Perioperative Management and Complications - exam-focused guide
Perioperative Management and Complications covers preoperative assessment, anticoagulation, prophylaxis, postoperative monitoring and recognition of common neurosurgical complications. The exam tests safe transitions of care.
Core rules
- Preoperative assessment includes neurological baseline, comorbidities, anticoagulant/antiplatelet use, airway and positioning risks. Reversal follows urgency and agent: warfarin with vitamin K and PCC; DOACs may need specific reversal agents or time.
- Antibiotic prophylaxis is given before incision, usually cefazolin, and redosed for long operations. VTE prophylaxis uses compression devices early and pharmacologic prophylaxis when bleeding risk allows.
- Postoperative hematoma presents with declining consciousness, new deficit, headache or pupillary change; urgent CT and return to theatre are needed.
- Transsphenoidal surgery can cause diabetes insipidus then SIADH; monitor sodium and urine output. Postoperative hyponatremia must be corrected slowly to avoid osmotic demyelination.
- Seizure prophylaxis is not routine for all craniotomies; it is considered for cortical resection or high-risk lesions.
- Steroids are tapered, not stopped abruptly, after chronic use.
Worked example: A patient develops polyuria and thirst 24 hours after transsphenoidal surgery, with urine output 250 mL/h and rising sodium. This suggests diabetes insipidus. Fluids and desmopressin are given with close sodium monitoring. Several days later, hyponatremia may signal SIADH; treatment is fluid restriction rather than rapid hypertonic saline.
Traps: missing postoperative hematoma because the patient is "just sleepy"; reversing anticoagulation without a plan; correcting hyponatremia too fast; continuing steroids without taper; forgetting VTE prophylaxis.