt, or stereotactic procedures. Most components default-on; titrate vitals/neuro-check frequency to acuity.

Patient Care / Monitoring

Activity / Positioning

Diet / IV Fluids

Medications — Symptomatic

Pain — Mild

Pain — Moderate (select ONE)

Pain — Severe (select ONE)

Antihypertensives

GI Prophylaxis / Bowel Regimen

Other

Perioperative Antibiotic Prophylaxis Logic

Post-Op Imaging & Labs

Respiratory & Consults

Generic critical care admission shell — overlay specialty subphase (Neuro ICU, post-op, etc.).

Admit / Code Status / Prophylaxis

Patient Care / Monitoring

Vasoactive Drips

Continuous IV Antihypertensives

Stress Ulcer Prophylaxis — Indications

Bowel & Glucose

Labs

Labs Now (STAT): ABG, BMP, Ca, CBC w/ diff, CMP, CPK, D-dimer, fibrinogen, lactic acid, hepatic panel, Mg, aPTT, Phos, PT/INR, resuscitation panel arterial, troponin I.

Labs in AM (T+1;0200): Same panel + prealbumin.

Microbiology, Imaging & Cardiac

Respiratory, Therapies & Consults

Step-down or floor-level TBI orders. Escalate to Neuro ICU subphase if GCS deteriorates, ICP monitoring needed, or hemodynamic instability.

Patient Care

Weight Bearing Status

Order per affected extremity (LUE/RUE/LLE/RLE):

• Non-weight bearing
• Partial weight bearing
• Toe-touch weight bearing (LE only)
• Weight bearing as tolerated (WBAT)

Activity / Positioning

Diet / IV Fluids

Seizure Prophylaxis (Levetiracetam)

Early post-traumatic seizure prophylaxis is commonly considered for severe TBI during the first 7 days. Brain Trauma Foundation guidance does not establish levetiracetam as superior to phenytoin, so agent and dose should follow local neurotrauma practice.

Analgesia

Antipyretic / Mild Pain

Pain — Moderate (select ONE)

Pain — Severe (select ONE)

GI Prophylaxis & Bowel Regimen

Antiemetic / Antihypertensive

Labs & Imaging

Consults

Educational structure for how a TBI/head-injury plan is commonly organized. Adapt to the patient, service preferences, and supervising resident/attending.

• Q4H neuro checks
• Blood pressure goal per neurosurgery team, commonly SBP <140 after cranial surgery/head injury
• Seizure prophylaxis if indicated, with dose adjusted to patient factors
• Antibiotics only if prophylaxis window or infection indication applies
• PT / OT
• DVT prophylaxis: SCDs ± pharmacologic prophylaxis per team and imaging stability
• Keep HOB > 30°
• Diet: Regular (pending dysphagia screen)
• Code status: Full

SCIP = Surgical Care Improvement Project — a CMS / Joint Commission national quality initiative (launched 2006) aimed at reducing surgical complications, especially SSIs, VTE, and perioperative cardiac events.

Antibiotic prophylaxis measures

• Prophylactic abx given within 1 hour before incision (2 hours for vanc / fluoroquinolones)
• Correct agent selected for the procedure
• Prophylactic antibiotics discontinued within 24 hours of anesthesia-end time for most procedures unless there is documented infection or a procedure-specific reason to extend.

Other historical SCIP measures

• Hair removal with clippers, not razors
• Perioperative normothermia
• Perioperative glucose control (cardiac surgery)
• Beta-blocker continuation
• VTE prophylaxis ordered + given within 24 h of surgery

This section is designed for students learning what to anticipate before and after common functional neurosurgery cases. The goal is not to memorize an order set; it is to understand the handoff logic, device-specific hazards, and the questions that should be asked before the patient leaves the perioperative area.

Pre-Operative STN DBS Checklist

Post-Operative STN DBS Checklist

Post-Operative Functional Craniotomy / Epilepsy Resection Checklist

SCS Trial / Permanent Implant Checklist

IPG / Battery Change Checklist

Intrathecal Baclofen Pump Emergencies

Neuromodulation Hardware Infection — First Steps

Pre-op huddle prompts and agent considerations for DBS, SCS, intrathecal pump, RFA/rhizotomy, and VNS. Built around what actually affects intraoperative neurophysiology and surgical conditions — not generic GA checklists.

DBS — Awake with Microelectrode Recording (MER)

The most anesthesia-sensitive functional case. Almost every common sedative degrades MER signal quality and the clinical exam.

Agents — what to use and what to avoid

Hemodynamics

• SBP target <140 mmHg from skin incision through final lead placement — every 10 mmHg above baseline increases ICH risk along the lead track.
• Treat hypertension early and aggressively. Have labetalol and nicardipine drip drawn up before incision.
• Avoid hypotension too — cerebral hypoperfusion in elderly PD patients triggers confusion that ruins testing.
• Vasopressor preference: phenylephrine bolus over ephedrine (avoid tachycardia and tremor exacerbation in PD).

Patient prep

• Hold PD meds 12 h pre-op for STN targeting — need patient in OFF state for tremor/rigidity assessment. Confirm with movement disorders neurologist.
• Hold anticoagulants/antiplatelets per standard cranial protocol (ASA 7 d, clopidogrel 7 d, warfarin INR <1.3, DOACs 48–72 h).
• Foley placed after frame on, before draping — long case + dex diuresis = full bladder = ruined exam.
• Position: semi-sitting with frame fixed to table. VAE risk — precordial Doppler if available, T-piece on CVL, vigilant ETCO₂ monitoring.
• Temperature: warming blanket on lower body only, avoid covering arms (need to see tremor).
• Skip N₂O if any pneumocephalus expected.

DBS — Asleep (Image-Guided, No MER)

iCT or iMRI verification, no intraop testing. Anesthetic flexibility is much greater.

• Standard GA acceptable — TIVA or volatile.
• Same SBP <140 target during lead pass.
• NMB acceptable since no motor testing.
• If doing macrostimulation testing under light anesthesia: switch to TIVA + dex 30 min before testing window, hold NMB, communicate the "test window" timeline to anesthesia.
• Pre-op PD meds can be continued (no exam needed) — confirm with movement disorders.

DBS — Asleep with MER (rare hybrid)

• TIVA preferred: low-dose propofol (≤75 mcg/kg/min) + remifentanil + dex (≤0.3 mcg/kg/hr).
• If volatile is unavoidable, keep sevoflurane <0.3 MAC (some centers tolerate up to 0.5 MAC but recording quality drops measurably above 0.3). Desflurane and isoflurane suppress MER more than sevo at equivalent MAC — avoid if possible.
• NMB only for intubation, then allow full reversal before recording.
• Recognize MER quality will be inferior to awake — adjust expectations and physiology mapping interpretation accordingly.

SCS — Trial (Percutaneous)

• Local + light MAC: fentanyl 25–50 mcg, ± versed 1–2 mg titrated.
• Patient must be responsive for paresthesia mapping — they need to report coverage of pain area as leads are advanced.
• No NMB. No deep sedation.
• Prone positioning — confirm airway access plan with anesthesia.

SCS — Permanent Paddle Lead (Laminotomy)

• GA with IONM — SSEPs and EMG to confirm midline placement and avoid cord injury.
• TIVA preferred (propofol + remifentanil ± low-dose ketamine) for stable SSEP signals. Volatile agents >0.5 MAC degrade SSEPs.
• NMB ONLY for intubation — full reversal required before stimulation testing or EMG monitoring.
• Confirm IONM tech is booked in pre-op huddle. Most common reason cases get delayed.
• Some surgeons wake patient briefly intraop for paresthesia confirmation — flag this to anesthesia in advance so they plan emergence.

Intrathecal Drug Delivery (Pump Implant / Revision)

• GA or spinal acceptable — spinal often preferred to avoid post-op nausea and allow dose titration awake.
• If intraop test bolus given: respiratory monitoring × 24 h post-op (capnography preferred), naloxone at bedside.
• Watch for CSF leak intraop — communicate to anesthesia for positioning and post-op flat bed orders.
• Avoid IM opioids post-op — confounds intrathecal dose assessment.

Percutaneous Rhizotomy / RFA for Trigeminal Neuralgia

• MAC with deep boluses for the noxious portions (foramen ovale cannulation, lesioning) and rapid emergence for sensory testing.
• Typical pattern: propofol bolus 30–50 mg for cannulation → wake for sensory mapping → bolus for thermocoagulation → wake for re-test.
• Anesthesia must be comfortable with repeated deep-light cycling. Discuss timing in pre-op huddle.
• Watch for trigeminocardiac reflex — bradycardia/asystole on cannulation. Glycopyrrolate pre-treatment, atropine drawn up.
• Airway: nasal cannula with ETCO₂, no NMB, no LMA (interferes with V3 access).

SRS (Gamma Knife / LINAC) — Sedation for Frame Placement

• Local anesthetic infiltration at pin sites is the workhorse — generous lidocaine + bupivacaine mix.
• Light sedation only: fentanyl 25–50 mcg ± midazolam 1 mg. Patient must protect airway and cooperate.
• Anxiolysis is the main need — many patients tolerate frame placement with versed alone.
• For pediatric or claustrophobic adults: consider GA with LMA for the imaging/treatment portion (rare in adult practice).

VNS Implant

• Standard GA, neck extension positioning.
• No NMB after intubation if intraop device interrogation/lead test planned (need to see vocal cord/diaphragm response).
• Watch for bradycardia/asystole during initial lead test — atropine drawn up, communicate test timing to anesthesia.

Pre-Op Huddle — Questions to Ask Anesthesia

For every case

• What's our BP target during the critical phase, and what agents do you have ready to treat HTN?
• What's the planned vasopressor of choice if hypotension occurs? Phenylephrine is often useful in PD/elderly patients because it avoids tachycardia and tremor exacerbation.
• Are anticoagulants and antiplatelets confirmed held per protocol?
• Are we avoiding N₂O?
• What's the post-op disposition — ICU, step-down, or PACU-to-floor?

DBS with MER

• What's your TIVA recipe for the MER window? Confirm: no propofol within 20 min of recording, no benzos at all, dex ≤0.5 mcg/kg/hr.
• Are PD meds confirmed held since last night?
• Scalp block plan — supraorbital, supratrochlear, auriculotemporal, occipital. Want me to do it or you?
• VAE monitoring — precordial Doppler available? CVL aspiration plan?
• Foley before drape?
• What's the plan if patient becomes uncooperative or panicky mid-case? (Convert to dex bolus, abort and switch to asleep, etc.)

SCS paddle / spinal IONM cases

• IONM tech confirmed and in room?
• TIVA with propofol + remi, volatile <0.5 MAC?
• NMB fully reversed before SSEP baseline?
• Are we planning a brief wake-up for paresthesia mapping?

RFA / Rhizotomy

• Comfortable with deep-light cycling for cannulation → testing → lesioning → testing?
• Glycopyrrolate given? Atropine drawn up for trigeminocardiac reflex?
• ETCO₂ via nasal cannula in place?

Pump / intrathecal

• Test bolus planned — respiratory monitoring orders for 24 h post-op confirmed?
• Naloxone at bedside in PACU and floor?

Quick Drug Reference — Functional OR

General Safety Principles

• High-frequency, low-risk items are usually easy to anticipate: vitals, neuro checks, SCDs, HOB ≥30°, acetaminophen, ondansetron, and bowel regimen.
• High-risk items should always trigger deliberate review: opioids, anticoagulants, steroids, antibiotics, insulin, pressors, and sedatives.
• Pain ladders should avoid duplicate opioid pathways; students should notice when more than one PRN opioid could be given for the same pain score.
• Seizure prophylaxis, antibiotic prophylaxis, and stress-ulcer prophylaxis are best understood as indication-based decisions, not automatic medications.
• Age, frailty, weight, renal function, hepatic function, and baseline cognition should change how medication defaults are interpreted.

Functional / Pain Neuromodulation Pearls

• DBS Post-Op Day 0: frequent early vitals/neuro checks, no anticoagulation until cleared, prompt post-op CT or MRI per surgeon/device protocol, BP goal defined by the team, and a deliberate plan for restarting dopaminergic medications.
• SCS Trial / Permanent Implant: peri-incision antibiotics by local prophylaxis guidance, neuraxial anticoagulation precautions, focused lower-extremity motor/sensory exam, wound check, activity restrictions, and device interrogation/programming before discharge.
• Intrathecal Pump: bowel/bladder check, respiratory monitoring when intrathecal opioid dosing is involved, naloxone availability when appropriate, pump interrogation, and explicit withdrawal/overdose return precautions.

Radiosurgery-Specific Pearls

• GK / LINAC SRS day-of: steroid, antiemetic, and anxiolytic plans are indication-specific; frame-pin care if a Leksell frame is used; post-procedure observation and neuro checks per local discharge criteria.
• Post-SRS for trigeminal neuralgia: continue current neuropathic regimen, document baseline BNI pain score, schedule 3-month follow-up with imaging.

Safety Defaults Worth Remembering

• Default mechanical VTE ppx (SCDs) on every neuro admission; require active opt-out with reason.
• Default "Notify provider for UOP >250 mL/hr × 3 hrs" on every cranial post-op (DI surveillance).
• Default "Notify provider for any GCS drop ≥2 points or new focal deficit" on all neuro admissions.
• Default isotonic fluids only (NS or LR) on TBI/SAH/post-craniotomy sets — block hypotonic at order-entry.
• Hyperosmolar therapy should be treated as an escalation pathway, not a routine floor order: central-line requirements, sodium/osmolality monitoring, renal status, and ICU-level oversight matter.

Documentation Habits

• Document the neurologic baseline clearly before sedating medications, transfer, or discharge.
• For device cases, document device type, laterality, target/lead level, generator site, interrogation status, and any programming changes.
• For ICU patients, document the reason for ICU-level care, neurologic monitoring frequency, BP/MAP goals, airway status, and escalation triggers.
• For SRS-related peri-procedure care, document baseline cranial nerve/pain score when relevant, steroid plan, frame or mask details, and follow-up imaging plan.

These links are intended as starting points for students who want to understand the source logic behind the checklist. For patient care, use local protocols and supervising-team guidance.