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Wu C, Yu L, Wang L, Yan X, Li S, Wen J, Jiang Y. Association of Complication Rates and Intensive Care Unit Use With Sinonasal and Skull Base Malignancies: A Propensity Score Matching Analysis. EAR, NOSE & THROAT JOURNAL 2023:1455613231215195. [PMID: 38031430 DOI: 10.1177/01455613231215195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background: Patients with sinonasal and skull base malignancies experience many types of complications after surgery. The intensive care unit (ICU) provides a high level of care for these patients; however, the effect of ICU care on complication rates remains unclear. Methods: Between November 2014 and November 2022, we retrospectively analyzed 151 patients with sinonasal and skull base malignancies. Fifty-six of these patients were admitted to the ICU and 95 were admitted to the non-ICU after surgery. Propensity score matching (PSM) was performed to balance baseline characteristics. The complication rates of the ICU and non-ICU groups were compared. Results: Before PSM, the complication rate was 28.5%. Patients admitted to the ICU had a higher incidence of medical complications (P = .032). Orbital injury (n = 9) and diplopia or visual changes (n = 9) were the most common surgical complications, whereas respiratory tract infections (n = 7) were the most common medical complications. After PSM, the incidences of surgical, medical, and all complications in the ICU and non-ICU groups were 23.8% and 19.0% (P = .791), 16.7% and 9.5% (P = .520), and 38.1% and 26.2% (P = .350), respectively. Conclusions: This preliminary study revealed that ICU admission did not reduce the complication rate of patients with sinonasal and skull base malignancies. Further studies are required to validate these findings and clarify the potential role of the ICU.
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Affiliation(s)
- Ce Wu
- Department of Otolaryngology, Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Longgang Yu
- Department of Otolaryngology, Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Lin Wang
- Department of Otolaryngology, Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Xudong Yan
- Department of Otolaryngology, Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Shunke Li
- Department of Otolaryngology, Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Junfeng Wen
- Department of Operating Room, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yan Jiang
- Department of Otolaryngology, Head and Neck Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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Sangtongjaraskul S, Lerdsirisopon S, Sae-phua V, Kanta S, Kongkiattikul L. Factors Influencing Prolonged Intensive Care Unit Length of Stay after Craniotomy for Intracranial Tumor in Children: A 10-year Analysis from a University Hospital. Indian J Crit Care Med 2023; 27:205-211. [PMID: 36960121 PMCID: PMC10028711 DOI: 10.5005/jp-journals-10071-24418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/04/2023] [Indexed: 03/05/2023] Open
Abstract
Background Postoperative intensive care unit (ICU) admission is routinely practiced in pediatric and adult craniotomy. This study aims to identify the factors associated with an ICU stay of more than one day (prolonged ICU stay, PIS) after pediatric brain tumor surgery. Methods Medical records of children who underwent craniotomy for brain tumor during a 10-year period were reviewed and analyzed. Perioperative variables were examined and compared between the one-day ICU stay (ODIS) and PIS groups. Results A total of 314 craniotomies performed on 302 patients was included. Patients requiring postoperative ICU care for more than a day represented 37.9% of the sample. Significant factors found in the multivariate analysis affecting prolonged ICU length of stay included operative time ≥360 minutes (adjusted odds ratio [AOR], 2.438; 95% confidence interval [CI]: 1.223-4.861; p = 0.011), presence of an endotracheal (ET) tube (AOR, 7.469; 95% CI: 3.779-14.762; p < 0.001), and external ventricular drain (EVD) at ICU admission (AOR, 2.512; 95% CI: 1.458-4.330; p = 0.001). Conclusion While most children undergoing a craniotomy for brain tumor need a postoperative ICU care of ≤1 day, slightly more than a one-third in our study stayed longer. The prediction of a PIS can be beneficial for optimal resource utilization, increasing ICU bed turnover rate, reduction of operation cancellation, and improved preparation for parent expectations. How to cite this article Sangtongjaraskul S, Lerdsirisopon S, Sae-phua V, Kanta S, Kongkiattikul L. Factors Influencing Prolonged Intensive Care Unit Length of Stay after Craniotomy for Intracranial Tumor in Children: A 10-year Analysis from a University Hospital. Indian J Crit Care Med 2023;27(3):205-211.
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Affiliation(s)
- Sunisa Sangtongjaraskul
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Sunisa Sangtongjaraskul, Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand, Phone: +66935569556, e-mail:
| | | | - Vorrachai Sae-phua
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sukanya Kanta
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Lalida Kongkiattikul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Dey A, Bidkar PU, Swaminathan S, M MK, Joy JJ, Balasubramanian M, Bhimsaria S. Comparison of two techniques of goal directed fluid therapy in elective neurosurgical patients - a randomized controlled study. Br J Neurosurg 2023:1-9. [PMID: 36734344 DOI: 10.1080/02688697.2023.2173722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 09/06/2022] [Accepted: 10/12/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Goal directed fluid therapy (GDFT) may be a rational approach to adopt in neurosurgical patients, in whom intravascular volume optimization is of utmost importance. Most of the parameters used to guide GDFT are derived invasively. We postulated that the total volume of intraoperative intravenous fluid administered during elective craniotomy for supratentorial brain tumours would be comparable between two groups receiving GDFT guided either by the non-invasively derived plethysmography variability index (PVI) or by stroke volume variation (SVV). METHODS 60 ASA category 1, 2 and 3 patients between 18 and 70 years of age were randomized to receive intraoperative fluid guided either by SVV (SVV group; n = 31) or PVI (PVI group; n = 29). The total volume of fluid administered intraoperatively was recorded. Serum creatinine was measured before the surgery, at the end of the surgery, 24 h after surgery and on the fifth post-operative day. Arterial cannulation was performed before induction in all patients. Serum lactate was measured before induction, once in 2 h intraoperatively, at the end of the surgery and 24 h after the surgery. Brain relaxation score was assessed by the surgeon during dural opening and dural closure. Patients were followed up till discharge or death. The duration of mechanical ventilation and the duration of hospital stay was noted for all patients. RESULTS The volume of fluid given intraoperatively was significantly higher in the SVV group (p = 0.005). The two groups were comparable with respect to serum lactate and serum creatinine measured at pre-determined time intervals. Brain relaxation score was also comparable between the groups. SVV and PVI displayed moderate to strong correlation intraoperatively. The duration of mechanical ventilation and the length of the hospital stay were comparable between the two groups. CONCLUSIONS PVI and SVV are equally effective in guiding GDFT in adults undergoing elective craniotomy for supratentorial brain tumours.
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Affiliation(s)
- Ankita Dey
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Bathinda, India
| | | | | | | | - Jerry Jame Joy
- Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India
| | | | - Sakshi Bhimsaria
- Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India
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Cao Q, Fan C, Li W, Bai S, Dong H, Meng H. Unplanned Post-Anesthesia Care Unit to ICU Transfer Following Cerebral Surgery: A Retrospective Study. Biol Res Nurs 2023; 25:129-136. [PMID: 36028934 DOI: 10.1177/10998004221123288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Unplanned transfer to intensive care unit (ICU) lead to reduced trust of patients and their families in medical staff and challenge medical staff to allocate scarce ICU resources. This study aimed to explore the incidence and risk factors of unplanned transfer to ICU during emergence from general anesthesia after cerebral surgery, and to provide guidelines for preventing unplanned transfer from post-anesthesia care unit (PACU) to ICU following cerebral surgery. Methods: This was a retrospective case-control study and included patients with unplanned transfer from PACU to ICU following cerebral surgery between January 2016 and December 2020. The control group comprised patients matched (2:1) for age (±5 years), sex, and operation date (±48 hours) as those in the case group. Stata14.0 was used for statistical analysis, and p < .05 indicated statistical significance. Results: A total of 11,807 patients following cerebral surgery operations were cared in PACU during the study period. Of the 11,807 operations, 81 unscheduled ICU transfer occurred (0.686%). Finally, 76 patients were included in the case group, and 152 in the control group. The following factors were identified as independent risk factors for unplanned ICU admission after neurosurgery: low mean blood oxygen (OR = 1.57, 95%CI: 1.20-2.04), low mean albumin (OR = 1.14, 95%CI: 1.03-1.25), slow mean heart rate (OR = 1.04, 95%CI: 1.00-1.08), blood transfusion (OR = 2.78, 95%CI: 1.02-7.58), emergency surgery (OR = 3.08, 95%CI: 1.07-8.87), lung disease (OR = 2.64, 95%CI: 1.06-6.60), and high mean blood glucose (OR = 1.71, 95%CI: 1.21-2.41). Conclusion: We identified independent risk factors for unplanned transfer from PACU to ICU after cerebral surgery based on electronic medical records. Early identification of patients who may undergo unplanned ICU transfer after cerebral surgery is important to provide guidance for accurately implementing a patient's level of care.
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Affiliation(s)
- Qinqin Cao
- Department of Anesthesiology, 562122Affiliated Hospital of Jining Medical University, Jining, China
| | - Chengjuan Fan
- Department of Urology, 562122Affiliated Hospital of Jining Medical University, Jining, China
| | - Wei Li
- Nursing Department, 562122Affiliated Hospital of Jining Medical University, Jining, China
| | - Shuling Bai
- Department of Anesthesiology, 562122Affiliated Hospital of Jining Medical University, Jining, China
| | - Hemin Dong
- Department of Anesthesiology, 562122Affiliated Hospital of Jining Medical University, Jining, China
| | - Haihong Meng
- Department of Anesthesiology, 562122Affiliated Hospital of Jining Medical University, Jining, China
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Hatipoglu Majernik G, Wolff Fernandes F, Al-Afif S, Heissler HE, Palmaers T, Atallah O, Scheinichen D, Krauss JK. Routine postoperative admission to the neurocritical intensive care unit after microvascular decompression: necessary or can it be abandoned? Neurosurg Rev 2022; 46:12. [PMID: 36482263 PMCID: PMC9732061 DOI: 10.1007/s10143-022-01910-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
Postoperative neurocritical intensive care unit (NICU) admission of patients who underwent craniotomy for close observation is common practice. In this study, we performed a comparative analysis to determine if there is a real need for NICU admission after microvascular decompression (MVD) for cranial nerve disorders or whether it may be abandoned. The present study evaluates a consecutive series of 236 MVD surgeries performed for treatment of trigeminal neuralgia (213), hemifacial spasm (17), vagoglossopharyngeal neuralgia (2), paroxysmal vertigo (2), and pulsatile tinnitus (2). All patients were operated by the senior surgeon according to a standard protocol over a period of 12 years. Patients were admitted routinely to NICU during the first phase of the study (phase I), while in the second phase (phase II), only patients with specific indications would go to NICU. While 105 patients (44%) were admitted to NICU postoperatively (phase I), 131 patients (56%) returned to the ward after a short stay in a postanaesthesia care unit (PACU) (phase II). Specific indications for NICU admission in phase I were pneumothorax secondary to central venous catheter insertion (4 patients), AV block during surgery, low blood oxygen levels after extubation, and postoperative dysphagia and dysphonia (1 patient, respectively). There were no significant differences in the distribution of ASA scores or the presence of cardiac and pulmonary comorbidities like congestive heart failure, arterial hypertension, or chronic obstructive pulmonary disease between groups. There were no secondary referrals from PACU to NICU. Our study shows that routine admission of patients after eventless MVD to NICU does not provide additional value. NICU admission can be restricted to patients with specific indications. When MVD surgery is performed in experienced hands according to a standard anaesthesia protocol, clinical observation on a neurosurgical ward is sufficient to monitor the postoperative course. Such a policy results in substantial savings of costs and human resources.
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Affiliation(s)
- Gökce Hatipoglu Majernik
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Filipe Wolff Fernandes
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Shadi Al-Afif
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Hans E Heissler
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Thomas Palmaers
- Department of Anaesthesiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Dirk Scheinichen
- Department of Anaesthesiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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Bahna M, Hamed M, Ilic I, Salemdawod A, Schneider M, Rácz A, Baumgartner T, Güresir E, Eichhorn L, Lehmann F, Schuss P, Surges R, Vatter H, Borger V. The necessity for routine intensive care unit admission following elective craniotomy for epilepsy surgery: a retrospective single-center observational study. J Neurosurg 2022; 137:1203-1209. [PMID: 35120311 DOI: 10.3171/2021.12.jns211799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traditionally, patients who underwent elective craniotomy for epilepsy surgery are monitored postoperatively in an intensive care unit (ICU) overnight in order to sufficiently respond to potential early postoperative complications. In the present study, the authors investigated the frequency of early postoperative events that entailed ICU monitoring in patients who had undergone elective craniotomy for epilepsy surgery. In a second step, they aimed at identifying pre- and intraoperative risk factors for the development of unfavorable events to distinguish those patients with the need for postoperative ICU monitoring at the earliest possible stage. METHODS The authors performed a retrospective observational cohort study assessing patients with medically intractable epilepsy (n = 266) who had undergone elective craniotomy for epilepsy surgery between 2012 and 2019 at a tertiary care epilepsy center, excluding those patients who had undergone invasive diagnostic approaches and functional hemispherectomy. Postoperative complications were defined as any unfavorable postoperative surgical and/or anesthesiological event that required further ICU therapy within 48 hours following surgery. A multivariate analysis was performed to reveal preoperatively identifiable risk factors for postoperative adverse events requiring an ICU setting. RESULTS Thirteen (4.9%) of 266 patients developed early postoperative adverse events that required further postoperative ICU care. The most prevalent event was a return to the operating room because of relevant postoperative intracranial hematoma (5 of 266 patients). Multivariate analysis revealed intraoperative blood loss ≥ 325 ml (OR 6.2, p = 0.012) and diabetes mellitus (OR 9.2, p = 0.029) as risk factors for unfavorable postoperative events requiring ICU therapy. CONCLUSIONS The present study revealed routinely collectable risk factors that would allow the identification of patients with an elevated risk of postsurgical complications requiring a postoperative ICU stay following epilepsy surgery. These findings may offer guidance for a stepdown unit admission policy following epilepsy surgical interventions after an external validation of the results.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lars Eichhorn
- 3Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Felix Lehmann
- 3Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Apriawan T, Meizikri R, Harmawan EW, Kustono H. Intraparenchymal fiberoptic intracranial pressure monitoring and decompressive craniectomy in meningioma case with critical intracranial pressure: A case report during COVID-19 pandemic. Int J Surg Case Rep 2022; 97:107364. [PMID: 35789669 PMCID: PMC9242682 DOI: 10.1016/j.ijscr.2022.107364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/25/2022] [Accepted: 06/25/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Meningioma is a slow-growing tumor that can cause neurological emergency due to intracranial hypertension. The definitive therapy is indeed emergency resection, but it is not always possible in several countries due to limited capacity and/or capability of the emergency operating room. The use of intraparenchymal fiberoptic intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in cases of brain tumors might be possible, but it is uncommon. We report a meningioma patient in whom immediate meningioma resection was considered too risky due to intensive care unit (ICU) shortage during COVID-19 pandemic and, therefore, underwent these procedures as life-saving measures. Case presentation A 24-year-old man was brought to the emergency room with a chief complaint of seizure. Physical examination was notable for decreased consciousness (Glasgow Coma Scale (GCS) 11) and a dilated left pupil with intact light reflex. A contrasted Brain CT Scan revealed extra-axial mass on the left sphenoid with extensive tentacle edema, which pushed the midline structures 2 cm toward the contralateral side. Discussion The patient was diagnosed with Left Sphenoid Meningioma. We decided to perform intraparenchymal fiberoptic ICP monitor insertion and DC considering the situation, device availability, safety, and efficacy. The patient slowly regained consciousness in the recovery room after the procedure. The best-observed GCS was 12. Two weeks afterward, the patient came back to our outpatient clinic neurologically intact. The patient was then planned for elective tumor resection. Conclusion ICP monitoring and DC are not commonly performed on brain tumor cases. However, in suboptimal situations, these procedures might save lives. The present case showed that ICP monitor and DC were helpful in times of ICU shortage.
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Affiliation(s)
- Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga - Dr. Soetomo Academic General Hospital, Surabaya, Indonesia.
| | - Rizki Meizikri
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga - Dr. Soetomo Academic General Hospital, Surabaya, Indonesia
| | - Endra Wibisono Harmawan
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga - Dr. Soetomo Academic General Hospital, Surabaya, Indonesia
| | - Heru Kustono
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga - Dr. Soetomo Academic General Hospital, Surabaya, Indonesia
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Sangtongjaraskul S, Yuwapattanawong K, Sae-phua V, Jearranaiprepame T, Paarporn P. Incidence and Perioperative Risk Factors of Delayed Extubation following Pediatric Craniotomy for Intracranial Tumor: A 10-Year Retrospective Analysis in a Thailand Hospital. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1750421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Background The determination of extubation (early or delayed) after pediatric craniotomy for intracranial tumor should be carefully considered because each has its pros and cons. The aim of this study was to investigate the incidence of the delayed extubation in these patients. The secondary goal was to identify the perioperative factors influencing the determination of delayed extubation.
Methods This retrospective study was performed in pediatric patients with intracranial tumor who underwent craniotomy at a university hospital between April 2010 and March 2020. Preoperative and intraoperative variables were examined. The variables were compared between the delayed extubation and early extubation group.
Results Forty-two of 286 pediatric patients were in the delayed extubation group with an incidence of 14.69%. According to multivariate analyses, the risk factors that prompted delayed extubation were the intracranial tumor size ≥ 55 mm (adjusted odds ratio [AOR], 2.338; 95% confidence interval [CI], 1.032–5.295; p = 0.042), estimated blood loss (EBL) ≥ 40% of calculated blood volume (AOR, 11.959; 95% CI, 3.457–41.377; p < 0.001), blood transfusion (AOR, 3.093; 95% CI, 1.069–8.951; p = 0.037), duration of surgery ≥ 300 minutes (AOR, 2.593; 95% CI, 1.099–6.120; p = 0.030), and completion of the operation after working hours (AOR, 13.832; 95% CI, 2.997–63.835; p = 0.001).
Conclusions The incidence of delayed extubation after pediatric craniotomy was 14.69%. The predictive factors were the size of tumor ≥ 55 mm, EBL ≥ 40% of calculated blood volume, blood transfusion, duration of surgery ≥ 300 minutes, and completion of surgery after routine working hours.
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Affiliation(s)
- Sunisa Sangtongjaraskul
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kornkamon Yuwapattanawong
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Vorrachai Sae-phua
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Thichapat Jearranaiprepame
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Paweena Paarporn
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Reexamining the Role of Postoperative ICU Admission for Patients Undergoing Elective Craniotomy: A Systematic Review. Crit Care Med 2022; 50:1380-1393. [PMID: 35686911 DOI: 10.1097/ccm.0000000000005588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES 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.
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Munari M, De Cassai A, Sandei L, Correale C, Calandra S, Iori D, Geraldini F, Vitalba A, Grandis M, Chioffi F, Navalesi P. Optimizing post anesthesia care unit admission after elective craniotomy for brain tumors: a cohort study. Acta Neurochir (Wien) 2022; 164:635-641. [PMID: 33517465 DOI: 10.1007/s00701-021-04732-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative admission to intensive care unit (ICU) after craniotomy for brain tumor was the routine in the past years. However, there is little evidence supporting this dogma and doubts have been casted by many authors in the last years. Our aim was to identify risk factors for ICU admission after elective brain tumor surgery in order to propose an individualized admission to ICU tailored on patient needs. METHODS We conducted a retrospective cohort study including all patients undergoing elective surgery for brain tumor in a neurosurgical post anesthesia care unit of a university hospital over a period of 6 years. In order to identify and validate risk factors for ICU admission, we split the final cohort of patients in a training cohort (two/third of the cohort) and the validation cohort (one/third of the cohort) using a random sequence. Using univariate and multivariate logistic regression, we created a scoring system in the training cohort and tested it with the validation cohort. Moreover, we perform a sensitivity analysis on the overall population. RESULTS A total of 420 patients were eligible for this study. ASA-PS, tumor volume, and surgery length entered the scoring system. Sensitivity analysis on the overall population for the scoring system had an AUC of 0.774 (95% CI 0.668-0.880, the best threshold at 12.5) CONCLUSIONS: We created a tool based on ASA-PS, length of surgery, and tumor volume to evaluate the risk for ICU admission after supratentorial tumor resection. Prospective studies are deemed necessary to validate our tool.
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Affiliation(s)
- Marina Munari
- UOC Anaesthesia and Intensive Care Unit, University Hospital of Padua, via Giustiniani 2, 35128, Padua, Italy
| | - Alessandro De Cassai
- UOC Anaesthesia and Intensive Care Unit, University Hospital of Padua, via Giustiniani 2, 35128, Padua, Italy.
| | - Ludovica Sandei
- Department of Medicine-DIMED, University of Padua, Padua, Italy
| | | | | | - Davide Iori
- Department of Medicine-DIMED, University of Padua, Padua, Italy
| | | | | | - Marzia Grandis
- UOC Anaesthesia and Intensive Care Unit, University Hospital of Padua, via Giustiniani 2, 35128, Padua, Italy
| | - Franco Chioffi
- Department of Neurosurgery, University Hospital of Padua, Padua, Italy
| | - Paolo Navalesi
- UOC Anaesthesia and Intensive Care Unit, University Hospital of Padua, via Giustiniani 2, 35128, Padua, Italy
- Department of Medicine-DIMED, University of Padua, Padua, Italy
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Neurosurgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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12
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Mattingly TK. Commentary: Postoperative Admission of Adult Craniotomy Patients to the Neuroscience Ward Reduces Length of Stay and Cost. Neurosurgery 2021; 89:E11-E12. [PMID: 33862626 DOI: 10.1093/neuros/nyab092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/20/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas K Mattingly
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
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13
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Hunsaker JC, Khan M, Gamblin A, Karsy M, Couldwell WT. Use of a Surgical Stepdown Protocol for Cost Reduction After Transsphenoidal Pituitary Adenoma Resection: A Case Series. World Neurosurg 2021; 152:e476-e483. [PMID: 34098141 DOI: 10.1016/j.wneu.2021.05.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost. METHODS In 2018-2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated. RESULTS Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of -8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016. CONCLUSIONS These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.
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Affiliation(s)
| | - Majid Khan
- Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Austin Gamblin
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
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14
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Laan MT, Roelofs S, Van Huet I, Adang EMM, Bartels RHMA. Selective Intensive Care Unit Admission After Adult Supratentorial Tumor Craniotomy: Complications, Length of Stay, and Costs. Neurosurgery 2020; 86:E54-E59. [PMID: 31541243 PMCID: PMC6911731 DOI: 10.1093/neuros/nyz388] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 07/05/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Admitting patients to an intensive care or medium care unit (ICU/MCU) after adult supratentorial tumor craniotomy remains common practice even though some studies have suggested lower level care is sufficient for selected patients. We have introduced a “no ICU, unless” policy for tumor craniotomy patients. OBJECTIVE To provide a quieter postoperative environment for patients, reduce the burden on the ICU department, and to evaluate whether costs can be reduced. METHODS A cohort study was performed comparing patients that underwent tumor craniotomy for supratentorial tumors during 1 yr after introduction (n = 109) of the new policy with the year before (n = 107). Rate of complications was evaluated, as was the length of stay and patient satisfaction using qualitative evaluation. Finally, costs were evaluated comparing the situation before and after implementation of the new protocol. RESULTS A reduction in ICU/MCU admittance from 64% to 24% of patients was found resulting in 13.3% cost reduction (€1950 per case), without increasing the length of stay at the ward. The length of stay in the hospital was similar. Complications were significantly reduced after implementing the new policy (0.98 vs 0.53 per patient, P = .003). Patients that were interviewed after the new policy reported feeling safe and at ease at the ward. CONCLUSION Changing our policy from “ICU, unless” to “no ICU, unless” reduced complication rates and length of stay in the hospital while keeping patients satisfied. Hospital costs related to the admission have been significantly reduced by the new policy.
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Affiliation(s)
- Mark Ter Laan
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Suzanne Roelofs
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ineke Van Huet
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eddy M M Adang
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ronald H M A Bartels
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
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15
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Neville IS, Ureña FM, Quadros DG, Solla DJF, Lima MF, Simões CM, Vicentin E, Ribeiro U, Amorim RLO, Paiva WS, Teixeira MJ. Safety and costs analysis of early hospital discharge after brain tumour surgery: a pilot study. BMC Surg 2020; 20:105. [PMID: 32410602 PMCID: PMC7227314 DOI: 10.1186/s12893-020-00767-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/05/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND A daily algorithm for hospital discharge (DAHD) is a key point in the concept of Enhanced Recovery After Surgery (ERAS) protocol. We aimed to evaluate the length of stay (LOS), rate of complications, and hospital costs variances after the introduction of the DAHD compared to the traditional postoperative management of brain tumour patients. METHODS This is a cohort study with partial retrospective data collection. All consecutive patients who underwent brain tumour resection in 2017 were analysed. Demographics and procedure-related variables, as well as clinical outcomes, LOS and healthcare costs within 30 days after surgery were compared in patients before/pre-implementation and after/post-implementation the DAHD, which included: stable neurological examination; oral feeding without aspiration risk; pain control with oral medications; no intravenous medications. The algorithm was applied every morning and discharge was considered from day 1 after surgery if criteria was fulfilled. The primary outcome (LOS after surgery) analysis was adjusted for the preoperative performance status on a multivariable logistic regression model. RESULTS A total of 61 patients were studied (pre-implementation 32, post-implementation 29). The baseline demographic characteristics were similar between the groups. After the DAHD implementation, LOS decreased significantly (median 5 versus 3 days; p = 0.001) and the proportion of patients who were discharged on day 1 or 2 after surgery increased (44.8% vs 3.1%; p < 0.001). Major and minor complications rates, readmission rate, and unplanned return to hospital in 30-day follow-up were comparable between the groups. There was a significant reduction in the median costs of hospitalization in DAHD group (US$2135 vs US$2765, p = 0.043), mainly due to a reduction in median ward costs (US$922 vs US$1623, p = 0.009). CONCLUSIONS Early discharge after brain tumour surgery appears to be safe and inexpensive. The LOS and hospitalization costs were reduced without increasing readmission rate or postoperative complications.
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Affiliation(s)
- Iuri Santana Neville
- Instituto do Cancer do Estado de São Paulo do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil. .,Division of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil.
| | - Francisco Matos Ureña
- Division of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil
| | - Danilo Gomes Quadros
- Division of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil
| | - Davi J F Solla
- Division of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil
| | - Mariana Fontes Lima
- Division of Anaesthesiology, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Claudia Marquez Simões
- Instituto do Cancer do Estado de São Paulo do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil
| | - Eduardo Vicentin
- Financial, Planning, and Control Board, Instituto do Cancer do Estado de São Paulo do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ulysses Ribeiro
- Instituto do Cancer do Estado de São Paulo do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil.,Department of Gastroenterology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Robson Luis Oliveira Amorim
- Division of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil.,Universidade Federal do Amazonas, Manaus, Brazil
| | - Wellingson Silva Paiva
- Division of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Arnaldo 251 Cerqueira Cesar, CEP, São Paulo, 01246-000, Brazil
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16
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van Niftrik CHB, van der Wouden F, Staartjes VE, Fierstra J, Stienen MN, Akeret K, Sebök M, Fedele T, Sarnthein J, Bozinov O, Krayenbühl N, Regli L, Serra C. Machine Learning Algorithm Identifies Patients at High Risk for Early Complications After Intracranial Tumor Surgery: Registry-Based Cohort Study. Neurosurgery 2020; 85:E756-E764. [PMID: 31149726 DOI: 10.1093/neuros/nyz145] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/12/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Reliable preoperative identification of patients at high risk for early postoperative complications occurring within 24 h (EPC) of intracranial tumor surgery can improve patient safety and postoperative management. Statistical analysis using machine learning algorithms may generate models that predict EPC better than conventional statistical methods. OBJECTIVE To train such a model and to assess its predictive ability. METHODS This cohort study included patients from an ongoing prospective patient registry at a single tertiary care center with an intracranial tumor that underwent elective neurosurgery between June 2015 and May 2017. EPC were categorized based on the Clavien-Dindo classification score. Conventional statistical methods and different machine learning algorithms were used to predict EPC using preoperatively available patient, clinical, and surgery-related variables. The performance of each model was derived from examining classification performance metrics on an out-of-sample test dataset. RESULTS EPC occurred in 174 (26%) of 668 patients included in the analysis. Gradient boosting machine learning algorithms provided the model best predicting the probability of an EPC. The model scored an accuracy of 0.70 (confidence interval [CI] 0.59-0.79) with an area under the curve (AUC) of 0.73 and a sensitivity and specificity of 0.80 (CI 0.58-0.91) and 0.67 (CI 0.53-0.77) on the test set. The conventional statistical model showed inferior predictive power (test set: accuracy: 0.59 (CI 0.47-0.71); AUC: 0.64; sensitivity: 0.76 (CI 0.64-0.85); specificity: 0.53 (CI 0.41-0.64)). CONCLUSION Using gradient boosting machine learning algorithms, it was possible to create a prediction model superior to conventional statistical methods. While conventional statistical methods favor patients' characteristics, we found the pathology and surgery-related (histology, anatomical localization, surgical access) variables to be better predictors of EPC.
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Affiliation(s)
- Christiaan H B van Niftrik
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Frank van der Wouden
- Department of Geography, University of California - Los Angeles, United States of America.,Management and Organizations Department, Kellogg School of Management, Northwestern University, Evanston, Illinois
| | - Victor E Staartjes
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Tommaso Fedele
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Johannes Sarnthein
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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17
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Aaronson DM, Mueller WM. Commentary: Selective Intensive Care Unit Admission After Adult Supratentorial Tumor Craniotomy: Complications, Length of Stay, and Costs. Neurosurgery 2020; 86:E62-E63. [PMID: 31642508 DOI: 10.1093/neuros/nyz453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/23/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Daniel M Aaronson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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18
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Behling F. Commentary: Selective Intensive Care Unit Admission After Adult Supratentorial Tumor Craniotomy: Complications, Length of Stay, and Costs. Neurosurgery 2020; 86:E60-E61. [PMID: 31670369 DOI: 10.1093/neuros/nyz427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 07/31/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Felix Behling
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University, Tuebingen, Germany.,Center for CNS Tumors, Comprehensive Cancer Center Tuebingen Stuttgart, University Hospital Tuebingen, Eberhard-Karls University Tuebingen, Tuebingen, Germany
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19
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Hasan M, Diep D, Manoranjan B, Maharaj A, Chaudhry S, Shaheen S, Farrokhyar F, Fleming AJ, Ajani O, Singh SK, Yarascavitch B. Analysis of factors that influence neurosurgical length of hospital stay among newly diagnosed pediatric brain tumor patients. Pediatr Blood Cancer 2020; 67:e28041. [PMID: 31612572 DOI: 10.1002/pbc.28041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/11/2019] [Accepted: 09/27/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Postoperative length of stay (LOS) carries a high burden of healthcare costs. In resource-intense specialties such as neurosurgery, it is imperative to identify factors that influence LOS to improve care. The current study investigates the potential for variables that affect clinical presentation, tumor characteristics, treatment modalities, and postoperative complications to impact overall LOS in pediatric brain tumor patients. METHODS A retrospective cohort study design was used with patients enrolled in the McMaster Pediatric Brain Tumor Study Group database. All patients up to 18 years of age, presenting with a newly diagnosed brain tumor admitted to and discharged from neurosurgery, were included. Patients were sorted into three cohorts: short LOS (≤3 days), extended LOS (≥20 days), and control LOS (4-19 days). RESULTS Of the 124 patients included, 20 (65% male; median age: 9.1 years; range, 0.8-17.4 years) were considered short LOS, 28 (61% male; median age: 4.7 years; range, 0.4-14.7 years) were considered extended LOS, and 76 (57% male; median age: 8.5 years; range, 0.3-17.9 years) were considered control LOS. Variables that prolonged LOS were emesis at presentation (P < 0.001), developmental delay (P = 0.02), multiple surgeries (P = 0.004), tumor location (P < 0.05), subtotal resection (P = 0.02), feeding tube (P < 0.001), adjuvant chemoradiotherapy (P < 0.001), and posterior fossa syndrome (P = 0.004). CONCLUSIONS This study identifies variables related to clinical presentation, tumor characteristics, treatment modalities, and postoperative complications associated with extended LOS. These findings uncover novel predictors of LOS that can be used to guide future research and improve health resource management.
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Affiliation(s)
- Muhammad Hasan
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada
| | - Dion Diep
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada
| | - Branavan Manoranjan
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada.,Michael G. DeGroote School of Medicine MD/PhD Program, McMaster University, Hamilton, Ontario, Canada
| | - Arjuna Maharaj
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sabrina Chaudhry
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Saqib Shaheen
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Adam J Fleming
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada.,Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi Ajani
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sheila K Singh
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Blake Yarascavitch
- McMaster Pediatric Brain Tumor Study Group, McMaster University, Hamilton, Ontario, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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20
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Incidence and risk factors of postoperative delirium in patients admitted to the ICU after elective intracranial surgery. Eur J Anaesthesiol 2020; 37:14-24. [DOI: 10.1097/eja.0000000000001074] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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de Almeida CC, Boone MD, Laviv Y, Kasper BS, Chen CC, Kasper EM. The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review. Neurocrit Care 2019; 28:35-42. [PMID: 28808901 DOI: 10.1007/s12028-017-0433-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. METHODS We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." RESULTS The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. CONCLUSION Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.
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Affiliation(s)
- Cesar Cimonari de Almeida
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
| | - M Dustin Boone
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Yosef Laviv
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
| | | | - Clark C Chen
- Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Ekkehard M Kasper
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
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22
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Clinical Factors Associated With ICU-Specific Care Following Supratentoral Brain Tumor Resection and Validation of a Risk Prediction Score. Crit Care Med 2019; 46:1302-1308. [PMID: 29742589 DOI: 10.1097/ccm.0000000000003207] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The postoperative management of patients who undergo brain tumor resection frequently occurs in an ICU. However, the routine admission of all patients to an ICU following surgery is controversial. This study seeks to identify the frequency with which patients undergoing elective supratentorial tumor resection require care, aside from frequent neurologic checks, that is specific to an ICU and to determine the frequency of new complications during ICU admission. Additionally, clinical predictors of ICU-specific care are identified, and a scoring system to discriminate patients most likely to require ICU-specific treatment is validated. DESIGN Retrospective observational cohort study. SETTING Academic neurosurgical center. PATIENTS Two-hundred consecutive adult patients who underwent supratentorial brain tumor surgery. An additional 100 consecutive patients were used to validate the prediction score. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Univariate statistics and multivariable logistic regression were used to identify clinical characteristics associated with ICU-specific treatment. Eighteen patients (9%) received ICU-specific care, and 19 (9.5%) experienced new complications or underwent emergent imaging while in the ICU. Factors significantly associated with ICU-specific care included nonelective admission, preoperative Glasgow Coma Scale, and volume of IV fluids. A simple clinical scoring system that included Karnofsky Performance Status less than 70 (1 point), general endotracheal anesthesia (1 point), and any early postoperative complications (2 points) demonstrated excellent ability to discriminate patients who required ICU-specific care in both the derivation and validation cohorts. CONCLUSIONS Less than 10% of patients required ICU-specific care following supratentorial tumor resection. A simple clinical scoring system may aid clinicians in stratifying the risk of requiring ICU care and could inform triage decisions when ICU bed availability is limited.
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23
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Prediction Score for Postoperative Neurologic Complications after Brain Tumor Craniotomy. Anesthesiology 2018; 129:1111-1120. [DOI: 10.1097/aln.0000000000002426] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Craniotomy for brain tumor displays significant morbidity and mortality, and no score is available to discriminate high-risk patients. Our objective was to validate a prediction score for postoperative neurosurgical complications in this setting.
Methods
Creation of a score in a learning cohort from a prospective specific database of 1,094 patients undergoing elective brain tumor craniotomy in one center from 2008 to 2012. The validation cohort was validated in a prospective multicenter independent cohort of 830 patients from 2013 to 2015 in six university hospitals in France. The primary outcome variable was postoperative neurologic complications requiring in–intensive care unit management (intracranial hypertension, intracranial bleeding, status epilepticus, respiratory failure, impaired consciousness, unexpected motor deficit). The least absolute shrinkage and selection operator method was used for potential risk factor selection with logistic regression.
Results
Severe complications occurred in 125 (11.4%) and 90 (10.8%) patients in the learning and validation cohorts, respectively. The independent risk factors for severe complications were related to the patient (Glasgow Coma Score before surgery at or below 14, history of brain tumor surgery), tumor characteristics (greatest diameter, cerebral midline shift at least 3 mm), and perioperative management (transfusion of blood products, maximum and minimal systolic arterial pressure, duration of surgery). The positive predictive value of the score at or below 3% was 12.1%, and the negative predictive value was 100% in the learning cohort. In–intensive care unit mortality was observed in eight (0.7%) and six (0.7%) patients in the learning and validation cohorts, respectively.
Conclusions
The validation of prediction scores is the first step toward on-demand intensive care unit admission. Further research is needed to improve the score’s performance before routine use.
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24
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Huang HW, Yan LM, Yang YL, He X, Sun XM, Wang YM, Zhang GB, Zhou JX. Bi-frontal pneumocephalus is an independent risk factor for early postoperative agitation in adult patients admitted to intensive care unit after elective craniotomy for brain tumor: A prospective cohort study. PLoS One 2018; 13:e0201064. [PMID: 30024979 PMCID: PMC6053234 DOI: 10.1371/journal.pone.0201064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/07/2018] [Indexed: 12/18/2022] Open
Abstract
Postoperative agitation frequently occurs after general anesthesia and may be associated with serious consequences. However, studies in neurosurgical patients have been inadequate. We aimed to investigate the incidence and risk factors for early postoperative agitation in patients after craniotomy, specifically focusing on the association between postoperative pneumocephalus and agitation. Adult intensive care unit admitted patients after elective craniotomy under general anesthesia were consecutively enrolled. Patients were assessed using the Sedation-Agitation Scale during the first 24 hours after operation. The patients were divided into two groups based on their maximal Sedation-Agitation Scale: the agitation (Sedation-Agitation Scale ≥ 5) and non-agitation groups (Sedation-Agitation Scale ≤ 4). Preoperative baseline data, intraoperative and intensive care unit admission data were recorded and analyzed. Each patient's computed tomography scan obtained within six hours after operation was retrospectively reviewed. Modified Rankin Scale and hospital length of stay after the surgery were also collected. Of the 400 enrolled patients, agitation occurred in 13.0% (95% confidential interval: 9.7-16.3%). Body mass index, total intravenous anesthesia, intraoperative fluid intake, intraoperative bleeding and transfusion, consciousness after operation, endotracheal intubation kept at intensive care unit admission and mechanical ventilation, hyperglycemia without a history of diabetes, self-reported pain and postoperative bi-frontal pneumocephalus were used to build a multivariable model. Bi-frontal pneumocephalus and delayed extubation after the operation were identified as independent risk factors for postoperative agitation. After adjustment for confounding, postoperative agitation was independently associated with worse neurologic outcome (odd ratio: 5.4, 95% confidential interval: 1.1-28.9, P = 0.048). Our results showed that early postoperative agitation was prevalent among post-craniotomy patients and was associated with adverse outcomes. Improvements in clinical strategies relevant to bi-frontal pneumocephalus should be considered. TRIAL REGISTRATION ClinicalTrials.gov (NCT02318199).
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Affiliation(s)
- Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-Mei Yan
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Inner Mongolia People’s Hospital, Hohhot, Inner Mongolia, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan He
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiu-Mei Sun
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu-Mei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- * E-mail:
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The Prophylactic Use of Remifentanil for Delayed Extubation After Elective Intracranial Operations: a Prospective, Randomized, Double-Blinded Trial. J Neurosurg Anesthesiol 2018; 29:281-290. [PMID: 27152427 DOI: 10.1097/ana.0000000000000311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endotracheal extubation is a painful and stressful procedure. The authors hypothesized that the prophylactic use of remifentanil would attenuate the pain intensity and stress responses resulting from extubation in neurosurgical patients. MATERIALS AND METHODS In this prospective, randomized, double-blinded, controlled trial, 160 patients with planned delay extubation after elective intracranial operation were randomized 1:1 to receive either remifentanil or normal saline (control) before their extubation. The dose regime of remifentanil was a bolus of 0.5 μg/kg over 1 minute, followed by a continuous infusion of 0.05 μg/kg/min for 20 minutes. The primary outcome was the incidence of severe pain during the periextubation period. Secondary outcomes included changes in the pain intensity and vital signs, failing to pass an extubation evaluation after the study drug infusion, severe adverse events, postextubation complications, and clinical outcomes. RESULTS Two patients in the remifentanil group did not pass the extubation evaluation. The incidence of severe pain during the periextubation period was significantly lower in the remifentanil group compared with the control group (25.0% vs. 41.3%, P=0.029). Compared with the control group, the visual analog scale in the remifentanil group was significantly lower after the bolus of remifentanil (12±18 vs. 25±27, P=0.001) and immediately after extubation (19±25 vs. 34±30, P=0.001). There were no significant differences in the vital signs immediately after extubation between the 2 groups (P>0.05). CONCLUSIONS The prophylactic use of remifentanil decreases the incidence of severe pain. Our preliminary findings merit a larger trial to clarify the effect of the prophylactic use of remifentanil on clinical outcomes and adverse events.
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Wu C, Lin Y, Tseng H, Cheng H, Lee T, Lin P, Chou W, Cheng Y. Comparison of two stroke volume variation-based goal-directed fluid therapies for supratentorial brain tumour resection: a randomized controlled trial. Br J Anaesth 2017; 119:934-942. [DOI: 10.1093/bja/aex189] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2017] [Indexed: 11/13/2022] Open
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Mirza FA, Wang C, Pittman T. Can patients safely be admitted to a ward after craniotomy for resection of intra-axial brain tumors? Br J Neurosurg 2017; 32:201-205. [DOI: 10.1080/02688697.2017.1390064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Farhan A. Mirza
- Department of Neurosurgery, University of Kentucky, Lexington, KY, USA
| | - Catherine Wang
- Department of Neurosurgery, University of Kentucky, Lexington, KY, USA
| | - Thomas Pittman
- Department of Neurosurgery, University of Kentucky, Lexington, KY, USA
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Lonjaret L, Guyonnet M, Berard E, Vironneau M, Peres F, Sacrista S, Ferrier A, Ramonda V, Vuillaume C, Roux FE, Fourcade O, Geeraerts T. Postoperative complications after craniotomy for brain tumor surgery. Anaesth Crit Care Pain Med 2016; 36:213-218. [PMID: 27717899 DOI: 10.1016/j.accpm.2016.06.012] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION After elective craniotomy for brain tumour surgery, patients are usually admitted to an intensive care unit (ICU) for monitoring. Our goal was to evaluate the incidence and timing of neurologic and non-neurologic postoperative complications after brain tumour surgery, to determine factors associated with neurologic events and to evaluate the timing and causes of ICU readmission. PATIENTS AND METHODS This prospective, observational and analytic study enrolled 188 patients admitted to the ICU after brain tumour surgery. All postoperative clinical events during the first 24hours were noted and classified. Readmission causes and timing were also analysed. RESULTS Twenty-one (11%) of the patients were kept sedated after surgery; the remaining 167 patients were studied. Thirty one percent of the patients presented at least one complication (25% with postoperative nausea and vomiting (PONV), 16% with neurologic complications). The occurrence of neurological complications was significantly associated with the absence of preoperative motor deficit and the presence of higher intraoperative bleeding. Seven patients (4%) were readmitted to the ICU after discharge; 43% (n=3) of them had a posterior fossa surgery. CONCLUSION Postoperative complications, especially PONV, are frequent after brain tumour surgery. Moreover, 16% of patients presented a neurological complication, probably justifying the ICU postoperative stay for early detection. The absence of preoperative motor deficit and intraoperative bleeding seems to predict postoperative neurologic complications. Finally, patients may present complications after ICU discharge, especially patients with fossa posterior surgery, suggesting that ICU hospitalization may be longer in this type of surgery.
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Affiliation(s)
- Laurent Lonjaret
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Marine Guyonnet
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Emilie Berard
- Department of Epidemiology, HealthEconomics and public health, UMR-1027 Inserm, Toulouse University Hospital, Toulouse, France.
| | - Marc Vironneau
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Françoise Peres
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Sandrine Sacrista
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Anne Ferrier
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Véronique Ramonda
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Corine Vuillaume
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Franck-Emmanuel Roux
- Department of Neurosurgery, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Olivier Fourcade
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Thomas Geeraerts
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
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Velly L, Simeone P, Bruder N. Postoperative Care of Neurosurgical Patients. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0175-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Lawrence JD, Tuchek C, Cohen-Gadol AA, Sekula RF. Utility of the intensive care unit in patients undergoing microvascular decompression: a multiinstitution comparative analysis. J Neurosurg 2016; 126:1967-1973. [PMID: 27518528 DOI: 10.3171/2016.5.jns152118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Use of the ICU during admission to a hospital is associated with a significant portion of the total health care costs for that stay. Patients undergoing microvascular decompression (MVD) for cranial neuralgias are routinely admitted postoperatively to the ICU for monitoring. The primary purpose of this study was to compare complication rates of patients with and without a postoperative ICU stay following MVD. The secondary intents were to identify predictors of complications, to analyze variables of health care resource utilization, and to estimate the cost of postoperative management. METHODS The authors performed a retrospective comparative analysis of consecutive patients undergoing MVD at 2 institutions. A total of 199 patients without a postoperative ICU stay from Institution A and 119 patients with an ICU stay from Institution B were reviewed. Inclusion criteria included any adult (i.e., 18 years of age or older) undergoing MVD for trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, or geniculate neuralgia. Patients with incomplete medical records were excluded. Medical comorbidities, intraoperative variables, complications, postoperative interventions, and variables indicating health care resource utilization were reviewed. RESULTS The study compared 190 patients without a postoperative ICU stay from Institution A with 90 patients with an ICU stay from Institution B. Seven patients without an ICU stay and 5 patients with an ICU stay experienced complications after surgery (p = 0.53). Multivariate analysis identified coronary artery disease to be a predictor of complications (p = 0.037, OR 6.23, 95% CI 1.12-34.63). Patients from Institution A without a postoperative ICU stay had a significantly shorter length of stay, by approximately 16 hours (p < 0.001), and received less postoperative imaging (p < 0.001, OR 14.39, 95% CI 7.75-26.74) and postoperative diagnostic testing (p < 0.001) than patients from Institution B with an ICU stay. Estimated cost savings in patients without an ICU stay and 1 less day of inpatient recovery was calculated as $1400 per patient. CONCLUSIONS Selective versus routine use of ICU care as well as postoperative imaging and diagnostic testing may be safe after MVD and can lead to a reduction in overall health care costs.
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Affiliation(s)
| | | | - Aaron A Cohen-Gadol
- Department of Neurological Surgery, Indiana University.,Goodman Campbell Brain and Spine; and.,Simon Cancer Center, Indiana University, Indianapolis, Indiana
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Smith M. Postoperative Care After Elective Endovascular Treatment of Unruptured Intracranial Aneurysms. Anesth Analg 2015; 121:17-19. [DOI: 10.1213/ane.0000000000000767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gracia I, Perelló L, Valero R, Hervías A, Perdomo J, Pujol R, González J, Hurtado P, de Riva N, Tercero FJ, Carrero E, Ferrer E, Fàbregas N. Eficacia diagnóstica y manejo posoperatorio de los pacientes sometidos a biopsia cerebral en un hospital universitario. Neurocirugia (Astur) 2015; 26:23-31. [DOI: 10.1016/j.neucir.2014.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 04/16/2014] [Accepted: 06/10/2014] [Indexed: 01/22/2023]
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McLaughlin N, Upadhyaya P, Buxey F, Martin NA. Value-based neurosurgery: measuring and reducing the cost of microvascular decompression surgery. J Neurosurg 2014; 121:700-8. [DOI: 10.3171/2014.5.jns131996] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Object
Care providers have put significant effort into optimizing patient safety and quality of care. Value, defined as meaningful outcomes achieved per dollar spent, is emerging as a promising framework to redesign health care. Scarce data exist regarding cost measurement and containment for episodes of neurosurgical care. The authors assessed how cost measurement and strategic containment could be used to optimize the value of delivered care after the implementation and maturation of quality improvement initiatives.
Methods
A retrospective study of consecutive patients undergoing microvascular decompression was performed. Group 1 comprised patients treated prior to the implementation of quality improvement interventions, and Group 2 consisted of those treated after the implementation and maturation of quality improvement processes. A third group, Group 3, represented a contemporary group studied after the implementation of cost containment interventions targeting the three most expensive activities: pre-incision time in the operating room (OR) and total OR time, intraoperative neuromonitoring (IOM), and bed assignment (and overall length of stay [LOS]). The value of care was assessed for all three groups.
Results
Forty-four patients were included in the study. Average preparation time pre-incision decreased from 73 to 65 to 45 minutes in Groups 1, 2, and 3, respectively. The average total OR time and OR cost were 434 minutes and $8513 in Group 1; 348 minutes and $7592 in Group 2; and 407 minutes and $8333 in Group 3. The average cost for IOM, excluding electrode needles, was $1557, $1585, and $1263, respectively, in Groups 1, 2, and 3. Average total cost for bed assignment was $5747, $5198, and $4535, respectively, in Groups 1, 2, and 3. The average total LOS decreased from 3.16 days in Group 1 to 2.14 days in Group 3. Complete relief of or a significant decrease in preoperative symptomatology was achieved in 42 of the 44 patients, respectively. Overall, the average cost of a surgical care episode (index hospitalization + readmission/reoperation) decreased 25% from Group 1 to 3.
Conclusions
Linking cost-containment and cost-reduction strategies to ongoing outcome improvement measures is an important step toward the optimization of value-based delivery of care.
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Shum S, Tanzola R, McMullen M, Hopman WM, Engen D. How well are prebooked surgical step-down units utilized? J Clin Anesth 2013; 25:202-8. [PMID: 23523574 DOI: 10.1016/j.jclinane.2012.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 10/04/2012] [Accepted: 10/06/2012] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To evaluate the utilization of the surgical step-down unit (SSDU) by a sample of patients who were preoperatively booked for admission to the unit, and to identify those patient characteristics and perioperative variables that are associated with an intervention in the unit. DESIGN Retrospective chart review. SETTING Canadian tertiary-care facility. MEASUREMENTS Data from 133 elective surgery patients with prebooked SSDU beds were recorded, including comorbidities, Surgical Risk Scale (SRS), Surgical Apgar Score (SAS), and number and nature of interventions and events occurring in the SSDU. MAIN RESULTS Of the 133 patients scheduled for SSDU admission, 60 (45.1%) were actually admitted and the other 73 (54.9%) were admitted directly to the surgical ward or else discharged. Of the patients admitted to the SSDU, 48.3% had an intervention during their stay. In logistic regression, the SRS was a significant predictor (P < 0.001) of SSDU use, while the SAS was a significant predictor (P = 0.034) of the need for an intervention or the likelihood of an event while in the SSDU. CONCLUSIONS Less than half of patients identified were actually admitted to the SSDU postoperatively; of those, less than half required an intervention. The Surgical Apgar Score, a score based on intraoperative factors, predicted the need for an intervention during SSDU admission. Consideration should be given to the development of a predictive score that emphasizes intraoperative factors and early postoperative factors to optimize allocation of this scarce resource.
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Affiliation(s)
- Serena Shum
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON K7L 2V7, Canada
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Cai YH, Zeng HY, Shi ZH, Shen J, Lei YN, Chen BY, Zhou JX. Factors influencing delayed extubation after infratentorial craniotomy for tumour resection: a prospective cohort study of 800 patients in a Chinese neurosurgical centre. J Int Med Res 2013; 41:208-17. [PMID: 23569147 DOI: 10.1177/0300060513475964] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To investigate prospectively the rate of, and factors influencing, delayed extubation following infratentorial craniotomy in a Chinese neurosurgical centre. METHODS Patients undergoing infratentorial craniotomy for tumour resection were prospectively enrolled and stratified according to whether extubation was attempted in the operating theatre (early extubation) or not (delayed extubation). Pre- and intraoperative variables were collected and analysed. Multiple logistic regression analysis was performed, to identify factors related to delayed extubation. RESULTS The study included 800 patients, 398 (49.8%) of whom underwent delayed extubation. The overall rate of extubation failure was 3.6%. Independent factors related to delayed extubation were: preoperative lower cranial nerve dysfunction; hydrocephalus; tumour location; duration of surgery ≥ 6 h; estimated blood loss ≥ 1000 ml. Compared with patients in the early extubation group, those in the delayed extubation group had a higher rate of pneumonia, longer intensive care unit and postoperative hospital stays, and higher hospitalization costs. CONCLUSIONS Brain stem and lower cranial nerve function were the main factors affecting extubation decision-making. Further research is required, to establish criteria for delayed extubation following infratentorial craniotomy.
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Affiliation(s)
- Ye-Hua Cai
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Hanak BW, Walcott BP, Nahed BV, Muzikansky A, Mian MK, Kimberly WT, Curry WT. Postoperative intensive care unit requirements after elective craniotomy. World Neurosurg 2012. [PMID: 23182731 DOI: 10.1016/j.wneu.2012.11.068] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Commonly, patients undergoing craniotomy are admitted to an intensive care setting postoperatively to allow for close monitoring. We aim to determine the frequency with which patients who have undergone elective craniotomies require intensive care unit (ICU)-level interventions or experience significant complications during the postoperative period to identify a subset of patients for whom an alternative to ICU-level care may be appropriate. METHODS Following Institutional Review Board approval, a prospective, consecutive cohort of adult patients undergoing elective craniotomy was established at the Massachusetts General Hospital between the dates of April 2010 and March 2011. Inclusion criteria were intradural operations requiring craniotomy performed on adults (18 years of age or older). Exclusion criteria were cases of an urgent or emergent nature, patients who remained intubated postoperatively, and patients who had a ventriculostomy drain in place at the conclusion of the case. RESULTS Four hundred patients were analyzed. Univariate analysis revealed that patients with diabetes (P = 0.00047), those who required intraoperative blood product administration (P = 0.032), older patients (P < 0.0001), those with higher intraoperative blood losses (P = 0.041), and those who underwent longer surgical procedures (P = 0.021) were more likely to require ICU-level interventions or experience significant postoperative complications. Multivariate analysis only found diabetes (P = 0.0005) and age (P = 0.0091) to be predictive of a patient's need for postoperative ICU admission. CONCLUSIONS Diabetes and older age predict the need for ICU-level intervention after elective craniotomy. Properly selected patients may not require postcraniotomy ICU monitoring. Further study of resource utilization is necessary to validate these preliminary findings, particularly in different hospital types.
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Affiliation(s)
- Brian W Hanak
- Department of Neurosurgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Brian P Walcott
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alona Muzikansky
- Biostatistics Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew K Mian
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William T Kimberly
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William T Curry
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Bui JQH, Mendis RL, van Gelder JM, Sheridan MMP, Wright KM, Jaeger M. Is postoperative intensive care unit admission a prerequisite for elective craniotomy? J Neurosurg 2011; 115:1236-41. [PMID: 21888476 DOI: 10.3171/2011.8.jns11105] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Routine postoperative admission to the intensive care unit (ICU) is often considered a necessity in the treatment of patients following elective craniotomy but may strain already limited resources and is of unproven benefit. In this study the authors investigated whether routine postoperative admission to a regular stepdown ward is a safe alternative. METHODS Three hundred ninety-four consecutive patients who had undergone elective craniotomy over 54 months at a single institution were retrospectively analyzed. Indications for craniotomy included tumor (257 patients) and transsphenoidal (63 patients), vascular (31 patients), ventriculostomy (22 patients), developmental (13 patients), and base of skull conditions (8 patients). Recorded data included age, operation, reason for ICU admission, medical emergency team (MET) calls, in-hospital mortality, and postoperative duration of stay. RESULTS Three hundred forty-three patients were admitted to the regular ward after elective craniotomy, whereas there were 43 planned and 8 unplanned ICU admissions. The most common reasons for planned ICU admissions were anticipated lengthy operations (42%) and anesthetic risks (40%); causes for unplanned ICU admissions were mainly unexpected slow neurological recovery and extensive intraoperative blood loss. Of the 343 regular ward admissions, 10 (3%) required a MET call; only 3 of these MET calls occurred within the first 48 postoperative hours and did not lead to an ICU admission. The overall mortality rate in the investigated cohort was 1%, with no fatalities in patients admitted to the normal ward postoperatively. CONCLUSIONS Routine ward admission for patients undergoing elective craniotomies with selective ICU admission appears safe; however, approximately 2% of patients may require a direct postoperative unplanned ICU admission. Patients with anticipated long operation times, extensive blood loss, and high anesthetic risks should be selected for postoperative ICU admission, but further study is needed to determine the preoperative factors that can aid in identifying and caring for these groups of patients.
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Affiliation(s)
- John Q H Bui
- Department of Neurosurgery, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia
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Successful extubation in the operating room after infratentorial craniotomy: the Cleveland Clinic experience. J Neurosurg Anesthesiol 2011; 23:25-9. [PMID: 21252705 DOI: 10.1097/ana.0b013e3181eee548] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is lack of information in the literature about the rate of successful extubation after infratentorial craniotomy and the risk factors associated with failed extubation. This retrospective analysis assessed the rate of successful extubation after infratentorial craniotomy in a tertiary hospital. METHODS Only infratentorial craniotomies for tumors, vascular malformations in the brainstem or cerebellum, and fourth ventricle cysts performed in prone position were included. Failed extubation was defined as the need for airway reintubation in the operating room (OR), postanesthesia care unit, or intensive care unit after surgery. Only those patients, in whom the primary reason for reintubation was respiratory failure, deteriorating level of consciousness, or inability to protect the airway were included in the statistical analysis. Prolonged intubation was defined as airway intubation longer than 48 hours from the initial intubation. RESULTS This is a retrospective study that included perioperative information from 145 adult patients. One hundred and twenty patients (82%) were primarily extubated in the OR and the rest remained intubated (18%). From the latter group, 9 (36%) and 16 (64%) were extubated in the postanesthesia care unit or intensive care unit, respectively. The rate of failed extubation within 24 hours after primary extubation in the OR was 0.83%. Patients not extubated in the OR had a statistically significant higher American Society of Anesthesiologists score, a longer length of surgery, a larger blood loss, and a longer stay in the hospital compared with those who were extubated in the OR. CONCLUSIONS We conclude that primary extubation in the OR after infratentorial craniotomy is feasible. However, cautions should be taken in patients with poor physical status undergoing vascular surgery and long procedures with potential significant fluid shifts.
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Abstract
BACKGROUND AND OBJECTIVE Emergency laparotomy is a common high-risk surgical procedure, but with few outcome data and few data on postoperative care. We aimed to observe mortality within a mixed general surgical population and to explore the potential impact of postoperative care on mortality. METHOD A prospective observational study of 124 patients undergoing emergency laparotomy. For all patients, overall mortality and 30-day survival were observed; the predicted death rate (PDR) using the P-POSSUM (Portsmouth predictor - Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) score and the standardised mortality ratio (SMR) were calculated. RESULTS Twenty-four patients died (19.4%); 21 in the first 30 days (16.9%). Twenty-six patients were over 80 years; 10 died (38%). PDR for all patients was 27.4%. The overall SMR was 0.71. Eighty-seven patients (70.2%) followed a postanaesthesia care unit (PACU)-ward pathway (observed mortality 13.6%; mean PDR 15.4%; SMR 0.82). Thirty (24.2%) patients followed an ICU-high dependency unit (HDU)-ward pathway (observed mortality 40.0%; mean PDR 57.2%; SMR 0.69). Six patients (4.8%) followed a PACU-HDU-ward pathway (observed mortality 0%, mean PDR 41.8%, SMR 0.0). CONCLUSION Mortality after emergency laparotomy was high and very high in patients more than 80 years of age. The SMR was higher in the PACU-ward pathway compared to the ICU-HDU-ward pathway, suggesting room for improvement in the postoperative period.
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Nowak AK, Maujean JE, Jackson M, Knuckey N. A prospective study of surgical patterns of care for high grade glioma in the current era of multimodality therapy. J Clin Neurosci 2010; 18:227-31. [PMID: 21185727 DOI: 10.1016/j.jocn.2010.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 05/13/2010] [Accepted: 05/15/2010] [Indexed: 11/30/2022]
Abstract
Previous surgical patterns of care reports in high grade glioma (HGG) antedated the use of chemo-radiotherapy. This study, from an elective neurosurgical centre serving an isolated population of over 2 million, identified adult patients with HGG from a prospective multidisciplinary database. Of 328 patients in Western Australia who were diagnosed with HGG between 1 June 2006 and 30 June 2008, 283 patients (86%) received care at the study site. A total of 4% were diagnosed on imaging and clinical factors alone; 12% had surgery outside the study site. The remaining 231 patients had 264 surgical procedures; 78% resection and 22% biopsy. Median survival (grade IV) was 9.4 months. Resection predicted improved survival (hazard ratio 0.64; 95% confidence interval 0.4-0.89); however, in multivariable analysis, only age and grade predicted outcome. The proportion of patients having no tissue diagnosis, or biopsy alone, compares favourably with data before the use of chemo-radiotherapy, as does survival. The therapeutic nihilism surrounding HGG may have decreased since the introduction of temozolomide.
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Affiliation(s)
- A K Nowak
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
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Is pediatric neurointensive care a legitimate programmatic advancement to benefit our patients and our trainees, or others? Pediatr Crit Care Med 2010; 11:758-60. [PMID: 21057270 DOI: 10.1097/pcc.0b013e3181d8e292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To describe the pediatric intensive care unit (PICU) course and resource utilization for children with brain tumor resection and to identify factors predicting prolonged (>1 day) PICU length of stay. After craniotomy for brain tumor resection, children recover in the PICU. A few require critical care interventions and a >24-hr length of stay. DESIGN We reviewed all brain tumor resection patients admitted to the PICU over 2 yrs. Preoperative, intraoperative, and postoperative variables and tumor characteristics were examined. The extracted variables were compared between two groups with a length of stay in the PICU of >1 or <1 day. SETTING Pediatric intensive care unit in a tertiary academic children's medical center. PATIENTS A total of 105 patients post brain tumor resection were admitted to the PICU over the study period and analyzed. INTERVENTIONS Record review. MEASUREMENTS AND MAIN RESULTS Thirty-two (31%) of 105 patients remained in the PICU for >1 day. The mean age of patients in the >1 day group was 5.0 ± 0.81 yrs and 8.78 ± 0.65 yrs in the <1 day group (p < .05). The estimated blood loss was 20 ± 2.37 mL/kg in the >1 day and 9 ± 0.92 mL/kg in the <1 day group (p < .05). Fifteen (14.3%) patients were mechanically ventilated on arrival in the PICU; these patients more often had a length of stay of >1 day (p < .05). The number of unexpected intensive care unit interventions were 0.7 per patient, were more common in the >1 day group, and included treatment of sodium abnormalities, new neurologic deficits, paresis, or seizures (p < .05). In a logistic regression model, estimated blood loss and intubation on arrival predicted longer lengths of stay in the PICU (odds ratio, 1.1; 95% confidence interval, 1.05-1.18; and odds ratio, 33; 95% confidence interval, 2.57-333, respectively), with a receiver operating characteristic curve of 0.86 and 95% confidence interval, 0.78-0.94. CONCLUSIONS Large intraoperative estimated blood loss and intubation on arrival may be predictive of PICU lengths of stay of >1 day for children who have had a craniotomy for brain tumor resection. Intensive care unit interventions are more common in these children.
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Seferian EG, Afessa B. Demographic and clinical variation of adult intensive care unit utilization from a geographically defined population. Crit Care Med 2006; 34:2113-9. [PMID: 16763514 DOI: 10.1097/01.ccm.0000227652.08185.a4] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine population-based rates of adult intensive care unit (ICU) use and evaluate the effects that demographic variables and chronic illness have on ICU utilization. DESIGN Retrospective, population-based cohort study. SETTING Olmsted County, Minnesota. PARTICIPANTS Adult residents admitted to an ICU in 1998. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Measurements included demographics, Acute Physiology and Chronic Health Evaluation III score, ICU admission diagnosis, ICU interventions, Charlson comorbidity index and conditions, ICU length of stay (LOS), and ICU, hospital, 1-month, and 1-yr mortalities. Risk of ICU admission and rates of ICU utilization increased substantially with increasing age, peaking in the very elderly. The rates of ICU admission and utilization in those > or =85 yrs old were 58.2 admissions/1,000 residents and 195.8 days/1,000 residents compared with 3.8 admissions/1,000 residents and 11.5 days/1,000 residents in those 18 to 44 yrs old. Residents > or =85 yrs old were 3.75 times as likely (p < .001) to be admitted to the ICU compared with those 18-44 yrs old after controlling for the presence of comorbid illness. ICU admission rates increased with an increasing number of comorbid illnesses. Residents with cardiovascular conditions and renal disease had high rates of ICU admission. Repeat users of the ICU were more likely to have a chronic condition and higher degree of comorbid illness compared with nonrepeat users. ICU mortality was similar across all age groups, except in those > or =85 yrs old, for whom mortality was greater. One-year mortality after ICU admission increased with increasing age. CONCLUSIONS Population-based rates of ICU admission and utilization in Olmsted County, Minnesota, increased with age and are highest in the very elderly. The presence of chronic illness, particularly cardiovascular conditions, significantly increases ICU utilization and risk of ICU admission.
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Affiliation(s)
- Edward G Seferian
- Division of Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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