Eisen Sarah H, Hindman Bradley J, Bayman Emine O, Dexter Franklin, Hasan David M
From the Department of Anesthesia, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa; Department of Biostatistics, The University of Iowa College of Public Health, Iowa City, Iowa; Division of Management Consulting, Department of Anesthesia, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa; and Department of Neurosurgery, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa.
Anesth Analg. 2015 Jul;121(1):188-197. doi: 10.1213/ANE.0000000000000699.
Our intention in this case series was to review the postoperative care and neurologic outcomes of patients who had undergone elective endovascular treatment of unruptured intracranial aneurysms. The case series is unique managerially in that a progressively increasing percentage of patients were admitted to the postanesthesia care unit (PACU; 1:2 nurse-to-patient ratio) and subsequently to the neurosurgical ward (1:3 nurse-to-patient ratio) instead of directly to the intensive care unit (ICU; 1:1 nurse-to-patient ratio).
A retrospective review was performed of 170 consecutive elective endovascular procedures to treat unruptured intracranial aneurysms between July 2009 and September 2012. Data included patient, aneurysm, procedural characteristics, and adverse events within 96 hours after the procedure. Rates of ICU admission and perioperative neurologic adverse events were compared over time.
Although direct ICU admission rates decreased over time (P < 0.0001) from 100% to 15%, perioperative neurologic event rates did not change (P = 0.79). Sixteen of 170 patients experienced perioperative neurologic events. The percentages of patients with neurologic events who died or had deficits that did not resolve before discharge were 38% (3 of 8) among patients directly admitted to the ICU versus 38% (3 of 8) among those first admitted to the PACU. Although the duration of anesthesia was greater among patients admitted to the ICU, duration was not useful in predicting decisions on the day of surgery for individual patients. The duration of anesthesia also was not meaningfully associated with information available preoperatively (i.e., for use when scheduling the case).
In centers in which PACU and ward care are comparable to those in this case series, in the absence of intraoperative events with the potential for ongoing cerebral ischemia, most patients undergoing elective endovascular treatment of unruptured cerebral aneurysms can be managed without direct ICU admission. Scheduling all these procedures by using the mean historical anesthesia duration is reasonable.
在本病例系列中，我们旨在回顾接受未破裂颅内动脉瘤择期血管内治疗患者的术后护理及神经学转归。该病例系列在管理方面具有独特性，即越来越多的患者先被收入麻醉后监护病房（PACU；护士与患者比例为1:2），随后转入神经外科病房（护士与患者比例为1:3），而非直接进入重症监护病房（ICU；护士与患者比例为1:1）。
对2009年7月至2012年9月期间连续进行的170例未破裂颅内动脉瘤择期血管内治疗手术进行回顾性分析。数据包括患者、动脉瘤、手术特征以及术后96小时内的不良事件。比较不同时间点的ICU入住率及围手术期神经学不良事件发生率。
尽管直接入住ICU的比例随时间下降（P < 0.0001），从100%降至15%，但围手术期神经学事件发生率未改变（P = 0.79）。170例患者中有16例发生围手术期神经学事件。直接入住ICU的患者中，发生神经学事件且死亡或出院前神经功能缺损未恢复的患者比例为38%（8例中的3例），而先入住PACU的患者中这一比例同样为38%（8例中的3例）。尽管入住ICU的患者麻醉时间更长，但麻醉时间对单个患者手术当日的决策并无预测作用。麻醉时间与术前可获得的信息（即安排手术时使用）也无显著关联。
在PACU和病房护理与本病例系列相当的中心，若术中无持续脑缺血风险事件，大多数接受未破裂脑动脉瘤择期血管内治疗的患者无需直接入住ICU即可得到妥善管理。使用平均历史麻醉时间来安排所有这些手术是合理的。
