Hypertensive cerebral hemorrhage clinical pathway standard inpatient procedure
1.Applicable objects.
The first diagnosis of hypertensive cerebral hemorrhage
Perform craniotomy for hematoma removal
2. Diagnosis basis.
According to the Clinical Diagnosis and Treatment Guide-Neurosurgery Branch (edited by the Chinese Medical Association, People’s Health Publishing House), Clinical Technical Operation Specification-Neurosurgery Branch (edited by the Chinese Medical Association, People’s Military Medical Publishing House), Wang Loyalty Neurosurgery (edited by Wang Loyalty, Hubei Science and Technology Publishing House), Neurosurgery (edited by Zhao Jizong, People’s Health Publishing House).
Clinical manifestations.
(1) clear history of hypertension
(2) Acute intracranial pressure increase symptoms: often severe headache, dizziness and vomiting, and severe patients may become unconscious
(3) Neurological symptoms: depending on the site of hemorrhage, some corresponding symptoms of the corresponding site may appear, with different degrees of hemiparesis, hemianesthesia, hemianopsia, pupillary changes, etc.
(①) Shell nucleus hemorrhage: the best site of hypertensive cerebral hemorrhage, the contralateral limb hemiparesis appears first, which may progress to coma or even death in severe cases.
(ii) Thalamic hemorrhage: generally appears as contralateral hemianesthesia, when the internal capsule hemorrhage also appears as hemiparesis symptoms.
(iii) Cerebellar hemorrhage: due to the direct compression of the brainstem by the hemorrhage, the patient appears coma first instead of hemiparesis first.
④Lobar hemorrhage: symptoms vary depending on the lobe of the brain where the hematoma is located. For example, frontal lobe may present with contralateral hemiparesis, mostly in the upper limbs, and lower limbs and face are less severe; parietal lobe may present with contralateral hemianesthesia; occipital lobe may present with ipsilateral eye pain and contralateral ipsilateral hemianesthesia; temporal lobe hemorrhage may present with non-fluent speech and hearing impairment if it occurs in the dominant hemisphere.
Auxiliary examinations.
(1) CT scan of the head: it is the first choice for hypertensive cerebral hemorrhage to clarify the site and volume of hemorrhage, and the hematoma shows high-density shadow
(2) cranial MRI scan: not as the first choice examination, which helps in differential diagnosis.
(3) Basis for selecting treatment plan.
According to the Clinical Diagnostic and Treatment Guide-Neurosurgery Branch (edited by the Chinese Medical Association, People’s Health Publishing House), Clinical Technical Practice Specification-Neurosurgery Branch (edited by the Chinese Medical Association, People’s Military Medical Publishing House), Wang Loyalty Neurosurgery (edited by Wang Loyalty, Hubei Science and Technology Publishing House), Neurosurgery (edited by Zhao Jizong, People’s Health Publishing House).
Indications for open cranial hematoma removal surgery.
(1) Patients with impaired consciousness, bilateral pupils of unequal size and other signs of brain herniation
(2) The amount of supratentorial hematoma is >30ml, the midline structure is displaced >5mm, and the lateral ventricle is obviously compressed
(3) Sub-screen hematoma amount >10ml, with significant pressure on the brainstem or the fourth ventricle
(4) Conservative treatment by internal medicine is ineffective, the hematoma volume gradually increases, and there is no absolute contraindication to surgery.
Contraindications.
(1) Severe heart disease or severe liver and kidney insufficiency, poor general condition, unable to tolerate surgery
(2) Late stage of brain herniation.
For those who are at greater risk of surgery (advanced age, pregnancy, combined with more serious medical diseases), the patient or family should be informed of the condition; if they do not agree to the surgery, they should be fully informed of the risks, perform the signature procedure, and be closely observed.
4.The standard hospitalization day is ≤21 days.
5.Enter the pathway criteria.
The first diagnosis must be in accordance with ICD-10: I61.902 hypertensive cerebral hemorrhage disease code.
When the patient also has other disease diagnosis, but does not need special treatment during hospitalization and does not affect the implementation of the clinical pathway process of the first diagnosis, he can enter the pathway. Patients with advanced brain herniation do not enter the pathway.
6. Preoperative preparation (on the day of admission)
Required examination items.
(1) Routine blood and urine, blood group.
(2) Coagulation function, liver and kidney function, blood electrolytes, blood glucose, screening for infectious diseases (hepatitis B, hepatitis C, AIDS, syphilis, etc.).
(3) electrocardiogram, chest X-ray plain film.
(4) CT scan of the head.
According to the patient’s condition, DSA, MRI for differential diagnosis if necessary.
7. Preventive antibacterial drug selection and timing of use.
Select drugs in accordance with the Guidelines for Clinical Application of Antimicrobial Drugs (Health Care Development [2004] No. 285). It is recommended to use the first and second generation cephalosporins, ceftriaxone, etc.; for patients with definite infection, the antimicrobial drugs can be adjusted according to the results of drug sensitivity test.
Prophylactic use of antimicrobial drugs for 30 minutes before surgery
8. The day of surgery is the day of admission.
Anesthesia mode: general anesthesia.
Surgical procedure: craniotomy for hematoma removal.
Surgical placement: dural repair material, skull fixation material, drainage tube system.
Intraoperative medications: dehydrating drugs, antihypertensive drugs, antibacterial drugs, antiepileptic drugs and hormones as appropriate.
Blood transfusion: decided according to the blood loss of surgery.
9. Postoperative hospital recovery ≤ 20 days.
Checkups that must be reviewed: head CT within 24 hours after surgery and before discharge according to the specific situation, to understand the intracranial situation; laboratory tests including blood routine, liver and kidney function, blood electrolytes, blood sugar, etc.
According to the patient’s condition, blood gas analysis, chest X-ray plain film, B ultrasound and other examinations are feasible.
The surgical incision was changed once every 2-3 days.
The sutures of the surgical incision will be removed 7 days after surgery, or the removal time will be extended according to the patient’s condition.
Postoperatively, tracheotomy was performed according to the patient’s condition.
10. Discharge criteria.
The patient’s condition is stable and the vital signs are stable.
The body temperature is normal, and there are no obvious abnormalities in the laboratory tests related to the surgery.
The surgical incision is healing well.
Patients who are still in coma, if their vital signs are stable, those who cannot recover in a short time after assessment, and there are no complications and/or comorbidities that require hospitalization, can be transferred to continue rehabilitation treatment.
11. Analysis of variants and causes.
Intraoperative or postoperative complications such as intracranial hematoma, cerebral edema, cerebral infarction at the surgical site or other sites secondary to surgery, which in severe cases require secondary surgery, resulting in longer hospital stay and increased costs.
Postoperative incisional and intracranial infections and serious neurological complications, resulting in longer hospital stays and increased costs.
Postoperative secondary development of other medical and surgical diseases, such as pulmonary infection, lower limb deep vein thrombosis, and stress ulcers, which require further consultation and treatment, leading to prolonged hospitalization.