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

Qasem, Lina-Elisabeth; Al-Hilou, Ali; Zacharowski, Kai; Funke, Moritz; Strouhal, U.; Reitz, Sandra; Jussen, Daniel; Forster, Marie Thérèse; Konczalla, Juergen; Prinz, Vincent; Lucia, Kristin; Czabanka, Marcus

doi:10.1007/s10143-022-01851-y

Cited by 5 publications

(4 citation statements)

References 11 publications

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“…Among these are comorbidities such as cardiovascular disease, diabetes, higher age, surgery-associated aspects (e.g., duration, blood loss, vasopressor therapy), tumor size, or certain surgical positions. However, the inclusion criteria vary greatly; some studies include patients with infratentorial tumors [ 2 – 5 , 17 , 20 ], while others include stereotactical biopsies and/or transsphenoidal approaches which carry a different postoperative risk [ 4 , 10 , 16 , 20 , 21 ]. Sometimes, the protocols for patients not transferred to ICU include hourly neurological exams performed by nurses and continuous or hourly monitoring of vital parameters which might not be possible in every hospital due to a lower nurse-to-patient ratio [ 4 , 13 ].…”

Section: Introductionmentioning

confidence: 99%

Routine ICU admission after brain tumor surgery: retrospective validation and critical appraisal of two prediction scores

et al. 2023

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Background Routine admission to an intensive care unit (ICU) following brain tumor surgery has been a common practice for many years. Although this practice has been challenged by many authors, it has still not changed widely, mainly due to the lack of reliable data for preoperative risk assessment. Motivated by this dilemma, risk prediction scores for postoperative complications following brain tumor surgery have been developed recently. In order to improve the ICU admission policy at our institution, we assessed the applicability, performance, and safety of the two most appropriate risk prediction scores. Methods One thousand consecutive adult patients undergoing elective brain tumor resection within 19 months were included. Patients with craniotomy for other causes, i.e., cerebral aneurysms and microvascular decompression, were excluded. The decision for postoperative ICU-surveillance was made by joint judgment of the operating surgeon and the anesthesiologist. All data and features relevant to the scores were extracted from clinical records and subsequent ICU or neurosurgical floor documentation was inspected for any postoperative adverse events requiring ICU admission. The CranioScore derived by Cinotti et al. (Anesthesiology 129(6):1111–20, 5) and the risk assessment score of Munari et al. (Acta Neurochir (Wien) 164(3):635–641, 15) were calculated and prognostic performance was evaluated by ROC analysis. Results In our cohort, both scores showed only a weak prognostic performance: the CranioScore reached a ROC-AUC of 0.65, while Munari et al.’s score achieved a ROC-AUC of 0.67. When applying the recommended decision thresholds for ICU admission, 64% resp. 68% of patients would be classified as in need of ICU surveillance, and the negative predictive value (NPV) would be 91% for both scores. Lowering the thresholds in order to increase patient safety, i.e., 95% NPV, would lead to ICU admission rates of over 85%. Conclusion Performance of both scores was limited in our cohort. In practice, neither would achieve a significant reduction in ICU admission rates, whereas the number of patients suffering complications at the neurosurgical ward would increase. In future, better risk assessment measures are needed.

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Section: Introductionmentioning

confidence: 99%

Routine ICU admission after brain tumor surgery: retrospective validation and critical appraisal of two prediction scores

et al. 2023

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“…Qasem et al . [ 25 ] also observed that most complications occur 24 h postoperatively. Further, the mean length of hospital stay in our study was relatively prolonged (17.86 days) due to COVID-19-related transfer delays within the hospital.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of risk factors for postoperative neurologic intensive care admission after brain tumor craniotomy: A single-center longitudinal study

Biswas,

Agrawal,

Gupta

et al. 2024

Journal of Anaesthesiology Clinical Pharmacology

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Background and Aims: Perioperative variable parameters can be significant risk factors for postoperative intensive care unit (ICU) admission after elective craniotomy for intracranial neoplasm, as assessed by various scoring systems such as Cranio Score. This observational study evaluates the relationship between these factors and early postoperative neurological complications necessitating ICU admission. Material and Methods: In total, 119 patients, aged 18 years and above, of either sex, American Society of Anesthesiologists (ASA) grades I–III, scheduled for elective craniotomy and tumor excision were included. The primary objective was to evaluate the relationship between perioperative risk factors and the incidence of early postoperative complications as a means of validation of the Cranio Score. The secondary outcomes studied were 30-day postoperative morbidity/mortality and the association with patient-related risk factors. Results: Forty-five of 119 patients (37.82%) required postoperative ICU care with the mean duration of ICU stay being 1.92 ± 4.91 days. Tumor location (frontal/infratemporal region), preoperative deglutition disorder, Glasgow Coma Scale (GCS) less than 15, motor deficit, cerebellar deficit, midline shift >3 mm, mass effect, tumor size, use of blood products, lateral position, inotropic support, elevated systolic/mean arterial pressures, and duration of anesthesia/surgery were associated with a higher incidence of ICU care. Maximum (P = 0.035, AOR = 1.130) and minimum systolic arterial pressures (P = 0.022, Adjusted Odds Ratio (AOR) = 0.861) were the only independent risk factors. Cranio Score was found to be an accurate predictor of complications at a cut-off point of >10.52%. The preoperative motor deficit was the only independent risk factor associated with 30-day morbidity (AOR = 4.66). Conclusion: Perioperative hemodynamic effects are an independent predictor of postoperative ICU requirement. Further Cranio Score is shown to be a good scoring system for postoperative complications.

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“…Under the impression of possible complications of an ICU admission, the repelling impression of an "apparatus medicine" as well as the increasing financial/capacity pressure, an increasing avoidance of postoperative ICU monitoring has recently gained interest [18][19][20]. However, the (desired) reduction of postoperative ICU monitoring mandates a detailed and individualized consideration of the patient's risk/benefit profile in order to weigh the safety of postoperative monitoring against unnecessary ICU treatment [21].…”

Section: Discussionmentioning

confidence: 99%

Unplanned intensive care unit readmission after surgical treatment in patients with newly diagnosed glioblastoma — forfeiture of surgically achieved advantages?

et al. 2023

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Postoperative intensive care unit (ICU) monitoring is an established option to ensure patient safety after resection of newly diagnosed glioblastoma. In contrast, secondary unplanned ICU readmission following complicating events during the initial postoperative course might be associated with severe morbidity and impair initially intended surgical benefit. In the present study, we assessed the prognostic impact of secondary ICU readmission and aimed to identify preoperatively ascertainable risk factors for the development of such adverse events in patients treated surgically for newly diagnosed glioblastoma. Between 2013 and 2018, 240 patients were surgically treated for newly diagnosed glioblastoma at the authors’ neuro-oncological center. Secondary ICU readmission was defined as any unplanned admission to the ICU during initial hospital stay. A multivariable logistic regression analysis was performed to identify preoperatively measurable risk factors for unplanned ICU readmission. Nineteen of 240 glioblastoma patients (8%) were readmitted to the ICU. Median overall survival of patients with unplanned ICU readmission was 9 months compared to 17 months for patients without secondary ICU readmission (p=0.008). Multivariable analysis identified “preoperative administration of dexamethasone > 7 days” (p=0.002) as a significant and independent predictor of secondary unplanned ICU admission. Secondary ICU readmission following surgery for newly diagnosed glioblastoma is significantly associated with poor survival and thus may negate surgically achieved prerequisites for further treatment. This underlines the indispensability of precise patient selection as well as the importance of further scientific debate on these highly relevant aspects for patient safety.

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

Cited by 5 publications

References 11 publications

Routine ICU admission after brain tumor surgery: retrospective validation and critical appraisal of two prediction scores

Routine ICU admission after brain tumor surgery: retrospective validation and critical appraisal of two prediction scores

Evaluation of risk factors for postoperative neurologic intensive care admission after brain tumor craniotomy: A single-center longitudinal study

Unplanned intensive care unit readmission after surgical treatment in patients with newly diagnosed glioblastoma — forfeiture of surgically achieved advantages?

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