Postoperative monitoring on ICU after elective craniotomies – How much monitoring is required?

Abstract-Text (inkl. Referenzen und Bildunterschriften)

INTRODUCTION

In most neurosurgical departments, patients undergoing elective craniotomy for intracranial surgery are postoperatively monitored on an intensive or intermediate care unit (ICU; IMC). However, a guideline for efficient and reasonable duration of monitoring after neurosurgical procedures is missing. The aim of this study was to evaluate the occurrence of complications in the early postoperative phase and to re-define the monitoring algorithm after elective craniotomy.

METHODS

Data acquisition was conducted as a single-center retrospective analysis. Patients undergoing elective craniotomy from 2018-2021 were included. Demographic data, diagnosis, American Society of Anesthesiologists (ASA)-score, Charlson comorbidity index (CCI), duration of surgery, blood loss, complications (hemorrhage, respiratory failure, decline of neurological status), and type and duration of monitoring were analyzed.

RESULTS

860 consecutive patients (376 men and 484 women) with a mean age of 60.6 years (range:19-93 years) were included. 274 (56.4%) patients underwent microsurgical resection of extra-axial, 515 (59.9%) of intra-axial tumors, and 93 (10.8%) were vascular cases.

152 (17.7%) cases were infratentorial.Forty-three patients experienced a postoperative incident identified by close monitoring that required intensive care monitoring/treatment. 8 of these patients needed an emergent revision surgery. The mean time to incident was 5.7h (SD=4.4h). Sex, age, and tumor type did not influence the risk for complications.

Independent predictive factors for postoperative complications were age (p=0.001) increasing the risk by 2.5%/year; CCI (p=0.011) increasing the risk by 11.7%/CCI grade (CI95%=1.03-1.21)[DK3] ; operating time (p<0.0001) increasing by 0.8% risk/minute (CI95%=1.06-1.01), and intraoperative blood loss (p<0.0001) increasing by 0.1%/ml (CI95%=1.0-1.001)). The threshold of operating time causing a higher risk was 195 min and the threshold of blood loss 550 ml (Youden-Score 0.32).

CONCLUSIONS

The principle of assigning a postoperative ICU bed already seems to be efficient. In the majority of cases a dense monitoring beyond around 6 hours doesn"t seem to be necessary. Considering comorbidity and surgery-associated complications to identify high-risk patients, a more precise algorithm with an earlier transfer to the normal ward should be established apart from the undisputed gold standard of ICU monitoring.