Perioperative Logistics & Orders Quick Reference

Use this as a case-setup checklist before opening the disease-specific guide. Local protocol, attending preference, anesthesia constraints, device instructions, and the patient’s physiology override these defaults.

Universal Pre-Case Questions

Question	Why it changes the room
Where should the patient go after the case?	ICU, step-down, floor, PACU, or outpatient orders determine lines, handoff detail, nursing skillset, and timing of imaging/labs.
What exam can be lost?	Drives baseline documentation, neuromonitoring, postop check frequency, and the first call for change.
What imaging or device data must be visible in the room?	Navigation, DTI, angiography, valve setting, implant plan, trajectory coordinates, and prior operative notes prevent wrong-level/wrong-device errors.
What is the perfusion target?	SCI/MAP augmentation, aneurysm/AVM BP ceiling, bypass graft protection, stroke reperfusion BP, and tumor edema plans need explicit anesthesia alignment.
What could force an ICU handoff while intubated?	Posterior fossa swelling, airway hematoma, lower-CN dysfunction, tract hemorrhage, major blood loss, severe TBI, malignant edema, or SCI.

Domain Defaults

Domain	Postop destination	OR / suite needs	Special needs	Immediate postop orders
Cranial tumor / craniotomy	ICU or step-down first night; floor for low-risk pathways	Mayfield, navigation, microscope/exoscope, ultrasound/fluorescence/mapping when used, pathology workflow	Arterial line for large/eloquent/vascular tumors, dex plan, seizure plan, blood for meningioma/skull base	Neuro checks, CT if concern, MRI 24-48h when EOR matters, dex taper, AED duration, DVT timing
Sellar / endonasal skull base	ICU/step-down for extended cases	Endoscope tower, navigation, Doppler, ENT co-surgeon, reconstruction materials	DI/sodium protocol, cortisol/steroid strategy, visual checks, CSF-leak precautions	Strict I/O, sodium/urine checks, AM cortisol/endocrine labs, nasal precautions, MRI/CT timing
Posterior fossa / skull base	ICU for most substantial cases	Mayfield, microscope/endoscope, CN monitoring/BAER, EVD plan, watertight closure supplies	Airway/swallow plan, antiemetics, dex if edema risk, VAE readiness if sitting	CN V-XII/voice/swallow checks, HOB 30, CT/MRI timing, CSF leak/pseudomeningocele watch
Cranial trauma	Neuro ICU	Trauma craniotomy/craniectomy tray, blood, hemostatics, dural substitute, ICP/EVD supplies	Reversal, seizure prophylaxis, hyperosmolar plan, arterial line, Foley, open-injury antibiotics/tetanus	ICU neuro checks, BP/CPP/ICP goals, CT timing, drain/EVD orders, DVT timing, repeat labs/coags
Aneurysm / AVM / bypass	Neuro ICU	Microscope, vascular tray, clips, ICG/Doppler, DSA/CTA displayed, blood	Arterial line, BP floor/ceiling, nimodipine/EVD pathway if SAH, antiplatelet plan for bypass	SBP goals, CTA/DSA/CT timing, vasospasm surveillance if SAH, graft checks, AED/DVT plan
Endovascular therapy	ICU/step-down for therapeutic cases	Biplane suite, access/closure tools, procedure-specific devices, bailout balloon/stent/aspiration	ACT/heparin workflow, antiplatelet status, BP target, contrast/renal/allergy plan	Neuro checks, access-site/pulse checks, BP parameters, antithrombotics, flat time, follow-up imaging
Shunt / EVD / CSF diversion	ICU for EVD; floor/step-down for routine shunt/ETV	Navigation/endoscope as needed, valve/hardware verified, drain system ready	Coags corrected, antibiotic timing, valve setting documented, EVD height/drain order explicit	Neuro/ICP checks, CT or shunt series, valve setting/MRI precautions, drain output, infection watch
Degenerative spine	Outpatient/PACU for selected decompressions; floor/step-down for fusion/cervical myelopathy	Radiolucent/Jackson table, fluoro/O-arm, microscope/loupes, implants/graft, neuromonitoring when cord risk	Arterial line/Foley/type-screen for long fusion, no long paralytic with MEPs, DVT/anticoagulation plan	Myotome/sensory checks, airway watch for anterior cervical, X-rays/CT, drain, brace/activity, PT/OT
Spine trauma / SCI	ICU or step-down; ICU for SCI/high cervical/polytrauma	Log-roll transfer, fluoro/O-arm/navigation, traction/Mayfield, implants, IONM, blood	Arterial line, Foley, type/cross, MAP augmentation per protocol, airway strategy	ASIA exams, MAP goal/duration, CT/X-rays, brace/collar, bowel/bladder/skin care, SCI rehab
Spine infection	Floor to ICU by sepsis/deficit	Decompression/instrumentation trays, culture media, drain, navigation/fluoro	Antibiotic timing versus cultures, ID plan, MAP support if cord compromise	Neuro checks, culture follow-up, organism-directed antibiotics, ESR/CRP trend, drain/wound care
Peripheral nerve	Outpatient or short PACU stay	Hand table/arm board, tourniquet, loupes/microscope for repair/tumor, nerve stimulator when needed	Regional/local/WALANT decision, anticoagulation plan, laterality/site marking	Elevation, dressing/splint duration, early ROM unless repair restricts it, therapy, wound follow-up
Pediatrics	PICU or pediatric step-down by age/risk	Pediatric anesthesia/equipment, warming, weight-based meds/implants, blood for craniosynostosis/tumor	Latex precautions for myelomeningocele, weight-based fluids, family handoff, age-specific neuro baseline	PICU/step-down checks, airway/swallow when relevant, drain/EVD/shunt orders, wound/skin precautions

Order Blocks To Clarify In Every Case

Disposition: ICU, step-down, floor, PACU, or outpatient; include reason if not obvious.
Exam cadence: neuro checks q1h/q2h/q4h and the exact focused exam: pupils, language, visual fields, facial/hearing/swallow, myotomes, sensory level, ASIA, NIHSS, or device exam.
Perfusion/BP: SBP ceiling/floor, MAP goal and duration, CPP/ICP goals, bypass graft protection, or reperfusion BP target.
Imaging: CT head, MRI brain/spine, CTA/DSA, X-rays, shunt series, postop CT for hardware, and timing.
Devices/drains: EVD level, lumbar drain rate/max output, JP suction, shunt valve setting, brace/collar, implant programming.
Meds: antibiotics, dexamethasone/steroid taper or cortisol plan, antiepileptic plan, antiplatelet/anticoagulation plan, pain/nausea, bowel regimen.
DVT: SCDs immediately unless contraindicated; chemical prophylaxis timing tied to hemorrhage risk, drain status, and attending protocol.
Diet/activity: HOB, swallow screen, nasal precautions, flat/bedrest orders, mobilization, PT/OT, brace/collar.
Consults/follow-up: ICU, neurology/stroke, endocrine, ENT, ophthalmology, ID, oncology/radiation, rehab, hand therapy, device representative/programming.

Perioperative Medication Defaults By Category

These are defaults to explicitly confirm, not automatic orders. Dose, duration, contraindications, renal/hepatic adjustment, allergy substitutions, local antibiograms, device instructions, and attending/anesthesia preference override the table.

Category	Medication defaults to clarify
Cranial tumor / craniotomy	Cefazolin within 60 minutes of incision; vancomycin when MRSA risk or institutional protocol. Dexamethasone when symptomatic edema/mass effect or skull-base/optic apparatus risk; taper tied to exam, imaging, and endocrine plan. Levetiracetam or other antiseizure medication when preop seizure, cortical/supratentorial lesion, hemorrhage, or high-risk manipulation. PPI/H2 blocker and glucose monitoring while on steroids.
Sellar / endonasal skull base	Cefazolin or institutional sinonasal/skull-base prophylaxis; nasal packing/splint antibiotic policy should be explicit. Hydrocortisone/dexamethasone plan depends on adrenal axis and intraop pituitary stalk manipulation. Desmopressin should be protocol-driven for DI, not reflexive. Avoid routine anticoagulation until reconstruction/CSF-leak risk is reconciled.
Posterior fossa / skull base	Cefazolin; vancomycin when indicated. Dexamethasone for edema, CN compression, or brainstem/cerebellar swelling risk. Aggressive antiemetics to reduce vomiting/CSF leak. Antiseizure medication is not routine unless supratentorial blood/seizure risk exists.
Cranial trauma	Reversal agents and repeat coagulation labs are time-critical. Levetiracetam or phenytoin-equivalent prophylaxis for severe TBI or traumatic intracranial hemorrhage per protocol, commonly limited to 7 days absent seizures. Open skull fracture/penetrating injury needs broader antibiotics and tetanus update. Hyperosmolar therapy should have sodium/osmolality targets.
Aneurysm / AVM / bypass	Cefazolin. Nimodipine for aneurysmal SAH unless contraindicated. Antiseizure medication for cortical blood, infarct, seizure, or AVM/cortical manipulation risk. Aspirin/antiplatelet continuation or restart must be explicit for bypass and endovascular adjuncts. BP medications should match clip/flow/bypass goals.
Endovascular therapy	Heparin/ACT workflow, antiplatelet loading/verification, GP IIb/IIIa bailout availability, contrast allergy prophylaxis, renal-protection plan when relevant, and post-procedure antithrombotic timing should be written before the case starts.
Shunt / EVD / CSF diversion	Cefazolin before incision or drain placement; antibiotic-impregnated catheter policy when available. Avoid prolonged prophylaxis unless infection is being treated. Anticoagulant/antiplatelet hold and restart timing should be tied to tract hemorrhage risk and imaging.
Degenerative spine	Cefazolin; add vancomycin for MRSA risk/institutional protocol and gram-negative coverage only when indicated. Multimodal analgesia, bowel regimen, nausea control, and muscle relaxant plan. TXA for long fusion/deformity/high-blood-loss cases when not contraindicated. DVT chemoprophylaxis timing depends on decompression, drain, hematoma risk, and mobility.
Spine trauma / SCI	Cefazolin for closed instrumentation; broaden for penetrating/open wounds. MAP augmentation often requires vasopressor orders rather than a medication name alone. Steroids for acute SCI are institution/attending-specific and should not be assumed. DVT prophylaxis timing should be explicit because risk is high.
Spine infection	If stable, antibiotics are ideally held until blood/intraop cultures are obtained; if septic, neurologically declining, or unstable, start broad empiric therapy immediately after cultures when feasible. Typical empiric coverage is vancomycin plus gram-negative coverage until ID narrows.
Functional / epilepsy / DBS / SEEG	Continue baseline antiseizure or movement-disorder medications unless the monitoring/programming plan requires holding them. DBS requires antibiotic, hardware infection-prevention, and postop programming medication plan. Awake mapping needs seizure rescue medication immediately available while preserving exam.
Biopsy / stereotactic / LITT / radiosurgery	Cefazolin for incisional/bolt/laser cases. Steroids for edema-prone lesions or ablation swelling. Antiseizure medication for cortical trajectories, hemorrhagic lesions, seizure history, or LITT edema risk. Anticoagulant/antiplatelet restart depends on tract hemorrhage imaging.
Peripheral nerve	Cefazolin for implant/tumor/long cases; many small clean decompressions follow local prophylaxis policy. Local/regional anesthetic plan, neuropathic pain regimen, NSAID/bleeding policy, and anticoagulation restart should match repair versus decompression.
Pediatrics	Weight-based cefazolin and all rescue medications. Avoid adult default doses. Craniosynostosis/tumor cases need blood-loss/TXA plan when used. Myelomeningocele requires latex precautions and antibiotic/skin protocol. Family handoff should include medication duration and warning signs.

Educational checklist only. Verify against the disease-specific guide, current institutional protocols, and attending/anesthesia orders before patient care.