Einführung eines postoperativen Step-Down-Care-Protokolls: Optimieren eines sicheren, patientenindividuellen und ökonomischen Patientenmanagements nach elektiver Kraniotomie

Capacity for postoperative intensive care unit (ICU)- or intermediate care unit (IMC)- monitoring of patients undergoing elective craniotomy (EC) can be a limiting factor for the number of EC performed per day. At the same time, the indication and benefit of standard ICU/IMC-monitoring after EC are being discussed controversially.1 Identifying those patients undergoing EC, that can safely reduce the usage of ICU/IMC-monitoring capacities is crucial for safely reducing ICU/IMC-patient load.

We developed a "Step-Down-Care"-protocol to select those patients undergoing EC that can step down from ICU/IMC to the regular neurosurgical ward 6 hours after the operation. We hypothesize, that with the correct identification of eligible patients, these patients can then be safely managed on the regular ward.

1. Qasem et al. (2022) Implementation of the "No ICU – Unless" approach in postoperative neurosurgical management in times of COVID-19. Neurosurg Rev. 45(5):3437-46.

We retrospectively analyzed those patients that were included in the protocol in the first full year of the Step-Down-Care-protocol usage, the year of 2023. Inclusion criteria of the protocol included amongst others duration of EC of no more than 6 hours, and expectation of low perioperative risk (ASA I or II according to ASA PS classification)2. At the end of the 6 hour-ICU/IMC-monitoring period, patients had to meet the following criteria to then in fact step down to the regular ward: regular postoperative imaging, no epileptic seizure, no unexpected neurological deficit and cardiovascular stability.

All patients included in the protocol in 2023 were included in this study and data was retrospectively collected concerning patient demographics, clinical and surgical characteristics, and postoperative complications.

2. Mayhew et al. (2019) A review of ASA physical status – historical perspectives and modern developments. Anesthesia. 74:373-9.

44 patients (mean age 54 years) followed the Step-Down-Care-protocol. Surgeries included supra- and infratentorial craniotomies. Of these patients, no patients had to step back up to ICU/IMC-monitoring and -therapy. No major clinical or radiological complications occurred.

Having patients step down from ICU/IMC-monitoring to a regular ward after 6 hours of uneventful postoperative monitoring according to the proposed criteria appears to be a safe procedure. Further evaluation of a larger group sample and a comparison to a control group is required.