Brain tumor resection in children: neurointensive care unit course and resource utilization

Factors Influencing Prolonged Intensive Care Unit Length of Stay after Craniotomy for Intracranial Tumor in Children: A 10-year Analysis from a University Hospital

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.

Defining Pediatric Chronic Critical Illness: A Scoping Review

OBJECTIVES

Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions.

DATA SOURCES

Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021.

STUDY SELECTION

We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening.

DATA EXTRACTION

We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed.

DATA SYNTHESIS

Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18).

CONCLUSIONS

Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.

Incidence and Perioperative Risk Factors of Delayed Extubation following Pediatric Craniotomy for Intracranial Tumor: A 10-Year Retrospective Analysis in a Thailand Hospital

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.

Hyperlactatemia in children following brain tumor resection: prevalence, associated factors, and clinical significance

PURPOSE

Hyperlactatemia is associated with worse outcome among critically ill patients. The prevalence of hyperlactatemia in children following craniotomy for intracranial tumor resection is unknown. This study was designed to assess the prevalence, associated factors, and significance of postoperative hyperlactatemia in this context.

METHODS

A retrospective study was conducted at an intensive care unit of a tertiary, pediatric medical center. Children younger than 18 years admitted following craniotomy for brain tumor resection between October 2004 and November 2019 were included.

RESULTS

Overall, 222 elective craniotomies performed in 178 patients were analyzed. The mean age ± SD was 8.5 ± 5.5 years. All but two patients survived to discharge. All were hemodynamically stable. Early hyperlactatemia, defined as at least one blood lactate level ≥ 2.0 mmol/L during the first 24 h into admission, presented following 74% of the craniotomies; lactate normalized within a mean ± SD of 11 ± 6.1 h. The fluid balance per body weight at 12 h and 24 h into the intensive care unit admission was similar in children with and without hyperlactatemia [7.0 ± 17.6 vs 3.5 ± 16.4 ml/kg, p = 0.23 and 4.0 ± 27.2 vs 4.6 ± 29.4 ml/kg, p = 0.96; respectively]. Hyperlactatemia was associated with higher maximal blood glucose, older age, and a pathological diagnosis of glioma. Intensive care unit length of stay was similar following craniotomies with and without hyperlactatemia (p = 0.57).

CONCLUSIONS

Hyperlactatemia was common in children following craniotomy for brain tumor resection. It was not associated with hemodynamic impairment or with a longer length of stay.

Lipid Peroxidation and Antioxidant Consumption as Early Markers of Neurosurgery-Related Brain Injury in Children

BACKGROUND AND AIMS

Lipid peroxidation represents a marker of secondary brain injury both in traumatic and in non-traumatic conditions-as in major neurosurgical procedures-eventually leading to brain edema amplification and further brain damage. Malondialdehyde (MDA), a lipid peroxidation marker, and ascorbate, a marker of antioxidant status, can represent early indicators of this process within the cerebrospinal fluid (CSF). We hypothesized that changes in cerebral lipid peroxidation can be measured ex vivo following neurosurgery in children.

METHODS

Thirty-six children (M:F = 19/17, median age 32.9 months; IQR 17.6-74.6) undergoing neurosurgery for brain tumor removal were admitted to the pediatric intensive care unit (PICU) in the postoperative period with an indwelling intraventricular catheter for intracranial pressure monitoring and CSF drainage. Plasma and CSF samples were obtained for serial measurement of MDA, ascorbate, and cytokines.

RESULTS

An early brain-limited increase in lipid peroxidation was measured, with a significant increase from baseline of MDA in CSF (p = 0.007) but not in plasma. In parallel, ascorbate in CSF decreased (p = 0.05). Systemic inflammatory response following brain surgery was evidenced by plasma IL-6/IL-8 increase (p 0.0022 and 0.0106, respectively). No correlation was found between oxidative response and tumor site or histology (according to World Health Organization grading). Similarly, lipid peroxidation was unrelated to the length of surgery (mean 321 ± 73 min), or intraoperative blood loss (mean 20.9 ± 16.8% of preoperative volemia, 44% given hemotransfusions). Median PICU stay was 3.5 days (IQL range 2-5.5 d.), and postoperative ventilation need was 24 h (IQL range 20-61.5 h). The elevation in postoperative MDA in CSF compared with preoperative values correlated significantly with postoperative ventilation need (P = 0.05, r² 0168), while no difference in PICU stay was recorded.

CONCLUSIONS

Our results indicate that lipid peroxidation increases consistently following brain surgery, and it is accompanied by a decrease in antioxidant defences; intraventricular catheterization offers a unique chance of oxidative process monitoring. Further studies are needed to evaluate whether monitoring post-neurosurgical oxidative stress in CSF is of prognostic utility.

Analysis of factors that influence neurosurgical length of hospital stay among newly diagnosed pediatric brain tumor patients

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.

Greater fluctuations in serum sodium levels are associated with increased mortality in children with externalized ventriculostomy drains in a PICU

OBJECTIVES

Dysnatremia is common in critically ill children due to disruption of hormonal homeostasis. Children with brain injury are at risk for syndrome of inappropriate antidiuretic hormone, cerebral salt wasting, and sodium losses due to externalized ventricular drain placement. We hypothesized that among PICU patients managed with an externalized ventricular drain, hyponatremia is common, hyponatremia is associated with seizures and in-hospital mortality, and greater sodium fluctuations are associated with in-hospital mortality.

DESIGN

Retrospective observational study.

SETTING

Tertiary care PICU.

PATIENTS

All pediatric patients treated in the PICU with an externalized ventricular drain from January 2005 to December 2009. Patients were identified by searching the physician order entry database for externalized ventricular drain orders. Hyponatremia was defined as the minimum sodium during patients' externalized ventricular drain time and was categorized as mild (131-134 mEq/L) or moderate to severe (≤ 130 mEq/L). Magnitude of sodium fluctuation was defined as the difference between a patient's highest and lowest sodium during the time in which an externalized ventricular drain was in use (up to 14 d). Seizure was defined as a clinically evident convulsion during externalized ventricular drain presence. A priori confounders were age, history of epilepsy, and externalized ventricular drain indication. Multivariable regression was performed to test the association between sodium derangements and outcomes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Three hundred eighty patients were eligible. One hundred nine (29%) had mild hyponatremia, and 30 (8%) had moderate to severe hyponatremia. Twenty-eight patients (7%) had a seizure while hospitalized. Eighteen patients died (5%) prior to discharge. Survivors had a median daily sodium fluctuation of 1 mEq/L [0-5] vs non-survivors 9 mEq/L [6-11] (p < 0.001) and a median sodium fluctuation of 5 mEq/L [2-8] vs non-survivors 15 mEq/L [9-24] (p < 0.001) during externalized ventricular drain management. After controlling for a priori covariates and potential confounders, hyponatremia was not associated with an increased odds of seizures or in-hospital mortality. However, greater fluctuations in daily sodium (odds ratio, 1.38; 95% CI, 1.06-1.8) and greater fluctuations in sodium during externalized ventricular drain management were associated with increased odds of in-hospital mortality (odds ratio, 1.59; 95% CI, 1.2-2.11).

CONCLUSIONS

Hyponatremia was common in PICU patients treated with externalized ventricular drains but not associated with seizures or in-hospital mortality. Greater sodium fluctuations during externalized ventricular drain management were independently associated with increased odds of in-hospital mortality.

Update on pediatric neurocritical care

Paralytic poliomyelitis, Reye syndrome, Hemophilus Influenzae type B epiglottitis, bacterial meningitis, and meningococcal septic shock are catastrophic illnesses that in the last 60 years have shaped the development of pediatric intensive care. Neurocritical care has been at the forefront of our thinking and, more latterly, as a specialty we have had the technology and means to develop this focus, educate the next generation and show that outcomes can be improved-first in adult critical care and now the task is to translate these benefits to critically ill children. In our future we will need to advance interventions in patient care with clinical trials. MeSH terms: Neurocritical care; child; traumatic brain injury; status epilepticus; cerebrovascular.

Pediatric neurocritical care: a neurology consultation model and implication for education and training

Pediatric neurocritical care is developing specialization within pediatric intensive care and pediatric neurology practice, and the evolving clinical expertise has relevance to training and education in both fields. We describe a model of service using a Neurology Consulting Team in the intensive care unit setting. Medical records were reviewed from a 32-month cohort of Neurology Consulting Team referrals. Six hundred eighty-nine (19%) of 3719 patients admitted to the intensive care unit were assessed by the team. The most common diagnostic categories were seizures, neurosurgical, cerebrovascular, or central nervous system infection. Fifty-seven percent (350 of 615 patients) required mechanical ventilation. Cohort mortality was 7% vs 2% for the general intensive care population (P < 0.01). The team provided 4592 initial and subsequent consultations; on average there were five to six new consultations per week. Each patient had a median of two (interquartile range, 1 to 6) consultations during admission. Three quarters of the cohort required neurodiagnostic investigation (1625 tests), with each patient undergoing a median of two (range, 0 to 3) studies. Taken together, the subset of pediatric intensive care unit patients undergoing neurology consultation, investigation, and management represents a significant practice experience for trainees, which has implications for future curriculum development in both pediatric critical care medicine and pediatric neurology.

Factors influencing delayed extubation after infratentorial craniotomy for tumour resection: a prospective cohort study of 800 patients in a Chinese neurosurgical centre

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.

Pediatric neurocritical care

Pediatric neurocritical care is an emerging multidisciplinary field of medicine and a new frontier in pediatric critical care and pediatric neurology. Central to pediatric neurocritical care is the goal of improving outcomes in critically ill pediatric patients with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and the support of brain function. There is a pressing need for evidence based guidelines in pediatric neurocritical care, notably in pediatric traumatic brain injury and pediatric stroke. These diseases have distinct clinical and pathophysiological features that distinguish them from their adult counterparts and prevent the direct translation of the adult experience to pediatric patients. Increased attention is also being paid to the broader application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit, in both primary neurological and primary non-neurological disease states. Although much can be learned from the adult experience, there are important differences in the critically ill pediatric population and in the circumstances that surround the emergence of neurocritical care in pediatrics.