Reexamining the Role of Postoperative ICU Admission for Patients Undergoing Elective Craniotomy: A Systematic Review*

Abstract

The standard-of-care for postoperative care following elective craniotomy has historically been ICU admission. However, recent literature interrogating complications and interventions during this postoperative ICU stay suggests that all patients may not require this level of care. Thus, hospitals began implementing non-ICU postoperative care pathways for elective craniotomy. This systematic review aims to summarize and evaluate the existing literature regarding outcomes and costs for patients receiving non-ICU care after elective craniotomy. DATA SOURCES:A systematic review of the PubMed database was performed following PRISMA guidelines from database inception to August 2021. STUDY SELECTION:Included studies were published in peer-reviewed journals, in English, and described outcomes for patients undergoing elective craniotomies without postoperative ICU care.DATA EXTRACTION: Data regarding study design, patient characteristics, and postoperative care pathways were extracted independently by two authors. Quality and risk of bias were evaluated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence tool and Risk Of Bias In Non-Randomized Studies-of Interventions tool, respectively. DATA SYNTHESIS:In total, 1,131 unique articles were identified through the database search, with 27 meeting inclusion criteria. Included articles were published from 2001 to 2021 and included non-ICU inpatient care and same-day discharge pathways. Overall, the studies demonstrated that postoperative non-ICU care for elective craniotomies led to length of stay reduction ranging from 6 hours to 4 days and notable cost reductions. Across 13 studies, 53 of the 2,469 patients (2.1%) intended for postoperative management in a non-ICU setting required subsequent care escalation. CONCLUSIONS: Overall, these studies suggest that non-ICU care pathways for appropriately selected postcraniotomy patients may represent a meaningful opportunity to improve care value. However, included studies varied greatly in patient selection, postoperative care protocol, and outcomes reporting. Standardization and multi-institutional collaboration are needed to draw definitive conclusions regarding non-ICU postoperative care for elective craniotomy.

Do We Need an ICU for All Elective Postcraniotomy Patients? A Critical Appraisal*

“…Clinical inertia has since set in: where a practice pattern set in motion stays in motion until the approach is revisited. However, much like the approach to early broad-spectrum antibiotics, or daily laboratories, new information (such as that provided by Azad et al [8] in this systematic review) warrants questioning of the existing practice paradigm. ICU utilization stewardship is particularly important in an era where the COVID-19 pandemic and increasing healthcare costs have highlighted the need for rationing and appropriate resource utilization.…”

“…Nonetheless, this study highlights important next steps in this process. Key questions now are as follows: 1) how robust and generalizable are the findings by Azad et al (8)? 2) how do we rigorously develop and standardize protocols with enough flexibility to account for site-specific variability to identify the patient subpopulations that do need ICU level care?…”

“…But it needs to be done safely. As a field, we do not yet know the answer to which postoperative elective-craniotomy patients can be monitored and managed effectively outside an ICU, but as Azad et al (8) point out, it is time to start having the conversation. T he renin-angiotensin system (RAS) pathway plays key roles in regulating blood pressure, water balance, inflammation, thrombosis, and response to injury.…”

“…Despite these nuances, the retrospective/small prospective data reviewed by Azad et al (8) generally suggest that the majority of patients undergoing elective craniotomies can likely be safely managed postoperatively outside of an ICU setting-at least in quaternary care institutions in high-income countries. Most patients did not have standard ICU needs such as vasopressors, antihypertensive drips, external ventricular drain monitoring, frequent suctioning, or mechanical ventilation-but were rather in the ICU for their perceived high risk of neurologic decline.…”

“…In this issue of Critical Care Medicine , Azad et al (8) address this important question in a thoughtful and methodologically rigorous systematic review re-examining the role of ICU admission for patients undergoing elective craniotomy. Of the 27 included studies (25 retrospective, 2 prospective) between 2001 and 2021, 17 (with 4,647 unique patients) investigated outcomes for non-ICU patients after craniotomy.…”