A new lease on life: Successful discharge after brain tumor

Vishnu

Deputy Nursing Superintendent, Kauvery Hospital, Hosur, Tamil Nadu

Abstract

Medulloblastoma is a cancerous brain tumor. The tumor can be fast -growing, can involve brain stem and cerebellum, and spread to other areas of the brain and spinal cord. Medulloblastoma is more common in children than adults. Treatment includes surgery, radiation therapy and chemotherapy.

Presentation

On 13th March, a 40 years aged female came to ER with the complaints of headache since 4 months, and one-week of increased intensity; and associated with multiple episodes of vomiting.

On examination

Patient was conscious, oriented, afebrile and vitals were stable.

  • BP – 110/80 mmHg
  • PR – 92/min
  • RR – 20/min
  • Temperature – 98ŸF
  • SpO2 – 99% on RA
  • GRBS – 140 mg/dL
  • GCS -E4V5M6
  • CVS – S1, S2 (+)
  • RS- B/L AE (+)
  • P/A – Soft, Non-tender
  • Pupils – B/L 3 mm RTL, Right sided nystagmus (+)
  • No Ataxia
  • Romberg (+ ve)
  • Moves all 4 limbs

Diagnosis and Clinical Evolution

  • In ER, IV line secured, prescribed medicine was given. Doctor informed ward admission and attender was also willing hence, ECG done. Blood sample collected and sent to lab for report and patient shifted to ward.
  • MRI Brain done in OP basis and Echo was planned. The next day planned for VP Shunt and Sub Occipital Craniotomy Excision of SOL with EVD. Admistered Inj. Xone 2-gram IV before surgery.
  • In Ward, Patient vitals checked, due medicine given as per consultant order. Patient slept well and comfortable with proper position, patient had no complaints.
  • Patient kept on NPO from 12am. Inj. KCL 40 mcg in 500ml given over 4 hours. OT preparation and PAC done.
  • Patient shifted to OT for procedure, while shifting patient’s vital signs were stable. General anesthesia given.
  • The procedure was uneventful, VP shunt placed and secured closure done.
  • Patient extubated then, shifted to ICU for the post op care.
  • On POD – 1, patient self-voided, conscious and oriented. IV fluid 100ml/hr on flow.
  • Consultant advice to do CT brain.
  • On POD-1 patient shifted to ward care, patient was oriented, conscious and stable. Patient was sleeping comfortably, there was no complaint from patient’s side.
  • On POD-2, patient had food, IV fluids 50ml/hr on flow.

Surgery and outcome

Surgery plan for the patient Midline Suboccipital Craniotomy with Excision, OT Preparation and PAC done. Surgery purposed needed blood reserved to 30 PRBC, 40 FFB. Patient on NPO from midnight. Neuro Surgeon advised to take head bath in the morning. Patient was prepared for the Surgery. Patient wheeled into OT, started on general anesthesia cup line & artery line. Surgery – Midline Suboccipital Craniotomy, Transluminal approach subtotal excision of SOL, during the surgery patient vitals were stable. Catheterization and Ryles tube in place, dressing done. Biopsy was sent to lab outside (Nimhans), reports are awaited.

Post- Op Care

  • On POD-1, patient shifted to ICU care with ventilator support. On ICU care, Inj. Fentanyl 5 ml/hr on flow. Consultant Neuro Surgeon advised to do the CT Brain. Anesthetist advised Inj. Methypred 1 gram.
  • On POD-2, Neuro surgeon advised to do the Facial physiotherapy and patient was ambulated. Patient artery line removed. Shifted to Stepdown ICU Care, patient was extubated and aspirated, and well mobilized, drain removed. On the day, patient had a complaint of vomiting hence, Inj. Levipil given. After 3 hours of NPO, Neuro surgeon advised to start on oral, removed CVC, on CBD. Patient was well mobilized.
  • On POD-3, patient feeding given, head elevation maintained and back care, oral care given, NG tube on position, consultant order medication given. Patient had a complaint of giddiness on ambulation, tolerating semi-solid diet. Patient not passed stools for 4 days, but passed flatus. Wound was healthy, dressing intact in neck, suturing in Lumbar region, advised for facial physiotherapy, side stimulation and to continue rest. With IV fluids 200ml/hr on flow, patient was mobilized. Neuro surgeon saw the patient and advised to remove the ryles tube. Patient had no urinary sensation, catheter clamped.
  • On POD- 4, patient had a food and well oriented. Neuro surgeon saw the patient and planned to discharge the next day.

Nursing Management

  • Monitor the level of consciousness GCS -E4V5M6
  • Elevate head end to reduce the Intracranial Pressure (ICP)
  • Administer Corticosteroids to reduce the brain swelling and analgesics for pain management.
  • Provide psychological support to patient and family members.
  • High calorie & high protein diet on nutritional therapy.
  • Educated the family members regarding the Chemotherapy counseling.

Conclusion

Brain tumors are diverse and potentially life-threatening, and are a complex medical concern requiring specialized care. Advancements in treatment are offering hope for improved outcomes and quality of life for the patients.

Learning Points

  • Early recognition of symptoms
  • Understanding Medulloblastoma
  • Multidisciplinary Management
  • Role of Timely intervention.
Kauvery Hospital