Criteria for Intensive Care admission and monitoring after elective craniotomy

Badenes, Rafael; Prisco, Lara; Maruenda, A; Taccone, Fabio Silvio

doi:10.1097/aco.0000000000000503

Cited by 26 publications

(18 citation statements)

References 23 publications

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“…A further retrospective study including 400 patients identified advanced age and diabetes as independent predictors for necessary postoperative ICU monitoring [ 6 ]. Overall, no study could reveal routine ICU admission in all postoperative patients as significantly beneficial for in-hospital morbidity and mortality [ 2 – 4 , 6 , 7 ].…”

Section: Discussionmentioning

confidence: 99%

Implementation of the “No ICU – Unless” approach in postoperative neurosurgical management in times of COVID-19

et al. 2022

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Following elective craniotomy, patients routinely receive 24-h monitoring in an intensive care unit (ICU). However, the benefit of intensive care monitoring and treatment in these patients is discussed controversially. This study aimed to evaluate the complication profile of a “No ICU – Unless” strategy and to compare this strategy with the standardized management of post-craniotomy patients in the ICU. Two postoperative management strategies were compared in a matched-pair analysis: The first cohort included patients who were managed in the normal ward postoperatively (“No ICU – Unless” group). The second cohort contained patients routinely admitted to the ICU (control group). Outcome parameters contained detailed complication profile, length of hospital and ICU stay, duration to first postoperative mobilization, number of unplanned imaging before scheduled postoperative imaging, number and type of intensive care interventions, as well as pre- and postoperative modified Rankin scale (mRS). Patient characteristics and clinical course were analyzed using electronic medical records. The No ICU – Unless (NIU) group consisted of 96 patients, and the control group consisted of 75 patients. Complication rates were comparable in both cohorts (16% in the NIU group vs. 17% in the control group; p = 0.123). Groups did not differ significantly in any of the outcome parameters examined. The length of hospital stay was shorter in the NIU group but did not reach statistical significance (average 5.8 vs. 6.8 days; p = 0.481). There was no significant change in the distribution of preoperative (p = 0.960) and postoperative (p = 0.425) mRS scores in the NIU and control groups. Routine postoperative ICU management does not reduce postoperative complications and does not affect the surgical outcome of patients after elective craniotomies. Most postoperative complications are detected after a 24-h observation period. This approach may represent a potential strategy to prevent the overutilization of ICU capacities while maintaining sufficient postoperative care for neurosurgical patients.

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Section: Discussionmentioning

confidence: 99%

Implementation of the “No ICU – Unless” approach in postoperative neurosurgical management in times of COVID-19

et al. 2022

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“…In addition, many of these studies reported on patients who underwent surgical decompression of their ICA infarction prior to 2005. Although the surgical technique has not changed, the anesthesia techniques 32,33 and perioperative care 34,35 have advanced, and the philosophy of patient selection has shifted, further improving outcomes. There may also be the effect of "self-fulfilling prophecy" seen in other neurosurgical conditions such as intracerebral hematomas, where prognostic pessimism is associated with early withdrawal of care, 36,37 possibly leading to the "predicted" poor outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…Patients and their families need to be counseled especially carefully when these negative prognostic factors are present. With appropriate patient selection and recent advances in neuroanaesthesia 32,33 and perioperative care, 34,35 the negative impression that outcomes for surgical decompression of ICA infarctions are worse than MCA infarctions can be quelled. Thus, these patients should not be given any less of a chance than a similar patient with an MCA infarction.…”

Section: Figmentioning

confidence: 99%

Decompressive craniectomy for internal carotid artery and middle carotid artery infarctions: a long-term comparative outcome study

Lim

Vedicherla

Chan

et al. 2021

Neurosurgical Focus

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OBJECTIVE Malignant internal carotid artery (ICA) infarction is an entirely different disease entity when compared with middle cerebral artery (MCA) infarction. Because of an increased area of infarction, it is assumed to have a poorer prognosis; however, this has never been adequately investigated. Decompressive craniectomy (DC) for malignant MCA infarction has been shown to improve mortality rates in several randomized controlled trials. Conversely, aggressive surgical decompression for ICA infarction has not been recommended. The authors sought to compare the functional outcomes and survival between patients with ICA infarctions and those with MCA infarctions after DC in the largest series to date to investigate this assumption. METHODS A multicenter retrospective review of 154 consecutive DCs for large territory cerebral infarctions performed from 2005 to 2020 were analyzed. Patients were divided into ICA and MCA groups depending on the territory of infarction. Variables, including age, sex, medical comorbidities, laterality of the infarction, preoperative neurological status, primary stroke treatment, and the time from stroke onset to DC, were recorded. Univariable and multivariable analyses were performed for the clinical exposures for functional outcomes (modified Rankin Scale [mRS] score) on discharge and at the 1- and 6-month follow-ups, and for mortality, both inpatient and at the 1-year follow-up. A favorable mRS score was defined as 0–2. RESULTS There were 67 patients (43.5%) and 87 patients (56.5%) in the ICA and MCA groups, respectively. Univariable analysis showed that the ICA group had a comparably favorable mRS (OR 0.15 [95% CI 0.18–1.21], p = 0.077). Inpatient mortality (OR 1.79 [95% CI 0.79–4.03], p = 0.16) and 1-year mortality (OR 2.07 [95% CI 0.98–4.37], p = 0.054) were comparable between the groups. After adjustment, a favorable mRS score at 6 months (OR 0.17 [95% CI 0.018–1.59], p = 0.12), inpatient mortality (OR 1.02 [95% CI 0.29–3.57], p = 0.97), and 1-year mortality (OR 0.94 [95% CI 0.41–2.69], p = 0.88) were similar in both groups. The overall survival, plotted using the Cox proportional hazard regression, did not show a significant difference between the ICA and MCA groups (HR 0.581). CONCLUSIONS Unlike previous smaller studies, this study found that patients with malignant ICA infarction had a functional outcome and survival that was similar to those with MCA infarction after DC. Therefore, DC can be offered for malignant ICA infarction for life-saving purposes with limited functional recovery.

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“…Provided there were no concerning findings, and the patient was awakening well from surgery, they were admitted to a step-down unit monitored bed [16,17]. ICU admission was generally reserved for patients with significant comorbidities, severe preoperative neurological deficits, severe preoperative brain edema, high seizure risk, new postoperative deficits, requiring continued mechanical ventilation or at significant risk of airway compromise [36][37][38]. A brain or pituitary MRI is typically performed on post-operative day (POD) #1.…”

Section: Post-operative Surveillance Imaging and Mobilizationmentioning

confidence: 99%

Streamlining brain tumor surgery care during the COVID-19 pandemic: A case-control study

et al. 2021

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Background The COVID-19 pandemic forced a reconsideration of surgical patient management in the setting of scarce resources and risk of viral transmission. Herein we assess the impact of implementing a protocol of more rigorous patient education, recovery room assessment for non-ICU admission, earlier mobilization and post-discharge communication for patients undergoing brain tumor surgery. Methods A case-control retrospective review was undertaken at a community hospital with a dedicated neurosurgery and otolaryngology team using minimally invasive surgical techniques, total intravenous anesthesia (TIVA) and early post-operative imaging protocols. All patients undergoing craniotomy or endoscopic endonasal removal of a brain, skull base or pituitary tumor were included during two non-overlapping periods: March 2019–January 2020 (pre-pandemic epoch) versus March 2020–January 2021 (pandemic epoch with streamlined care protocol implemented). Data collection included demographics, preoperative American Society of Anesthesiologists (ASA) status, tumor pathology, and tumor resection and remission rates. Primary outcomes were ICU utilization and hospital length of stay (LOS). Secondary outcomes were complications, readmissions and reoperations. Findings Of 295 patients, 163 patients were treated pre-pandemic (58% women, mean age 53.2±16 years) and 132 were treated during the pandemic (52% women, mean age 52.3±17 years). From pre-pandemic to pandemic, ICU utilization decreased from 92(54%) to 43(29%) of operations (p<0.001) and hospital LOS≤1 day increased from 21(12.2%) to 60(41.4%), p<0.001, respectively. For craniotomy cohort, median LOS was 2 days for both epochs; median ICU LOS decreased from 1 to 0 days (p<0.001), ICU use decreased from 73(80%) to 29(33%),(p<0.001). For endonasal cohort, median LOS decreased from 2 to 1 days; median ICU LOS was 0 days for both epochs; (p<0.001). There were no differences pre-pandemic versus pandemic in ASA scores, resection/remission rates, readmissions or reoperations. Conclusion This experience suggests the COVID-19 pandemic provided an opportunity for implementing a brain tumor care protocol to facilitate safely decreasing ICU utilization and accelerating discharge home without an increase in complications, readmission or reoperations. More rigorous patient education, recovery room assessment for non-ICU admission, earlier mobilization and post-discharge communication, layered upon a foundation of minimally invasive surgery, TIVA anesthesia and early post-operative imaging are possible contributors to these favorable trends.

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Criteria for Intensive Care admission and monitoring after elective craniotomy

Cited by 26 publications

References 23 publications

Implementation of the “No ICU – Unless” approach in postoperative neurosurgical management in times of COVID-19

Implementation of the “No ICU – Unless” approach in postoperative neurosurgical management in times of COVID-19

Decompressive craniectomy for internal carotid artery and middle carotid artery infarctions: a long-term comparative outcome study

Streamlining brain tumor surgery care during the COVID-19 pandemic: A case-control study

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